Every finding on record at Nexus at Alton

Based on interview, observation, and record review the facility failed to supervise a high-risk, exit seeking resident to prevent an elopement in 1 of 4 residents (R2) reviewed for supervision in the sample of 9. This failure resulted in R2 having multiple elopement attempts from 7/27/26 until he eloped on 8/10/26 at approximately 8:30 PM, R2 traveled approximately 3 miles along a busy 4 lane highway. R2 was found by police at approximately 10:23 PM sitting on his buttocks on the ground in the drive thru at a fast-food restaurant. This failure resulted in an Immediate Jeopardy. V1, Administrator, and V15, Regional Nurse Consultant were notified of the Immediate Jeopardy on 8/13/26 at 3:00 PM. The Past Non-Compliance and Immediate Jeopardy began on 8/10/26 when R2 eloped from the facility and traveled approximately 3 miles on a busy 4 lane highway. R2 was found by the police on 8/10/26 at approximately 10:23 PM sitting on the ground in the drive thru at a fast-food restaurant. Findings Include: R2's Hospital Admission/Referral Records, dated 7/22/26, documents R2 presented to the ED (Emergency Department) on 7/9/26 after an altercation that he has no memory of. R2 was admitted under observation until a bed in a memory care unit is available due to his inability to care for himself. Psychiatry was consulted for the inability to care for himself and agitation after patient attempted to elope multiple times during hospitalization with displays of agitation and aggression towards staff. R2's insight, memory and judgement were impaired. R2's Face Sheet, undated, documents R2 was admitted to the facility on [DATE] with the following diagnoses: GAD (Generalized Anxiety Disorder), Alzheimer's Disease, Dementia with Agitation, AMS (Altered Mental Status), Need for Assistance with Personal Care, HTN (Hypertension), Hyperlipidemia, Restlessness and Agitation, Violent Behavior, Bradycardia, Iron Deficiency Anemia, Vitamin D Deficiency, and Chest Pain. R2's MDS (Minimum Data Set) dated 8/5/26, documents R2 has severe cognitive impairment; exhibits hallucinations, delusions, has physical and verbal behaviors directed towards others, displays other behaviors not directed towards others; his behaviors put R2 and other residents at significant risk for physical illness and injury and significantly interferes with resident's care; R2's behaviors disrupt the living environment and intrudes on the privacy and activity of others; R2 rejects care and wanders; and requires supervision/touch assist with ambulation. R2's Elopement Risk Assessment, dated 7/29/26, documents R2 is at high risk for elopement. R2's Care Plan, dated 8/5/26, fails to document R2's risk for elopement or any interventions implemented to prevent an elopement. R2's Progress Note, dated 7/25/26 at 10:00 PM, documents the following: Remains on new admit observation. Resident is somewhat anxious trying to get out of locked unit and pacing the floor. Ambulates without difficulty. Resident is alert x (times) 1-2. Resident is continent of bowel and bladder. Feeds self at mealtimes. No s/s (signs/symptoms) of acute distress noted.R2's Progress Note, dated 7/27/26 1:50 PM, documents the following: Resident was talking to psych Dr. about past history, after conversation resident became angry and stated he wanted to leave. Nurse then asked what's wrong resident stated he not answering any questions because it was none of her business. Resident then pushed and kicked door trying to get out. Resident then began to talk to himself, stating y'all don't know me and can't stop him from leaving with his fist balled up. Nurse alerted DON (Director of Nurses) and staff members to move other resident from area. Per DON and Psych Dr orders to send resident to ER (Emergency Room) for psych evaluation under involuntary petition. The local police department was called for assistance with transfer. The local fire department arrived at 12:24 pm. Nurse gave report to ER nurse.R2's Progress Note, dated 7/27/26 at 2:58 PM, documents the following, in part: Psychiatry/med-management initial evaluation note. Date of Service: 2026-07-27. Reason for referral: Facility request for an initial psychiatric assessment to evaluate patients' mood, behavior, and cognitive status. Chief complaint: Initial psychiatric assessment to evaluate patients' mood, behavior, and cognitive status. R2 is a [AGE] year-old male seen today for an initial psychiatric evaluation to evaluate his mood, behavior, and cognitive status. He denies having a history of any mental illness. He is currently taking Sertraline 25mg (milligrams) daily for anxiety and Fluphenazine 1mg BID (twice daily) also for anxiety. The encounter took place while R2 was sitting on a couch, near the nurse's station on the locked unit. He reports his mood today is good, he reports his appetite has been alright, and he reports sleeping good. He denies any concerns about his mental health. During the evaluation, R2 was calm and cooperative, with no observed signs of agitation, distress, or mood instability. He denies negative thoughts, thoughts of self-harm, having self-harming behaviors, suicidal ideations, homicidal ideations, audible, visual, and tactile hallucinations. Updated clinical information for this evaluation was obtained from both the patient, the facility staff, and the patient's chart. Collateral information obtained from facility staff indicates the patient was recently admitted this past weekend, and he has exhibited signs of acute psychiatric behaviors. The patient remains compliant with his prescribed medication regimen, including Sertraline 25mg daily and Fluphenazine 1mg BID. At the conclusion of the encounter, the patient questioned why he was being asked certain questions. He was informed that the purpose of the assessment was to evaluate his mental health status. After this provider proceeded to evaluate another patient, R2 became verbally aggressive, threatening to hit the CNA (Certified Nursing Assistant) and RN (Registered Nurse). He stated he was ready to go home, that he had things he needed to do, and that he needed to take care of his children. He attempted to leave the locked unit through the emergency exit door. Staff were initially unable to calm or redirect him. When two male staff members arrived on the unit, he became less physically agitated but continued to insist on leaving. Due to ongoing safety concerns and continued attempts to elope, nursing staff contacted law enforcement for transport to the hospital for an involuntary psychiatric evaluation. Orientation to time, place, person: A&O (Alert & Oriented) x/times1. Incorrectly stated city he was in, was unable to recall the month, day of the week, or where he was at. Recent and remote memory: Poor. Attention span and concentration: Good and Intact. Language: WNL (Within Normal Limits), Demonstrates understanding. Fund of knowledge: Poor. Anxiety - Chronic, currently unstable. Observed signs of mood instability, anxiousness, nervousness, and excessive worrying and paranoia. New Order was obtained from MD for: Haldol 5mg every 6 hours as needed for anger, aggression, agitation, and mood instability. Rationale: Patient demonstrated escalating behavioral dysregulation, including verbal aggression, agitation, attempts to elope from the unit, and emerging paranoid ideation. These behaviors represent an acute safety concern for both the patient and staff. Given the severity of agitation and the presence of paranoia, a medication with reliable antipsychotic and behavioral-stabilizing properties is clinically indicated. Haloperidol is an evidence-supported option for rapid behavioral control in acute agitation associated with psychosis or severe disorganization. Initiation is justified to reduce risk of harm, stabilize thought processes, and support safe participation in care. Patient will be monitored closely for symptom response and potential adverse effects.R2's Progress Note, dated 7/27/26 at 11:47 PM, documents the following: Resident returned without call from the hospital. Resident arrived on gurney from ambulance with 2 attendants. Resident in decent mood asking for alcoholic beverages and for someone to get in kitchen and cook him some food. VSS. Resident ambulates without diff. Continent of bowel and bladder. A and O x1-2. No s/s acute distress noted. Call light within reach.R2's Progress Note, dated 7/30/26 at 7:32, documents the following: CNA informed nurse that during last smoke break resident climbed over the rail and started walking towards the end of the ramp and she told him he had to come back and he came back. Resident came in without incident and is sitting on the couch watching TV. The oncoming nurse was notified about the incident.R2's Progress Note, dated 8/3/26 at 9:00 PM, documents the following: Pt (Patient) very agitated and has walked his roommate out of his room [ROOM NUMBER]x. Pt stated HE DONT BELONG IN HERE! Pt closed the door and stated That ain't my problem. when trying to explain that this is a shared room, pts roommate has been temporarily placed in another room.R2's Progress Note, dated 8/3/26 at 11:43 PM, documents the following: Pt very confused and non-compliant. Pt was found trying to physically get a female pt out of her bed by pulling her up by her hands. Pt redirected back to his room in which seconds later the pt was in another female resident's room watching her sleep and refused to leave the room pt was reported to have been very aggressive today during prior shift, EMS called to transfer pt to hospital for a psych eval.R2's Progress Note, dated 8/4/26 at 3:20 AM, documents the following: Pt arrived back to facility via ambulance, with no new orders pt is calm and in bed will continue to monitor.R2's Progress Note, dated 8/7/26 at 7:54 AM, documents the following: Resident was up all night. He kept saying he was going to leave and kept going in resident's rooms being disruptive. Redirected all night by staff. NP (Nurse Practitioner) aware during rounds.R2's Progress Note, dated 8/10/26 at 10:45 PM, documents the following: Heard door alarm ringing at end of hall. Did a head count. Noted resident was missing from the floor. Staff went outside to look for resident. Resident was nowhere to be found in neighborhood. DON was called and informed of elopement.R2's Progress Note, dated 8/11/26 at 3:01 AM, documents the following: Arrived back to facility without incident per ambulance and two EMT. Resident was at the hospital for back pain, but he told them he did not have pain resident in bed at this time. No s/s acute distress noted.R2's Hospital Records, dated 8/10/26, document the following, in part: arrived 8/10 at 11:50 PM. Eloped from the locked unit, missing approx. 1-1/2 hours before being found by police at a fast-food restaurant sitting in the drive thru. C/O back pain sent to ER. A&O x4 at that time. Per V6, (nurse on duty at facility) who stated he had similar wandering behaviors previously approximately a week ago. On elopement precautions at the hospital.The Local Fire Department report, dated 8/10/26, documents the following, in part: called to fast-food restaurant sitting in the drive thru with the local police department who stated he left the facility around 9:00 PM and has been walking around town ever since. Called to the local fire department 8/1026 at 11:29 PM by the local police department.R2's Elopement Investigation, dated 8/10/26 at 8:15 PM, documents the following: Completed by V1, Administrator: Nursing description - Resident exited the 200 hall back door. Resident description: I was hungry and wanted to go get food. Immediate action taken: Staff did a complete head count in building, and two staff members went outside of the building to look for resident. No injuries at time of incident. There was no other information provided on the investigation.On 8/12/26 at 11:55AM, R2 was observed in the dining room and is alert to self and the year. When asked what month or date it was, he stated March but wasn't sure what day it was. When asked if he knew where he was, he stated he was in another town on the south side by the school. R2 stated he is allowed to go outside of the facility by himself, he went out yesterday. When asked where he went, R2 stated he went out. When asked if he went to a fast-food restaurant, he stated yes, two days ago. When asked how he crossed the busy streets and highway, he stated he just did. When asked if he told anyone before he left, he stated no. When asked why he left, he stated to get out for a while. When asked how he got back to the facility, he stated he walked. When asked if he told anyone he had returned, he stated no. On 8/12/26 at 3:26 PM, V9, Medical Director, stated R2 would not be safe to be out of the facility for a long period of time.On 8/13/26 at 7:40 AM, V6, LPN (Licensed Practical Nurse), stated on 8/10/26, she came into work at 7:00 PM, she got report and then went to the 100 hall to give meds. Around 8:30pm, she was coming through the double doors to the 200 hall when she heard the alarm sounding, the twoCNAs were trying to figure out where the alarm was coming from, and it was the 200-back door. V6 stated they did a head count and R2 was unable to be located. R6 stated they searched the rooms and hallway on the 200 hall and was unable to locate R2. They went outside looked around and couldn't find R2. V6 stated some of the staff including herself drove around to see if they could locate R2 but couldn't. V6 called V2, DON, and notified the police and gave them a description of R2. V6 stated she is unsure who found R2. V6 stated around midnight, activities told her R2 had been found at a fast-food restaurant. V6 stated R2 was not hurt but was sent to the hospital because he complained of back pain and then once he got there, he wasn't having the back pain anymore. V6 stated R2 returned to the facility 8/11/26 around 2:00 AM. V6 stated R2 had tried to elope about a week prior during smoke time, she was not at the facility when it happened but was told by the nurse. R6 stated she didn't know if R2 was at risk for elopement because there wasn't any information in his chart about that. V6 stated they were not doing anything to prevent an elopement with R2 prior to the elopement on 8/10/26. V6 stated when R2 returned to the facility on 8/11/26, they had a staff member at the double doors and the back door just through the night. V6 stated R2 maybe so, has a little safety awareness, he might think he does, but I wouldn't trust him out by himself.On 8/13/26 at 7:58 AM, V5, CNA, stated she worked the midnight shift on 8/11/26 and was working when R2 returned to the facility. V5 stated R2 was not hurt and they did 1:1 (One on One) monitoring with him the rest of the night. V5 stated R2 has tried to elope before and tried again yesterday (8/12/26) but they were able to redirect him. V5 stated they were not doing any extra monitoring, etc. with R2 prior to the elopement on 8/10/26, they would keep an eye on him and redirect him. V5 stated R2 is not safe to be out of the facility by himself, he is confused and is aggressive with others.On 8/13/26 at 10:38 AM, V1, Administrator, stated she started at the facility on 7/27/26. On the 27th R2 was being aggressive on that day and was sent to the hospital. V1 stated she was not aware R2 was exit seeking only that he had displayed aggressive behavior, which she did not witness. On 8/10/26 she was called by V2, DON, and told that R2 exited through the 200-hallway door. There is a camera on that hall but it had a screw that fell out so it wasn't showing the exit door so when she reviewed the camera footage, she saw two CNAs on the hall (V11, CNA & V12, CNA) but could not see the exit door. V1 stated to open the door, it has to be held for 15 seconds before it will open and the only question, she had was how did it happen, how did he get out, there were two CNAs on the hallway and the only thing I can come up with was the alarm to the double doors to enter the 200 hall was sounding at the same time the 200 hall exit door was sounding. V1 stated V11 was at the front of the hallway and V12 was in the middle of the hallway so she isn't sure how this could have happened. V1 stated the alarm to the double doors was reset but an alarm was still sounding and it was the 200 hall exit door alarm. V1 stated V11 and V12 were suspended pending the outcome of the investigation. V1 stated R2 had just been seen by the back door prior to the alarms going off. V1 stated R2 returned to the facility around 3:00 AM after being evaluated at the ER. V1 stated she was not aware of R2 being at risk for elopement or having a history of elopement because she was not working at the facility when he admitted . V1 stated they have changed the 200 hall exit door alarm so that it is much louder than the double door entrance onto the 200 hall. V1 stated prior to R2's elopement they would look at the social service notes and determine what they would need. V1 stated R2 was on the locked unit when the elopement occurred. V1 stated they would redirect R2, staff had voiced concerns that he was aggressive but not exit seeking. V1 stated she redid R2's BIMS (Brief Interview of Mental Status) and he is a score of 9 (indicates R2 has moderate cognitive impairment), he knows what he is doing and what is going on. V1 stated he doesn't know R2 well enough to say if he would be safe outside of the facility by himself. V1 stated even though R2 has Dementia, he is aware of his surroundings, is ambulatory, healthy. V1 stated after he eloped, she started reestablishing the systems, redoing BIM scores, redoing the elopement binder with pictures, updating the care plans, and in-servicing staff which is ongoing. V1 stated there is an elopement binder at each nurse's station and in the reception area. V1 stated they are auditing all new admissions and monitoring the doors. V1 stated V4, RN, has been doing more activities with R2 and they have added 4 nurses at night, V1 stated she talked to V7, R2's Family, and was told that R2 lived in another town with V7 and he would wander in the woods at night. V1 stated she doesn't know R2 well enough to determine if his cognition fluctuates or not.On 8/13/26 at 10:38 AM, V15, Regional Nurse Consultant, stated she received a call at 10:23 PM on 8/10/26 from the facility that R2 had been located at a fast-food restaurant. V15 stated R2 told her he was going to get a hamburger. V15 stated the intake team reviews referrals prior to admission by reviewing the hospital records, face sheet, medications, etc. and then that information is passed along to other facility staff. V15 stated R10, Prior SSD, reviewed the information and said he was having aggressive behaviors, but nothing was said about having a history of elopement. On 8/13/26 at 11:53 AM, V16, NP, stated she has only seen R2 once. During that visit he was able to read signs and follow instructions. V16 stated she is not sure if R2's cognition fluctuated or not. V16 stated if R2 can read the sign on how to exit the door, then he should be able to follow the signs and safety precautions to have made it to the fast-food restaurant, but he's in long term because he needs assistance. On 8/13/26 at 12:36 PM, V8, Psychiatric NP, stated she evaluated R2 on 7/27/26, during that he visit, R2 started out lucid was answering her questions and then it was like a switch flipped and he flipped out, wanted to know why I was asking him all those questions so I explained that I was making sure his psychiatric needs were being met and he denied having any problems. V8 stated R2 began kicking the door and trying to get out. When asked if he could be a danger to himself or others, she stated he could because of how instantly he changed. V8 stated there is a risk of serious injury or death to R2 and potentially others because he was lucid at first and then just flipped out. The Elopement Policy, with a review date of 2/2026, documents elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. All residents will be assessed for elopement risk upon admission, with significant change in condition, quarterly, and as needed. Residents who are at risk of elopement are closely supervised to keep them safe in their environment, while allowing them to move freely about the safe environment. Any resident identified at risk to elope upon admission will have the elopement risk identified and included in the plan of care. The Past Non-Compliance and immediate jeopardy began on 8/10/26 when R2 eloped from the facility and traveled approximately 3 miles on a busy 4 lane highway. R2 was found by the police on 8/10/26 at approximately 10:23 PM sitting on the ground in the drive thru at a fast-food restaurant. The surveyor confirmed by observation, interview, and record review the immediate jeopardy was removed on 8/14/26 with a past non-compliance completion date of 8/11/26 when the facility completed the following: Identification of Residents Affected or Likely to be Affected:R2 resides at the facility as a LTC (Long Term Care) resident as on 7-25-2026 with the following Dx (Diagnosis): Generalized Anxiety Disorder, Alzheimer's Disease, Anxiety Disorder, Dementia, HTN (Hypertension), Restlessness and Agitation with Violent BehaviorR2 was reassessed and a new elopement assessment was completed on 8-11-26R2 remains in the secured unit. The secured unit staff are encouraging residents to remain busy with activities. R-2 in activities such as [NAME] volleyball, basketball, Arts and craft, coloring and uno cards started on 8-11-26Whole house elopement assessment was performed on all residents in the facility and completed by V1, Administrator and V2, DON (Director of Nurses) on 8-11-26There is scheduled a nurse to cover the secured unit per shift which started on 8-11-26 and this is ongoingAdministrator/Designees provided in-service on Elopement and Supervision, Identifying Residents that Wander and Exit Seekers, Alarm Codes to all staff and agency staff on 8-10-26. In-service is ongoing, and all staff and agency staff who are not present on 8-10-26 will be in-serviced prior to the start of their next scheduled shift.V29, Maintenance Director inspected all facility door alarms and confirmed they were functioning appropriately on 8-10-26A second Alarm was installed on the 200 Hall secured Unit East Door on 8-11-26All residents were reassessed by the IDT (Interdisciplinary Team) Team using the Elopement Risk Assessment Tool completed 8-11-26.All residents identified as High Risk for elopements have had their care plans reviewed by the MDS (Minimum Data Set)/ Designee for resident specific interventions and completed on 8-11-26The elopement binder was reviewed by V15, Regional Nurse Consultant, to ensure those residents at risk for elopement, have a face sheet and picture in the binder. This was completed on 8-11-26Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring.(Completion Date: 8-11-26)The DON/Designee will in-service staff and agency on facility elopement policy, on Elopement and Supervision, Identifying Residents that Wander and Exit Seekers, Alarm Codes to all staff and agency on 8-10-26. The in-service is ongoing and all staff and agency who are not present on 8-10-26 will be in-serviced prior to the start of their next scheduled shift. The MDS/DON/Designee will review all new admissions within 24 hours after admission for elopement risk 3 days a week for 4 weeks, any residents who trigger as high risk will be place in the elopement binder along with care plan with resident specific interventions.The DON/MDS/designee will review all elopements at the daily stand-up meeting with IDT for three months to ensure appropriate elopement interventions are implemented, the resident's care plan has been reviewed and revised, and the individualized service planQAPI (Quality Assurance & Performance Improvement) meeting was held on 8-11-26 with IDT and MD (Medical Doctor).A QAPI has been initiated to report on the above monitoring and auditing procedures. All findings from the QA (Quality Assurance) Committee will be presented at the monthly QA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Date of Compliance- 8-11-26

Based on observation, interview, and record review, the facility failed to keep a resident's private areas from being exposed for others to see in 1 of 3 residents (R5), when reviewed for resident rights in the sample of 9. Using a reasonable person approach, this failure, verified through interviews regarding R5, who is confused, would cause humiliation, and shame. Findings Include:On 8/12/26 at 7:25 AM, R5 was observed in her room on her mattress on the floor with her gown off, completely exposed with the door open, R5's catheter was on the floor, and she was yelling out help me. R5 is alert to self only. R5's Face Sheet, undated, documents R5 has the following diagnoses: Cerebral Infarction, Tranischemic Attack, Speech & Language Deficits following a Cerebral Infarction, Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Difficulty in Walking, Need for Assistance with Personal Care, Malignant Neoplasm, Lack of Coordination, Repeated Falls, Neuromuscular Dysfunction of the Bladder, Poliomyelitis, Anxiety Disorder, Heart Disease, Hypertension, Neuropathy, Osteoarthritis, and Obstructive Sleep Apnea. R5's Minimum Data Set, dated [DATE], documents R5 has a BIMS (Brief Interview of Mental Status) score of 12, indicating R5 has moderate cognitive impairment and is dependent with toileting and transfers. R5's Care Plan, dated 5/8/, documents R5 requires assist with daily care needs. On 8/12/26 at 7:25 AM, V13, CNA (Certified Nursing Assistant) when notified of R5, stated we know it, she keeps doing it but how many times are we going to have to pick her up? On 8/13/26 at 7:55 AM, V14, CNA/LPN (Licensed Practical Nurse), stated R5 has been confused, getting in and out of bed, they had a trapeze over her bed that she would use to move herself in bed, they had to take that out of her room because R5 thought she could walk and was using it to get out of bed. V14 stated she has been yelling out, taking her clothes off, crawling off of the mattress that is now on the floor out into the hallway. V14 stated she has been like this for 3 weeks since she returned from the hospital and is now on hospice. On 8/13/26 at 9:40 AM, V1, Administrator, stated V13 is a new hire, and they are implementing new interventions for R5. On 8/14/26 at 10:11 AM, V34, R5's Friend, stated if R5 was alert and her old self, she would have been mortified that her private areas were exposed with the door open for others to see. V34 stated R5 has declined, is confused and she should have never been left exposed for others to see. On 8/14/26 at 2:35 PM, V9, Medical Director, stated he would work with the facility to correct the concern. The Resident Rights Policy, with a review date of 10/2025, documents the objective is to create an individualized home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences.

Based on interview, observation, and record review the facility failed to provide daily dressing changes as ordered and to ensure they are following physician's orders for outside physician's appointments for 2 (R51 and R28) of 2 residents reviewed for quality of care in a sample of 46.Findings Include: 1. R28's Undated Face Sheet, documents he was initially admitted to the facility on [DATE]. R28's Quarterly Minimum Data Set (MDS) dated [DATE] documents R28 is cognitively intact. R28's Physician's Order Sheet (POS), dated 6/5/2026 documents a new physician's order need to see ENT (ear, nose and throat) specialist for ear and swallowing discomfort. R28's Acute Care Note, dated 6/13/2026 documents patient has had left ear pain since before entrance into the facility. The patient has not had it previously evaluated. The clinician was unable to visualize the ear canal or tympanic membrane with a light. ENT referral still waiting appointment. On 7/7/2026 at 10:45 AM R28 was observed sitting on his bed in his room and wrote a note to the surveyor stating he hasn't been assessed by an ENT physician due to ear and throat pain and he was very frustrated about not having the ENT appointment scheduled yet. On 7/9/2026 at 10:55 AM V43, Transportation Aide looked at her transportation calendar and stated she didn't have R28 down for an ENT appointment. V43 stated she receives paperwork from nursing staff when there is an appointment that needs to be made and she calls the physician's office and makes the appointments. V43 wasn't aware R28 has a physician's order dated 6/5/2026 for an ENT appointment. On 7/10/2026 at 11:10 AM V7, Licensed Practical Nurse (LPN) stated the transportation aide is responsible for setting up outside appointments and she wasn't aware of any appointments not being scheduled. V7 stated she wasn't aware R28 had a POS order for an ENT appointment. On 7/10/2026 at 10:47 AM V29, Regional Nurse Consultant stated the facility does not have a policy on timely scheduling appointment. 2. R51's Undated Face Sheet documents R51 was admitted to the facility on [DATE] and has a medical diagnosis of Type 2 Diabetes Mellitus, Heart Failure, Difficulty in Walking, Hypertension, Chronic Diastolic (Congestive) Heart Failure, and End Stage Renal Disease. R51's Minimum Data Set, dated [DATE] documents R51 is cognitively intact. R51's Care Plan Date Initiated 9/26/23 documents Skin: R51 is at risk for skin complications related to (r/t) diagnosis (dx) of Diabetes Mellitus (DM), anemia, and End Stage Renal Disease (ESRD). R51's Physician Order dated 7/1/26 at 2:42 PM documents Bacitracin External Ointment 500 UNIT/GM (Bacitracin (Topical) Apply to top of right foot topically one time a day for rash/irritation Apply ointment and cover with bordered gauze. R51's July Treatment Administration Record dated 7/1/26-7/31/26 documents R51's order for Bacitracin External Ointment and dressing was completed on 7/5/26, 7/6/26, and 7/7/26 at 9:00 AM. R51's Follow Up Note dated 7/2/26 at 6:56 PM documents patient has wound on top of right foot in the form of scabbed scratches. The patient is unsure about the current appearance of the wound and reports it as irritating. If needed, antibiotic ointment will be ordered to apply and keep the wound covered. He denies any fever or hills or worsening symptoms. On 7/07/2026 at 11:18 AM R51 stated he has a wound on his right foot and the facility is not changing his dressing daily or checking on it daily. R51 stated the wound started as a spot that he had scratched and it flamed up after that. R51 stated he was seen by the facility Nurse Practitioner, and they ordered a dressing change to be done daily. R51 stated his bandage was changed over the weekend and prior to that it had been a week and a half since it was changed. R51 stated he is concerned that the facility is not cleaning and doing a dressing change daily to his foot because he is diabetic and does not want the wound to get worse. On 7/7/26 at 11:22 AM R51 took shoe off and showed this surveyor the bandage to his right foot. Bandage to right foot was dated 7/4. On 7/9/26 at 11:13 AM V4, Licensed Practical Nurse (LPN), and V8, LPN, stated R51 is an in house daily dressing change and staff are to change R51's dressing. On 7/9/26 at 12:17 PM V1, Administrator, stated she expects staff to follow physician orders and completed dressing changes as ordered. The Facility's Undated Wound and Pressure Injury Management and Treatment Document documents The dressing may be changed daily or may remain in longer based on the drainage and the provider order. The dressing should be checked every shift and changed as needed for soiling or drainage.

Based on observation, interview and record review, the facility failed to obtain physician orders to provide tracheostomy care and suctioning for three of five residents (R5, R6, and R9) reviewed for tracheostomy care in the sample of 17.Findings include: 1. On 6/22/26 at 10:35 AM R5 was walking in the hall with no tracheostomy (trach) appliance in place in R5's trach stoma. R5 used a paper and pen to communicate and wrote that staff do not take care of R5's tracheostomy and R5 is responsible for R5's own care. R5 wrote that R5 performs R5's tracheostomy care two or three times a day. R5 was visibly drooling and coughing up thin secretions while R5's tracheostomy was out. R5 pulled a tracheostomy cannula out of R5's pocket that had a pen inserted through it's opening. R5 stated the facility does not give R5 any supplies to take care of R5's tracheostomy, and R5 thought the hospital was supposed to send R5 supplies.On 6/22/26 at 3:10 PM R5 demonstrated how R5 performs R5's own tracheostomy care in R5's room. R5 took a torn cloth scrap out of R5's top dresser drawer, got the cloth wet in R5's sink and used a bar of soap to form a lather on the cloth. R5 wiped R5's mouth with this cloth, then rinsed the cloth in R5's sink, squeezed the excess water out of the cloth, and then pulled R5's tracheostomy cannula out of R5's pocket. R5 sat on R5's bed and wiped the outside of the cannula with the cloth, then sat the cannula on the bed, with no barrier between the bed and the cannula. R5 started rummaging through a box of miscellaneous tracheostomy supplies and pulled out a package containing a pipe cleaner which R5 used to clean the inner cannula. R5 sat the cannula directly on R5's bed again. R5 then picked up the cannula and inserted it into R5's stoma in R5's neck. R5 did not wash R5's hands or wear gloves during R5's tracheostomy care and did not clean around R5's stoma at all during R5's self-care. V10, Assistant Director of Nursing (ADON) was present during R5's self-care of R5's tracheostomy and did not offer any cues or instructions during the procedure.On 6/22/26 at 3:45 PM V10 stated R5 did not perform adequate tracheostomy care. V10 stated staff are supposed to be educating and monitoring R5 during R5's self-care of R5's tracheostomy. V10 confirmed that there were no orders for the care and treatment of R5's tracheostomy before 6/22/26. V10 stated R5 should have been care planned regarding R5's tracheostomy and the need for education regarding infection control.R5's Face Sheet dated 6/26/26 documents R5's diagnoses including Malignant Neoplasm of Oropharynx, Other Diseases of the Larynx and Pharynx, Acute and Chronic Respiratory Failure with Hypercapnia, and Acquired Absence of the Larynx. This Face Sheet documents R5 was admitted to the facility on [DATE].R5's Medication Review Report dated 6/26/26 documents R5 had no physician orders for tracheostomy care from the time R5 was admitted on [DATE] until it was brought to the facility's attention on 6/22/26 The new order dated 6/22/26 documents, Change suction cannister and tubing weekly and prn (as needed). Change trach inner cannula every HS (bedtime) for monitoring.R5's Minimum Data Set (MDS) dated [DATE] documents R5 is alert and oriented to person, time, place and situation with a brief interview for mental status score (BIMS) of 15. This MDS does not document the presence of R5's tracheostomy or the need for suctioning.R5's Care Plan dated 5/15/26 documents: Skin (R5) has throat opening related to previous surgical opening from previous tracheostomy from Malignant Neoplasm of Oropharynx. Interventions for this care plan include, educate resident on the risk of infection and poor healing related to non-compliance, monitor closely for sensory impairment, notify medical doctor of abnormal findings, observe and assess regularly, and skin assessment weekly. R5's care plan did not address R5's laryngostomy or the need for education and monitoring of R5's laryngostomy care and management of secretions. There is no care plan addressing education of R5 on proper technique and infection control management while performing self-care.R5's progress note by V34, Advanced Practice Nurse, dated 6/13/26 at 3:22 PM documents, Z93.0 Tracheostomy Status, Non-adherence to [NAME] tube (a tube used to keep the stoma open during healing and supports the airway) use has contributed to stoma narrowing, irritation, and minor bleeding, with education provided and wound nurse involvement for reinforcement and monitoring. Laryngostomy site appears intact with no signs of acute infection, but the patient has copius nasal and oral secretions and frequently refuses routine laryngostomy site care, resulting in poor hygiene and secretions left on skin and clothing. Patient intermittently performs self care of the [NAME] tube and refuse nurse assistance as observed on 4/22/26. Monitor for signs of stoma narrowing, bleeding, drainage, erythema, swelling or infection and document refusals of care. Continue to offer laryngostomy site care per protocol and encourage basic hygiene and secretion management as tolerated. Readdress education periodically and reassess willingness to accept care with consideration of ENT (Ear Nose and Throat) referral if progressive narrowing or recurrent trauma persists. 2. On 6/22/26 at 1:56 PM V3, Licensed Practical Nurse (LPN) was preparing to suction R6 but was having difficulty connecting the suction tube to the collection cannister. V10 ADON entered the room to assist V3 to get the suction hooked up. V3 stated the suction machine in R6's room was not working correctly. V10 removed V10's gloves and left the room without performing hand hygiene. V10 returned to R6's room, donned gloves without performing hand hygiene, and proceeded to attach suction tubing to suction cannister and turned the machine on and confirmed it was working. V3 loosened R6's trach tie to expose trach opening with V3's right gloved hand and with the same hand V3 then place the tip of the suction catheter into R6's trach cannula. V3 was not wearing a gown or mask. V3 then suctioned R6's trach.On 6/22/26 at 2:26 PM V3 stated V3 usually suctions R6's trach twice a day, once in the morning and once around midday. V3 stated R6 does not have specific orders for suctioning R6's trach or for trach care itself. V3 stated R6 should have specific orders for trach care. V3 stated V3 did find a discontinued order dated 4/14/26 for R6's trach to be suctioned but stated R6 should have a current order.R6's Face Sheet dated 6/26/26 documents R6's diagnoses as Chronic Respiratory Failure, unspecified whether with Hypoxia or Hypercapnia, Unspecified Dementia, and Tracheostomy Status.R6's Medication Review Report dated 6/26/26 did not document any orders for providing trach care or suctioning until 6/22/26 when it was brought to the facility's attention that R6 did not have orders for trach care or suctioning.R6's MDS dated [DATE] documents R6 is alert and oriented to person, place, time and situation and documents R6 receives both suctioning and tracheostomy care.R6's Care Plan dated 6/5/25 documents, Trach: (R6) at risk for complications related to tracheostomy placement. This care plan does not include any interventions for performing actual trach care or suctioning.3. R9's Face Sheet dated 6/25/26 documents R9 was admitted to the facility on [DATE] and was discharged to the hospital on 4/30/26 and R9 did not return to the facility. The Face Sheet documents R9 had the diagnosis of Respiratory Failure, unspecified whether with Hypoxia or Hypercapnia.R9's Clinical Physician Orders dated 6/25/26 do not document any orders for trach care or suctioning.R9's MDS dated [DATE] document R9 is severely cognitively impaired. This MDS documents R9 did receive tracheostomy care, but did not receive suctioning while R9 was a resident.R9's Care Plan dated 4/2/26 documents, Trach: at risk for complications related to tracheostomy placement. The interventions for this care plan do not include performing trach care or suctioning.The facility's Tracheostomy Care Policy, with a reviewed date of 10/2024 documents, Purpose: To provide guidelines for maintaining an unobstructed airway and preventing infection in residents with a tracheostomy. Policy: It is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway, that aseptic technique is used during dressing changes until the tracheostomy is healed, and a physician order is obtained for tracheostomy care. Procedure: Verify physician order.

Based on observation, interview, and record review, the facility failed to prevent potential cross contamination by failing to wear appropriate Personal Protective Equipment (PPE) to maintain enhanced barrier precautions and failing to perform appropriate hand hygiene and glove changes during care for three of three residents (R5, R6 and R7) reviewed for infection control in the sample list of 17.Findings include:1. On 6/22/26 at 10:35 AM R5 was walking in the hall with no tracheostomy appliance in place in R5's trach (tracheostomy) stoma. R5 was visibly drooling and coughing up thin secretions while R5's tracheostomy was out. R5 pulled a tracheostomy cannula out of R5's pocket that had a pen inserted through its opening. On 6/22/26 at 3:10 PM R5 demonstrated how R5 performs R5's own tracheostomy care in R5's room. R5 took a torn cloth scrap out of R5's top dresser drawer, got the cloth wet in R5's sink and used a bar of soap to form a lather on the cloth. R5 wiped R5's mouth with this cloth, then rinsed the cloth in R5's sink, squeezed the excess water out of the cloth, and then pulled R5's tracheostomy cannula out of R5's pocket. R5 sat on R5's bed and wiped the outside of the cannula with the cloth, then sat the cannula on the bed, with no barrier between the bed and the cannula. R5 started rummaging through a box of miscellaneous tracheostomy supplies and pulled out a package containing a pipe cleaner which R5 used to clean the inner cannula. R5 sat the cannula directly on R5's bed again. R5 then picked up the cannula and inserted it into R5's stoma in R5's neck. R5 did not wash R5's hands or wear gloves during R5's tracheostomy care and did not clean around R5's stoma at all during R5's self-care. V10, Assistant Director of Nursing (ADON) was present during R5's self-care of R5's tracheostomy and did not offer any cues or instructions during the procedure to educate R5 on good hygiene and infection control measures. V10 did not provide a barrier or gloves for R5 to use during care. There was no sign on R5's door indicating Enhanced Barrier Precautions should be maintained by staff while trach care is being performed.2. On 6/22/2026 at 1:56 PM, V3 LPN was setting up suction in R6's room. V3 was wearing gloves and was having difficulty connecting the tubing to the canister. V3 left the room and returned with V10. V3 and V10 both donned gloves and attempted to set up the suction machine. V3 and V10 began looking through drawers, moving R6's high backed wheelchair, and looking through a cardboard box of supplies in R6's closet. V3 and V10 continued to look through supplies while wearing gloves. V3 opened sterile packaging with the same gloved hands, removed a suction catheter with V3's gloved hand and set the suction catheter on the bedside table. V3 stated the suction machine was not working correctly and removed V3's gloves and left the room, without performing hand hygiene.V3 continued to look through supplies, reorganize items on dresser and bedside table. V3 picked up the suction catheter and touched the end of the catheter with gloved hands and then put it back in its paper sleeve. V3 had not changed V3's gloves or performed hand hygiene since entering R6's room. R6 began coughing up thick secretions and V3 opened R6's bathroom door with a gloved hand, entered the bathroom and then returned to the room with brown paper towels. V3 wiped thick secretions from R6's mouth and threw away the paper towels. V3 continued to move/touch various items on R6's dresser, bedside table and returned the cardboard box to closet, still wearing the same gloves. V3 stated V3 could do oral care while waiting on a different suction machine. V3 retrieved packaged premoistened oral swabs from R6's drawer and opened packaging with the same gloved hands. V3 then provided oral care. A large amount of yellow thick secretions noted to be attached to oral swab as V3 pulled oral swab out of R6's mouth and V3 used gloved index finger to pull string of mucus from R6's mouth. V3 wiped R6's mouth with brown paper towels and V3 discarded oral care items into R6's trash can. V3 did not change gloves or perform hand hygiene before or after performing R6's oral care. While waiting for V10 to return, V3 used the same gloved hands to touch R6's feeding pump and touched the bag of water on R6's feeding pump. V3 then discarded V3's soiled gloves and donned new gloves without performing hand hygiene. V3 continued to touch items on R6's bed side table. V10 returned to R6's room and donned gloves without performing hand hygiene. V10 attached tubing to suction canister and turned the machine on, then attached the suction catheter to the cannister and confirmed it was working. V10 then removed V10's gloves and left the room without performing hand hygiene. V3 loosened R6's trach tie to expose R6's trach opening with V3's right gloved hand, and with V3's same hand placed the catheter tip into the trach cannula opening. V3 was not wearing a mask or gown at this time. V3 removed the catheter and placed the tip of catheter into cup of clear liquid and cleared the catheter of yellow drainage. V3, with the same gloved hand, disconnected the catheter tubing and set the tubing directly on the bedside table. V3 then attached an oral suction tube to the suction machine and told R6, I'm going to suction your mouth now. R6 opened R6's mouth and V3 placed the tip inside R6's mouth and R6 closed mouth around the suction tube. V3 then turned off the suction machine and began looking through R6's drawers, touching items inside with the same gloved hands. V3 grabbed tissues and wiped R6's mouth after R6 had a coughing a fit. V3 then used tissues to dab at R6's tracheostomy where bubbled thick secretions were observed. V3 discarded the tissues and got new tissues and wiped the opening of R6's tracheostomy cannula. V3 then removed the soiled gauze from around R6's tracheostomy and placed clean dry gauze around tracheostomy. With the same gloved hands V3 repositioned R6 for comfort and adjusted R6's gown. V3 then pressed buttons on R6's feeding pump and then assessed the g-tube's (gastrostomy tube) connection site wearing the same gloves. V3 collected dirty supplies and left room without removing gloves and performing hand hygiene. V3 stated V3 was going to find the soiled utility room. V3 returned to the nurse's station and washed V3's hands in nursing station sink. A sign on the R6's doorframe documents Enhanced Barrier Precautions with guidelines listed of appropriate personal protective equipment to use. 3. On 6/25/26 at 10:56 AM, V14 LPN entered R7's room to perform trach care for R7. V14 donned a gown, mask, and gloves without first performing hand hygiene. Trach supplies were on R7's bedside table on the left side of room (R7's right side). V14 removed gloves and performed hand hygiene at R7's sink. V14 donned new gloves and used V14's right gloved hand to turn the crank at the foot of R7's bed. V14 repositioned R7's pillows with gloved hands, rearranged the trach supplies with gloved hands, and opened a new biohazard bag with the same gloved hands. V14 opened the sterile trach kit and then removed V14's gloves. V14 did not perform hand hygiene after removing V14's gloves. V14 opened a packet of sterile gloves and donned them. V14 picked up clean gauze with the right hand, folded the gauze and dipped the gauze into saline solution with the dirty gloved hand. V14 removed the soiled trach tie on R7's left side of R7's neck, and with V14's same soiled gloves, V14 applied a new trach tie to R7's left side. V14 inserted a trach tie into right side of the trach and moved R7's hair with V14's gloved hand to adjust R7's trach collar. V14 did not change V14's gloves after touching R7's hair. V14 proceeded with applying a clean dry trach gauze under R7's trach cannula and secured the trach ties. V14 used a cotton tipped applicator to wipe around the outer cannula. V14 adjusted R7's gown and removed V14's gloves with no hand hygiene. V14 opened another sterile trach kit with no gloves and donned sterile gloves from the kit. V14 carried the sterile kit in both hands and moved to left side of R7. V14 placed a sterile barrier on R7's bedside chest of drawers and placed the trach kit onto the sterile barrier. V14 opened a packaged suction catheter with sterile gloved hands and then removed V14's gloves but did not perform hand hygiene before V14 donned new sterile gloves and used the back of V14's left hand to open the top drawer of R7's chest of drawers. V14 inserted the tip and of the catheter into the cannula's opening and provided intermittent suctioning to R7's tracheostomy. V14 progressed catheter approximately four inches, removed and advised R7 to take some breaths. V14 inserted the tip and of the catheter into the cannula's opening and provided intermittent suctioning to R7's tracheostomy. V14 removed gloves and threw away gloves and catheter but did not perform hand hygiene. V14 donned new gloves and opened a trach oxygen mask and placed the mask on R7's trach. V14 then gathered trash and removed V14's gloves and threw everything away in a trash bag. V14 then knotted the trash bag and left the room without performing hand hygiene. V14 walked down the hall and disposed the trash into the soiled linen trash bin. V14 left the soiled utility room and washed V14's hands at the nurse's station sink.On 6/22/26 at 2:26 PM, V3 stated that enhanced barrier precautions are regular contact precautions, they require standard PPE on everyone with a g-tube or a trach. V3 stated that infection control is maintained by washing hands and changing gloves out when they become soiled.On 6/22/26 at 3:45 PM, V10 stated that enhanced barrier precautions are to be followed for all residents who are at risk of infection, such as residents with g-tube and trachs. V10 stated that staff are to perform hand hygiene after touching anything and going in and out of rooms.On 6/25/26 at 10:58 AM, V14 stated that infection control is maintained by keeping clean and dirty separate and using a biohazard bag for dirty items. And by switching out gloves and performing hand hygiene before and after and if needed during care.The facility's Tracheostomy Care Policy, with a reviewed date of 10/2024 documents, Purpose: To provide guidelines for maintaining an unobstructed airway and preventing infection in residents with a tracheostomy. Policy: It is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway, that aseptic technique is used during dressing changes until the tracheostomy is healed, and a physician order is obtained for tracheostomy care. Procedure: III. Tracheostomy Care a. wash hands b. gather equipment and apply sterile gloves; maintain sterility of dominate hand.The facility's Standard Precautions policy with a reviewed date of 9/2025, documents, GUIDELINE: Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care. PROCEDURE: 1. Hand Hygiene should be performed: a. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. b. When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash hands with soap and water.

Based on interview, observation and record review the facility failed to treat residents with dignity and respect for 3 of 4 residents; (R6, R7 and R8); reviewed for Resident Rights in a sample of 14. This failure caused R6 to have feelings of being unworthy of care and shamed and feeling worse about herself. This failure caused R7 to feel worse about himself and like he is a bother to staff. This failure caused R8 to feel insignificant.Findings include:1.R6's Facesheet with a print date of 6/18/26 documented she was admitted to the facility on [DATE] with diagnoses of, in part, rheumatoid arthritis, major depressive disorder, chronic pain and anxiety disorder.R6's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact and requires substantial/maximal assistance with toileting hygiene and partial/moderate assistance with chair to bed transfer.R6's Care Plan dated 12/16/24 documented she requires assistance with daily care needs.On 6/16/26 at 3:03 PM, V17 (CNA/Certified Nursing Assistant) stated to R6, you shouldn't be getting changed every day at shift change. V17 stated to R6, you can't be doing this all the time, this is ridiculous. V17 went with R6 into her room.On 6/17/26 at 8:53 AM, R6 was wheeling across the dining room crying. V11 asked R6 what was wrong. R6 stated to V11 she was told she was late and couldn't have breakfast. V11 stated to R6 No we will get you something, at least a bowl of cereal, they just need to clean a bowl for you. R6 went to a table and waited. At 8:57 AM, R6 was given a bowl of cereal.On 6/17/26 at 10:45 AM, R6 stated she feels like she is not getting the care she needs. R6 stated V6 (CNA) told her she wouldn't change her because she would need to wait until after lunch. R6 stated it makes her feel unworthy of care and shamed. R6 stated she wants to transfer to another facility where it might have nicer staff. R6 stated she feels like she can't ask for help, but she requires it because she needs a full body mechanical lift to be transferred right now. R6 stated earlier today staff were late getting me dressed and up out of bed for breakfast so by the time she got to the dining room breakfast was already done and that's not her fault. R6 stated a girl from the kitchen staff with red and black hair told her she couldn't eat breakfast because she was late. R6 stated she started crying after that because she was hungry and upset. R6 stated she's asked to get cleaned up multiple times which she can't control and has to urinate a lot because of the water pill she takes and some of the staff don't like she takes it. R6 stated they make her feel worse about herself.2.R7's Facesheet with a print date of 6/18/26 documented he was admitted to the facility on [DATE] with diagnosis of, in part, shortness of breath, localized edema, and pulmonary embolism without acute cor pulmonale.R7's MDS dated [DATE] documented he was cognitively intact and required partial/moderate assistance from staff for toileting hygiene and chair to bed or toilet transfers.R7's Care Plan dated 9/10/25 documented he requires assistance with daily care.On 6/17/26 at 12:44 PM, R7 stated he'll ask for help from the staff, and they will tell him to wait, that they are too busy at the time and will have to help him later. R7 stated the way the staff treat him makes him feel worse about himself and like he is a bother to them.3.R8's Facesheet with a print date of 6/18/26 documented she was admitted to the facility on [DATE] with diagnoses of, in part, chronic obstructive pulmonary disease, type two diabetes mellitus, depression, and acquired absence of right leg below the knee.R8's MDS dated [DATE] documented she was cognitively intact and required partial/moderate assistance from staff for toileting hygiene and chair to bed or toilet transfers.R8's Care Plan dated 10/23/24 documented she requires assistance with daily needs and for staff to assist with her activities of daily living.On 6/17/26 at 1:55 PM, R8 stated currently waiting to be cleaned up right now because she is soiled. R8 stated she told V10 (CNA) she was wet sometime around 1 o'clock today and his response to her was that she had to wait until he was done passing meal trays. R8 stated she is currently still sitting soaked, and it is very uncomfortable. R8 stated when she tells them they are being too rough (during care) they act like she is being a baby and tell her Oh, you're fine. R8 stated it makes her feel insignificant. R8 stated she's been told to help herself and wear pull ups instead of briefs to do things by herself, but she urinates too much for a pull up to hold. R8 pressed her call light at 1:57 PM, and at 2:01 PM, V14 responded and told her she would clean her up. At 2:04 PM, V14 (CNA) provided incontinent care for R8.On 6/18/2026 at 1:19 PM, R8 asked for assistance. V10 (CNA) stated that I'm busy passing trays. V10 did not provide R8 with any assistance.On 6/18/26 at 3:07 PM, V2 (Director of Nursing/DON) stated Some of these new people I wouldn't want taking care of me. I have high expectations. V2 stated if a resident is in need of assistance or requests help, staff should help them right away and not told to wait especially if not helping another resident at the time. V2 stated all residents should be treated with dignity and respect.On 6/18/26 at 3:30 PM, V29 (CNA) stated when a resident requests help or care, she would help them immediately or as soon as possible; all residents deserve to be treated with dignity and respect.On 6/20/26 at 12:44 PM, V26 (Medical Director) stated if a resident requests or needs assistance his expectation from staff is to respond and triage them appropriately. V26 stated it would be a case-by-case basis for what the staff response would cause a resident to feel. V26 stated all residents deserve to be treated with dignity and respect.The facility's Resident Rights policy last reviewed on 10/2025 documented the objective of the accommodation of the resident needs and preferences is to create an individualized, homelike environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences.

Based on interview and record review the facility failed to provide pain management for 1 of 5 (R5) residents reviewed for medication administration in a sample of 15. This failure resulted in R5 experiencing excruciating and unbearable pain.Findings include:R5's Care Plan, dated 10/09/2023, documents PAIN: Resident has potential for an alteration in comfort r/t (related to) osteomyelitis and spina bifida.R5's, Minimum Data Set, dated [DATE], documents that R5 was cognitively intact and experiences pain almost daily. R5's Physician Order Sheet documents 4/8/2026 Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours for Pain. R5's Oxycodone HCl Oral Tablet 10 MG Medication Monitoring Control Record, dated 4/16/2026, documents last administered 5/1/2026 at 11AM. R5's Medication Monitoring Control Record, dated 4/29/2026, documents first dose administered 5/2/2026 at 6AM. R5's Medication Monitoring Control Record, dated 5/15/2026, documents no dose administered 5/18/26 at 12AM. Last dose administered 6/6/2026 at 12pm. R5's Medication Monitoring Control Record, dated 6/6/2026, documents first dose administered 6/7/2026 at 12 AM.On 6/15/2026 at approximately 2:15 PM R5 stated that there are times that the facility is late with his medication and sometimes it is not available at all. R5 stated that he has pain as high as 11 on pain scale 1-10. R5 stated that the pain is horrible, and it affects his day-to-day life. R5 stated that when he does not receive his pain medication his pain exceeds his normal level. R5 stated that it's unbearable.On 6/18/2026 at 3:07 PM V2, Director of Nurses, stated that pain is what the person says it is. If a resident says that they are experiencing pain, then they are. V2 stated that if the resident did not receive his pain medication timely or at all their pain would increase. V2 stated that R5 is alert and oriented and able to make own decisions. V2 stated that she has had some problems with the nursing staff administering the medication late and sometimes not at all. V2 stated that if the medications was not documented and a blank is in the MAR then the medication was not given. V2 stated that the facility has a locked pharmacy system. V2 stated that she has a lot of agency staff and they are not given a code for the system. V2 stated that this can delay medication administration and contribute to missed medication.On 6/20/26 at 12:44 PM, V26 (Medical Director) stated that if pain medication is not available and resident is in severe pain of 7 or higher, it would be a reasonable expectation their pain would increase.The facility's Medication Administration policy, dated 10/2025, documents that All medications are administered safely, and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: 6. Check medication administration record prior to administering medication for right medication, dose, route, patient/resident, and time. 13. Verify that the medication is being administered at the proper time, in prescribed dose, and by correct route. 18. Document as each medication is prepared on the MAR. 26. If medication is ordered but not present, check to see if it was misplaced then call pharmacy to obtain the medication. If available obtain from contingency or convenience box.The Pain Management policy, dated 10/2025, documents that GENERAL: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our resident's the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. GUIDELINE: The pain management program is based on a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does

Based on record review, and interview, facility failed to ensure a nurse was appointed as charge nurse each shift and sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. This failure has the potential to affect all 82 residents in the facility. Findings include: The daily census provided on 6/15/2026 documents, dated 6/14/2026, documents 82 residents in the facility. The facility's Daily Staffing Sheet dated June 13, 2026, with a census of 77. It documents V15, Licensed Practical Nurse (LPN), V8, LPN, V22, LPN, and V9, Registered Nurse (RN), scheduled for 7:00 AM to 7:00 PM. V8 scheduled for 7:00 PM to 7:00 AM. The facility's Daily Staffing Sheet dated June 14, 2026, documents V8 scheduled for 7:00 AM to 7:00 PM. No other nurses scheduled for day shift. On 6/15/2026 at 2:15 PM R5 stated that last weekend there was no nurse. R5 stated that this happens a lot. R5 stated that he did not get his medication on time. R5 stated that he has to wait until a nurse comes in and sometimes its hours after the medication due. R5 stated that there was no nurse. No one.On 6/16/2026 at 4:28 PM R11 stated that this weekend there was no nurse for the hall.On 6/16/2026 at 9:13 AM R3, stated that there are no nurses. R3 stated that they don't show up and the others leave. R3 stated that this happens all the time. R3 stated that medication is not given on time or not at all.R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intactOn 6/17/2026 at 8:27 AM V18, CNA, stated that there were no nurses in the facility. V18 stated that shift change is at 7PM. V18 stated that the residents were asking for medication. V18 stated that sometimes the nurses are late. V18 stated that then around 9 PM there still wasn't a nurse. V18 stated that multiple attempts were made to contact management without success. V18 stated that finally around midnight a nurse showed up.On 6/17/2026 at 11:10 AM V8, LPN, stated that she was only scheduled for 6/13/2026 day shift and did not work in the evening. V8 stated that she is not sure why V8's name is on the evening because she did not work that shift and does not work evening shifts.On 6/17/2026 at approximately 1:13 PM V22, LPN, stated that not all scheduled nurses showed up for shift. On 6/17/2026 at 6:50 PM V9, RN, stated that they did have some problems with staffing over the weekend. V9 stated that calls were placed to management due to no relief. V9 stated that there was a nurse that came in and she was able to leave.On 6/17/2026 at 11:05 AM V2, Director of Nursing, stated that they are to run with 4 nurses. V2 stated that this past weekend there was an issue with staffing. V2 stated that with call offs and people not showing up for work there was only 2 nurses in the building. V2 stated that this is an ongoing problem due to agency not showing up and nurses leaving shift prior to relief. V2 stated that there was a delay in medication being administered due to no nurses being available. V2 stated that they have had some challenges with nurses in the facility. V2 stated that they use a program that manages the schedules and agency. V2 stated that the facility is actively hiring. V2 stated that she did have staff come in but was unsure of times but try to get those.As of 6/21/2026 at 2:00 PM the facility was unable to and did not provide additional nurse hours for 6/13/2026 and 6/14/2026.On 6/17/2026 at 10:48 AM V15, LPN, stated that she was scheduled for 6/13/2026 but called off and did not work the shift.On 6/18/2026 at 3:50 PM V1, Administrator, stated that they do not have a staffing policy and follow CMS guidelines.The daily census provided on 6/15/2026 documents, dated 6/14/2026, documents 82 residents in the facility.

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 82 residents who reside in the facility.Findings include:On 6/16/2026 May and June 2026 staffing schedules were reviewed. The facility did not have at least 8 consecutive hours of RN coverage a day for the following dates: 5/1, 5/2, 5/3, 5/4, 5/5, 5/6, 5/11, 5/13, 5/14, 5/17, 5/18, 5/19, 5/20, 5/21, 5/22, 5/23, 5/24, 5/26, 5/29, 5/30, 5/31,6/1, 6/2, 6/3, 6/4, 6/6, 6/8, 6/9, 6/10, 6/11, 6/14, 6/15, 6/16, and 6/17.On 6/18/2026 at V2, Director of Nursing, stated that they have had some challenges with nurses in the facility. V2 stated that they use a program that manages the schedules. V2 stated that the facility is actively hiring.On 6/18/2026 at 3:50 PM V1, Administrator, stated they do not have a staffing policy and follow CMS guidelines.The daily census provided on 6/15/2026 documents, dated 6/14/2026, documents 82 residents in the facility.

Based on observation, interview and record review the facility failed to provide food at preferred temperature and palatable. This failure has the ability to affect all 82 residents in the facility. Findings include: On 6/16/2026 at 1:05 PM hall trays at top of hall sitting. At 1:15 PM trays delivered to 300 hall.On 6/16/2026 at 1:05 R9 her food was cold. R9 stated that this happens all the time. R9 stated that sometimes the cart sits in the dining room because there is no one to come and get it. Causing the food to sit, be late and cold. Sometimes don't get served until 1:30 pm.On 6/16/2026 at 1:16 PM R14 stated that her food is rarely hot. R14 stated that it's always late.On 6/17/2026 noon meal was observed. 12:00 PM dietary staff ready to serve with temperatures taken. At 12:04 PM, 12:06 PM, 12:10 PM and 12:13 PM V24 looked outdoor and stated that there were no nursing staff. At 12:14 PM V24 stated that there were nursing staff in dining room. First tray prepared and served 12:15 PM. Dining room completed at 12:44 PM. 12:45 PM 100/200 hall cart was prepared. 1:15PM 300/400 hall cart served. A test tray was requested to be sent from Dietary with the 300/400 cart. 127 PM last tray served, and test tray removed from the cart. At 1:29 PM temperatures on test tray were completed and noted as follows: potatoes temp 124.5F and chicken temp 127.2F. The food on the tray was luke warm to touch.On 6/18/2026 at approximately 10:15 AM V24, Dietary Manager, stated that the dietary staff only prepares the meals and the nursing staff delivers. V24 stated that dietary is not allowed to serve the food unless there is a CNA or Nurse in the dining room. V24 stated that this causes a delay with the kitchen. V24 stated that at 11:45 AM dietary gets the cards ready and 12:00 PM they are ready to serve. V24 stated that this is placed on hold until nursing staff is available. V24 stated that if they are late, it causes the food to be late. V24 stated that after the main dining room the hall trays are prepared. V24 stated that the carts are prepared and then given to the nursing. V24 stated that once out of the kitchen the nursing staff pass the trays. V24 stated that the food is sent out hot. Once it goes out of the kitchen its nursing.On 6/17/2026 at 3:10 PM V25, CNA, stated that the hall trays are brought to the hall by the nursing staff assigned to the dining room. V25 stated then its nursing responsibility to pass the trays. V25 stated that there have been times that the cart has sat for a while. V25 stated that sometimes they are in rooms helping residents and the cart comes out and there is no one to pass it. V25 stated that the residents do complain about the trays being late and not coming out on time.On 6/18/2026 at 3:07 PM V1, Director of Nursing, stated that once the trays have been made, they are brought to the hall and nursing are to serve the cart when it arrives to the floor. V1 stated that this has been an ongoing problem and residents and complaining of food being late and cold. The facility's Meal-Service- Palatability and Nutritive Value policy, dated 3/7/2025 documented that Policy: Food will be prepared, held, and served in a manner that maintains its nutritive value and palatability while ensuring food safety. Procedure: Serving Temperature; Hot foods will be served hot, and cold foods using thermal lids, heated or chilled plates, and thermal pellets as needed to enhance the dining experience.The daily census provided on 6/15/2026 documents, dated 6/14/2026, documents 82 residents in the facility.

Based on observation, interview and record review, the facility failed to maintain the environment in clean and good repair for 8 of 15 residents (R1, R3, R4, R5, R6, R9, R10, R14) rooms reviewed for environment in a sample of 15. Findings include:1 R5's Minimum Data Set (MDS), dated [DATE], documents that R5 is cognitively intact.On 6/15/2026 at approximately 2:15 PM R5 stated that his room is dirty, and housekeeping does not clean his room on a regular basis. R5 stated that there is stains on the floor that have been there for days. R5 stated that the shower room is unsafe and needs to be repaired. R5 stated that the drain is broken, and the door is broken.2. R3's MDS, dated [DATE], documents that R3 is cognitively intact.On 6/16/2026 at 9:13 AM R3 stated that sometimes they clean the room and sometimes they don't. R3 instructed to look under her bed they never clean there. R5 stated that she uses the 300/400 hall shower room. R4 stated that the baseboards were coming away from the wall and the toilet handle was broken.On 6/16/2026 at observed dried liquid under R3's bed and on floor between R3 and R4. Toilet handle was flipped backwards and unusable and the baseboard was peeling away from wall. 6/17/2026 at approximately 9:15 AM dried liquid remained or base board.3. R4's MDS, dated [DATE], documents that R4 is cognitively intact.On 6/15/2026 at 3:09 PM R4 stated that they clean the rooms with a broom but don't mop. R4 stated that the room has things that need to be fixed. R4 stated that she uses the 300 Hall shower room. 4. On 6/16/2026 at 12:30 Observed baseboards coming off walls in R1, R3, R4, R6 and R10s rooms. Observed The 300-hall shower room's door has multiple strips of wood like particles peeling away from and hanging off the door. With pieces of door hanging from door with sharp edges. On 3/15/2026 at 2:50 PM V5, Certified Nurse Assistant stated that R1, R3, R4, R5, R6, R9, R10, and R14 use the shower room. On 6/16/2026 at 1:38 PM V1, Administrator stated that there are rooms that require fixing and maintenance are working on it. V1 stated that she was not aware of the shower room door and would have it fixed. V1 stated that the facility is working to get it clean. V1 stated that there are 2 great housekeepers, and they are working to get and train more to the facility's standards.On 6/18/2026 at 3:07 PM V2, Director of Nursing, stated that there are areas in the building that require repairs. V2 stated that maintenance is aware and working on them. V2 stated that the facility is dirty with strong odors and that is a work in progress.On 6/16/2026 at 2:36 PM V4, Maintenance Director, stated that he was not aware of any repairs needed on the hall. V4 stated that they have a maintenance book. The staff are to document in the book repairs needed. V4 stated that also the staff utilize a text service for things that come up and he is able to address immediately. V4 stated that the book is looked at daily by himself and his staff.The facility's Quarterly Inspections, not dated, documents 6. All residents' rooms should be inspected for any repairs needed and proper operation of equipment.

Based on interview and record review the facility failed to ensure medication was administered timely and as ordered for 4 of 4 (R1, R5, R6, R8) residents reviewed for medication administration in a sample of 14. Findings include: 1. R1's admission Record, dated 6/16/2026, documents that R1 admitted to the facility on [DATE] with the following diagnoses: Essential Hypertension, Dissection of Ascending Aorta, Gout, Syncope and Collapse, Acquired Absence of Right and Left Leg Below Knee. R1's Medication Administration Record (MAR), dated 4/126 to 4/30/26 documents that Carvedilol Oral Tablet 12.5 MG (milligram) (Carvedilol) Give 2 tablet by mouth two times a day for Elevated Blood Pressure scheduled 8PM blank on 4/28, 4/29, 4/30, and 5/15. R1's MAR, dated 5/1 to 5/31, documents that 5/15 morning dose of amlodipine Besylate Oral Tablet 5 MG, Aspirin 81 Oral Tablet Chewable 81 mg, Bisacodyl Rectal Suppository 10 MG, Apixaban Oral Tablet 2.5 MG (Apixaban) Give 2.5 mg, Gabapentin Oral Tablet 100 MG, Polyethylene Glycol 3350 Powder 17 gram, Protonix Tablet Delayed Release 40 MG, Sevelamer Carbonate Tablet 800 MG Give 2 tablet is blank. It also documents blanks for Acetaminophen Oral Tablet 500 MG 2 tablets 11AM and 3:00PM, Nystatin Mouth/Throat Suspension Give 5 ml (milliliter) 12PM and 5:00PM, Sevelamer Carbonate Tablet 800 MG Give 2 tablet 12PM and 5:00 PM. 5/18/2026 6AM Bisacodyl EC (enteric coated) 2 tablet by mouth one time a day 5/18 6AM dose blank. R1's MAR, dated June 1- June 30, documents that 6/8 6AM dose of Nystatin Mouth/Throat Suspension blank. 6/12 12PM Sevelamer Carbonate Tablet 800 MG, Acetaminophen Oral Tablet 500 MG, Nystatin Mouth/Throat Suspension R1's Medication Administration Audit Report, dated 6/18/2026 documents that R1's scheduled 9:00 AM medication was administered late. R1's Acetaminophen Oral Tablet 500 MG, Apixaban Oral Tablet 2.5 MG, Gabapentin Oral Tablet 100 MG, Protonix Tablet Delayed Release 40 MG, Aspirin 81 Oral Tablet Chewable, Polyethylene Glycol 3350 Powder, Sevelamer Carbonate Tablet 800 MG Give 2 tablet, Carvedilol Oral Tablet 12.5 MG, were administer on 6/7/2026 at 12:12 PM and on 6/7/2026 was administer at 2:14 PM. 2. R5's, MDS, dated [DATE], documents that R5 was cognitively intact and experience pain almost daily. R5's Physician Order Sheet documents 4/8/2026 Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours for Pain. R5's Oxycodone HCl Oral Tablet 10 MG Medication Monitoring Control Record, dated 4/16/2026, documents last administered 5/1/2026 at 11AM. R5's Medication Monitoring Control Record, dated 4/29/2026, documents first dose administered 5/2/2026 at 6AM. R5's Medication Monitoring Control Record, dated 5/15/2026, documents no dose administered 5/18/26 at 12AM. Last dose administered 6/6/2026 at 12pm. R5's Medication Monitoring Control Record, dated 6/6/2026, documents first dose administered 6/7/2026 at 12 AM. R5's Medication Administration Record, dated 6/1/2026 to 6/18/2026, documents that R5's 9:00 AM scheduled medication was administered outside of the administration window. R5's Fluticasone Propionate Suspension 50 MCG (micrograms)/ACT, Potassium Chloride ER Oral Tablet Extended Release 20 MEQ, Metamucil Oral Powder 48.57, MiraLAX Oral Packet 17 GM, Buspirone HCl Oral Tablet 10 MG, rifaximin Oral Tablet 550 MG, Omeprazole 40 MG, Midodrine HCl Tablet 5 MG, Aldactone Oral Tablet 50 MG, Folic Acid Tablet 1 MG, Calcium Carbonate Oral Tablet 600 MG, Vitamin D Oral Tablet, Lasix Oral Tablet 20 MG, bupropion HCl ER (XL) Oral Tablet Extended Release 24 Hour (Bupropion HCl) Give 300 mg by mouth in the morning are scheduled for 9:00 AM. R5's 9:00 AM medications were administered 6/2/2026 at 3:26 PM, 6/6/2026 at 11:56 Am, 6/8/2026 from 12:12 PM to 12:31 PM, 6/11/2026 at 10:53 Am, 6/12/2026 at 12:21 PM and 6/17/2026 at 1:32 PM. On 6/15/2026 at approximately 2:15 PM R5 stated that there are times that the facility is late with his medication and sometimes it is not available at all. R5 stated that he has pain as high as 11 on pain scale 1-10. R5 stated that the pain is horrible, and it affects his day-to-day life. R5 stated that when he does not receive his pain medication his pain exceeds his normal level. R5 stated that it's unbearable. On 6/18/2026 at 3:07 PM V2, Director of Nurses, stated that pain is what the person says it is. If a resident says that they are experiencing pain, then they are. V2 stated that if the resident did not receive his pain medication timely or at all their pain would increase. V2 stated that R5 is alert and oriented and able to make own decisions. V2 stated that she has had some problems with the nursing staff administering the medication late and sometimes not at all. V2 stated that if the medications was not documented and a blank is in the MAR then the medication was not given. V2 stated that the facility has a locked pharmacy system. V2 stated that she has a lot of agency staff and they are not given a code for the system. V2 stated that this can delay medication administration and contribute to missed medication. 3. R6's Face Sheet with a print date of 6/18/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, rheumatoid arthritis, major depressive disorder, chronic pain and anxiety disorder. R6's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact. On 6/17/26 at 10:45 AM, R6 stated she feels like she is not getting the care she needs. R6 stated they've missed medication administration for her on multiple days mostly for the day shift. R6 stated about three weeks ago on the weekend she remembers that happening. R6's May Medication Administration Record (MAR) documented on 5/16/26, she was not administered any of her 9:00 AM medications with a blank box. 4. R8's Face Sheet with a print date of 6/18/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, chronic obstructive pulmonary disease, type two diabetes mellitus, depression, and acquired absence of right leg below the knee. R8's MDS dated [DATE] documents R8 is cognitively intact. R8's May 2026 Medication Administration Record (MAR) documented on 5/16/26, she was not administered any of her 9:00 AM medications with a blank box. R8's May 2026 MAR also documented that she did not receive any of her sliding scale insulin Lispro or blood glucose checks before meals 5/16/26 which were left blank. Grievance Form dated 5/18/26 documented R8 made a grievance on medication administration for 5/16/26 and the grievance was confirmed; nurse was counseled. On 6/18/26 at 3:32 PM, V28 Licensed Practical Nurse (LPN) stated if the MAR has a blank box, it means it has not been administered. On 6/18/26 at 3:07 PM, V2 (DON/Director of Nursing) stated if medications are missing, she expects nurses to be getting on the phone with pharmacy and ordering them. V2 stated medications should be administered on time. V2 stated if the MAR has a blank box, that means it was not documented to be administered. The facility's Medication Administration policy, dated 10/2025, documents that All medications are administered safely, and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: 6. Check medication administration record prior to administering medication for right medication, dose, route, patient/resident, and time. 13. Verify that the medication is being administered at the proper time, in prescribed dose, and by correct route. 18. Document as each medication is prepared on the MAR. 26. If medication is ordered but not present, check to see if it was misplaced then call pharmacy to obtain the medication. If available obtain from contingency or convenience box.

Based on observation, interview and record review the facility failed to ensure the call light system was in place and working properly for 5 of 15 residents (R2, R3, R4, R6, R10) reviewed for call lights. Findings include: 1. R3's admission Record, dated June 16, 2026, documents that R3 was admitted [DATE] with the following diagnoses: Multiple Sclerosis, Chronic Obstructive Pulmonary Disease, Asthma, Obstructive Sleep Apnea, Epilepsy, Shortness of Breath, Type 2 Diabetes, Heart Failure, and Muscle Weakness. R3's Care Plan, dated 4/30/2026, documents that R3 has a self-care deficit in dressing and grooming r/t (related to) weakness. 1/27/2026 Resident is at high risk for falls r/t weakness. (R3) requires assistance with daily care needs r/t muscle weakness. R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact and requires partial/moderate assistance with activities of daily living. R3's Call Light Ability Screen, dated 6/12/2026, documents that R3 can use a call light. On 6/15/2026 at 3:09 PM observed R3's room. No call light. No bell or horn observed in room. On 6/16/2026 at 9:13 AM observed no call light in room. Bell sitting on overbed table next to roommate's (R4's) bed. On 6/15/2026 at 3:05 PM bell rang. No response from staff. On 6/16/2026 at 9:13 AM R3 stated that she does not have a call light. R3 stated that they gave her a bell, but no one responds. R3 stated that she starts yelling and then after a while they come into the room. R3 stated that her roommate used to call for R13, but she has since moved. R3 stated that her roommates are good to her and help her but that's not their job. R3 stated that she can do some things for herself. But needs help with others. R3 stated that she is a brittle diabetic, and her blood sugar fluctuates. R3 stated that she gets weak and needs help. No one comes. No one cares. I need help sometimes. How am I supposed to get that. This thing (bell) is a joke. 2. R4's MDS, dated [DATE], documents that R4 is cognitively intact. On 6/15/2026 at 3:09 PM R4 stated that R3 does not have a call light. R4 stated that she guesses they share the one R4 has but R3 doesn't have a string. R4 stated that sometimes R4 has to call for R3 because R3 dings the bell and no one comes. 3. R2's Care Plan, dated 1/8/26, documents that ADL/Activities of Daily Living: Resident requires assist with daily care needs r/t weakness. Has a self-care deficit in dressing and grooming r/t weakness, and hepatic encephalopathy. Resident is at high risk for falls r/t weakness. R2's MDS, dated [DATE], documents that R2 requires substantial/max assistance with some ADLs and dependent on staff for transfers. R2's Call Light Ability Screen, dated 3/3/2026, documents that R2 can use a call light. R2's Grievance, dated 4/10/2026, documents that Call light not working. Not lighting up outside room. On 6/16/2026 at approximately 10:30 AM observed R2 lying in bed. No call light in place. Observed metal plate on wall with metal button. No string attached. Button pushed. The light did not show outside R2'a door. On 6/16/2026 at approximately 10:30 AM R2 stated that he did have a problem with his call light. R2 stated that he did not have a way to call for help. R2 stated that they put a string on it and said it worked. R2 stated that if you look behind the dresser you will find the cord. R2 stated that it keeps coming apart. R2 stated that he needs help with getting up or even moving up in bed. R2 stated that if he is in pain or uncomfortable he is stuck. R2 stated that the string that was applied comes apart from the metal part of the call light and then he has no help, and it can take forever for them to come and check on him. 4. R6's Facesheet with a print date of 6/18/26 documented she was admitted to the facility on [DATE]. R6's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact. On 6/17/26 at 10:45 AM, R6 stated her call light isn't working right now it's the string on the floor she has to pull. R6's call light was pushed down, and nothing was going off. R6's roommate's (R10) call light also did not work when pressed down. R6 stated she is scared of being in bed without any call light in the room working because she is not able to get up and sometimes the CNAs are nowhere to be found. 5. R10's Face Sheet with a print date of 6/18/26 documented she was admitted to the facility on [DATE]. On 6/17/26 at 10:45 AM, R10's call light did not work when pressed down. On 6/17/26 at 11:11 AM, V1 (Administrator) was notified of R6 and R10's call light not working. On 6/17/26 at 11:22 AM, V13 (Maintenance) stated the call lights for R6 and R10 are working now but V4 (Maintenance Manager) will be here soon to work on the other call lights not working still. On 6/15/2026 at approximately 2:50 PM V5, Certified Nurse Aide (CNA), stated that there are some residents that have bells. V5 stated that if you're in the hallway or near the resident's room when the bell rings you can hear it. V5 stated that if you are in a room and unless they are still ringing it when you come out you don't know anyone needs anything. On 6/16/2026 at 1:38 PM V1, Administrator, stated that there are rooms that don't have call lights and are broken. V1 stated that they are working on fixing them. V1 stated that call lights were ordered, and they were not compatible with the current system. V1 stated that she did give the resident without a call light a bell. V1 stated that she was not aware of the bells being a problem. On 6/16/2026 at approximately 2:55 PM V6, CNA, stated that R3 does not have a call light. V6 stated that R3's roommates calls for help for R3. V6 stated that the bells are low unless they bang on them and sometimes you can't hear them. On 6/17/2026 at 11:12 AM V1 stated that the facility does not have a call light policy for residents to have one. V1 stated that they do have a response policy. On 6/18/2026 at approximately 2:00 PM V1 stated that they received an estimate on 6/17/2026 to replace the call light system. V1 stated that they are now working on replacing the system. On 6/18/2026 at 3:07 PM V2, Director of Nursing, stated that there have been problems with the call light. V2 stated that the if more than 1 call light is going off at a time the systems will get overwhelmed and he call lights will stop working. V2 stated that maintenance has been working on it. V2 stated that there are areas in the building that require repairs. V2 stated that maintenance is aware and working on them. V2 stated that some residents have bells, but you can't hear them. On 6/18/2026 at 3:30 PM V30, CNA, stated that it is everyone's responsibility to answer the call lights. V30 stated that some residents have bells and if you are near them, you can hear the bell. V30 stated that if you are in a room and they ring the bell unless you heard it you would not know anyone needed anything. Resident Council Minutes, dated April 24/26 and May 2026, documents that Nursing Issues/Concerns Call lights are never being answered. The facility's Call light policy, dated 9/2025, documents that General: To provide the staff with guidance on responding to residents' request and needs. PROTOCOL: 3. Ensure call light is within resident's reach at all times. 4. When the patient or resident is in bed or confined to bed or chair, provide the call light within easy reach of the patient or resident. On 6/16/2026 at 2:36 PM V4, Maintenance Director, stated that the call light system is on the 300/400 hall is an old system. V4 stated that once the call lights are on for long periods of time it overheats the system and the call lights won't work. V4 stated that he communicates with the staff to make sure that they are not allowing the lights to stay on for long periods of time. V4 stated that on the call lights on 100/200 hall require a specific battery. V4 stated that he is waiting for them to come in. V4 stated that he was not aware of any repairs needed on the hall. V4 stated that they have a maintenance book. The staff are to document in the book repairs needed. V4 stated that also the staff utilize a text service for things that come up and he is able to address immediately. V4 stated that the book is looked at daily by himself and his staff. The facility's Quarterly Inspections, not dated, documents 6. All residents' rooms should be inspected for any repairs needed and proper operation of equipment.

Based on interview, observation and record review the facility failed to provide timely incontinent care for 1 of 4 residents (R8); reviewed for incontinent care in a sample of 14.Findings include:R8's Facesheet with a print date of 6/18/26 documented she was admitted to the facility on [DATE] with diagnoses of, in part, chronic obstructive pulmonary disease, type two diabetes mellitus, depression, and acquired absence of right leg below the knee.R8's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact and required partial/moderate assistance from staff for toileting hygiene and chair to bed or toilet transfers.R8's Care Plan dated 10/23/24 documented she requires assistance with daily needs and for staff to assist with her activities of daily living. R8's Care Plan dated 10/16/24 documented she is incontinent of bowel and bladder.On 6/17/26 at 1:55 PM, R8 stated currently waiting to be cleaned up right now because she is soiled. R8 stated she told V10 Certified Nursing Assistant (CNA) she was wet sometime around 1 o'clock today and his response to her was that she had to wait until he was done passing meal trays. R8 stated she is currently still sitting soaked, and it is very uncomfortable. R8 stated it makes her feel insignificant. R8 stated she's been told to help herself and wear pull ups instead of briefs to do things by herself, but she urinates too much for a pull up to hold. R8 pressed her call light at 1:57 PM, and at 2:01 PM, V14 responded and told her she would clean her up. At 2:04 PM, V14 (CNA) provided incontinent care for R8.On 6/18/2026 at 1:19 PM, R8 asked for assistance. V10 (CNA) stated that I'm busy passing trays. V10 did not provide R8 with any assistance.On 6/18/26 at 3:07 PM, V2 (Director of Nursing/DON) stated Some of these new people I wouldn't want taking care of me. I have high expectations. V2 stated if a resident is in need of assistance or requests help, staff should help them right away and not told to wait especially if not helping another resident at the time.On 6/18/26 at 3:30 PM, V29 (CNA) stated when a resident requests help or care, she would help them immediately or as soon as possible.On 6/20/26 at 12:44 PM, V26 (Medical Director) stated if a resident requests or needs assistance his expectation from staff is to respond and triage them appropriately.The facility's Incontinence Care policy last revised on 9/2025 documented all nursing staff are responsible for providing the care to keep residents as dry, comfortable and odor free as possible; also helping prevent skin breakdown.

Based on interview and record review, the facility failed to provide wound care services as ordered by the Physician for 1 of 7 residents (R3) reviewed for Abuse and Neglect, in the sample of 15. This failure resulted in R3 being hospitalized for wound infections. Findings Include:R3's Face Sheet, undated, documents R3 has the following diagnoses, in part: Need for Assistance with Personal Care, Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Hypertension (HTN), ESRD (End Stage Renal Disease), Muscle Wasting/Atrophy, and Anemia. R3's MDS (Minimum Data Set), dated 4/6/26, documents R3 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R3 is cognitively intact. R3 requires substantial/maximal assist with toileting is always incontinent of urine, frequently incontinent of bowel, has two-foot ulcers, a diabetic foot ulcer, and a wound infection. R3's Pressure Ulcer Risk Assessment, dated 12/31/25, documents R3 is at risk for pressure ulcer development.R3's POS (Physician Order Sheet) documents the following: 5/26/26 Bactrim DS Tablet 800-160 MG (Milligrams) Give 1 tablet by mouth every 12 hours for Wound Infection for 7 Days. R3's POS documents the following treatment/wound care orders: 4/14/26 Clean wound with wound cleanser, moisten gauze and pack into wound, then apply gauze over wound to the left calcaneus (heel bone), apply kerlix as directed one time a day. 4/14/26 Clean wound with wound cleanser, moisten gauze and pack into wound, then apply gauze over wound to right calcaneus, apply kerlix as directed one time a day. 4/14/26 Clean wound with wound cleanser, moisten gauze and pack into wound, then apply gauze over wound to right plantar (sole/bottom) foot apply kerlix s directed one time a day. 4/13/26 Clean wound with wound cleanser, moisten gauze and pack into wound, then apply gauze over wound to the right medial foot, and apply kerlix as directed. 3/31/26 Povidone-Iodine External Solution 7.5 % (Povidone-Iodine) Apply to right foot topically one time a day for right foot. R3's Treatment Administration Record (TAR), dated 5/2026, fails to document that the above wound care orders were completed as ordered on 5/8/26; 5/10/26; 5/15/26; 5/16/26; 5/17/26; 5/21/26; and 5/24/26. R3's Progress Notes were reviewed with no documentation that R3's treatments were completed on the above dates.R3's Hospital History & Physical, dated 5/26/26, documents the following: (R3) with ESRD, on daily dialysis, CHF, COPD (Chronic Obstructive Pulmonary Disease), DM, (Diabetes Mellitus), Depression, HTN, prior history of heart attack, status post stenting, on 2 liters of oxygen, chronic wound status, post removal of hardware with application of integra bilayer to the right foot. R3 is here because of worsening wound infection. Patient currently stays at (Long Term Care Facility) and goes to the wound care clinic once a week. Patient says that the nursing home ought to have been changing wound dressings daily but says that wasn't done. Patient says she would feel pain more on her right ankle, radiating to the upper part of her legs. She has been feeling nauseated for several days. Endorses chills but says she can't tell if she had a fever. Assessment and Plan: Wound infection, PAD (Peripheral Artery Disease), history of MRSA (Methicillin Resistant Staph Aureus), stage 3 pressure injury to the sacral region, and ulcers of both feet with necrosis of muscle. Multiple wounds in both feet with significant purulent drainage and evidence of necrosis. On 5/28/26 at 9:37 AM, V22, Wound Care Provider, stated she saw R3 at the wound clinic on 5/26/26, R3's right foot wound had purulent drainage, she was worried that R3 had osteomyelitis, so she sent R3 to the emergency room. V22 stated R3 was admitted to the hospital with osteomyelitis of the right foot and the hospital physician is saying that R3 might need an amputation, but there haven't been any final decisions made as of yet. V22 stated she had concerns that the facility was not completing the dressing changes as ordered to R3's foot so she attempted to contact nursing management at the facility multiple times, but no one would call her back. V22 stated when she saw R3 last week, R3 had maceration to her buttocks, when she saw her on 5/26/26, she had full skin breakdown on her buttocks, and she doesn't think the facility was turning and positioning R2 leading to the further breakdown. V22 stated when she gives orders, she expects the facility to follow them. On 5/28/26 at 1:06 PM, V3, DON (Director of Nurses), stated the treatments should be completed as ordered and would be documented on the TAR or in the progress notes.The Abuse Prevention Program, dated 2/7/17, documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on interview and record review, the facility failed to complete pressure ulcer care and monitoring in 2 of 7 residents (R3, R4) reviewed for the Treatment/Services to Prevent/Heal pressure ulcers, in the sample of 15. This failure resulted in R3 being admitted to the hospital with wound infections. Findings Include:1) R3's Face Sheet, undated, documents R3 has the following diagnoses, in part: Need for Assistance with Personal Care, Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Hypertension (HTN), ESRD (End Stage Renal Disease), Muscle Wasting/Atrophy, and Anemia. R3's MDS (Minimum Data Set), dated 4/6/26, documents R3 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R3 is cognitively intact. R3 requires substantial/maximal assist with toileting is always incontinent of urine, frequently incontinent of bowel, has two foot ulcers, a diabetic foot ulcer, and a wound infection. R3's Pressure Ulcer Risk Assessment, dated 12/31/25, documents R3 is at risk for pressure ulcer development.R3's POS (Physician Order Sheet) documents the following: 5/26/26 Bactrim DS Tablet 800-160 MG (Milligrams) Give 1 tablet by mouth every 12 hours for Wound Infection for 7 Days. R3's POS documents the following treatment/wound care orders: 4/14/26 Clean wound with wound cleanser, moisten gauze and pack into wound, then apply gauze over wound to the left calcaneus (heel bone), apply kerlix as directed one time a day. 4/14/26 Clean wound with wound cleanser, moisten gauze and pack into wound, then apply gauze over wound to right calcaneus, apply kerlix as directed one time a day. 4/14/26 Clean wound with wound cleanser, moisten gauze and pack into wound, then apply gauze over wound to right plantar (sole/bottom) foot apply kerlix s directed one time a day. 4/13/26 Clean wound with wound cleanser, moisten gauze and pack into wound, then apply gauze over wound to the right medial foot, and apply kerlix as directed. 3/31/26 Povidone-Iodine External Solution 7.5 % (Povidone-Iodine) Apply to right foot topically one time a day for right foot. R3's Treatment Administration Record (TAR), dated 5/2026, fails to document that the above wound care orders were completed as ordered on 5/8/26; 5/10/26; 5/15/26; 5/16/26; 5/17/26; 5/21/26; and 5/24/26. R3's Progress Notes were reviewed with no documentation that R3's treatments were completed on the above dates.R3's Hospital History & Physical, dated 5/26/26, documents the following: (R3) with ESRD, on daily dialysis, CHF, COPD (Chronic Obstructive Pulmonary Disease), DM, (Diabetes Mellitus), Depression, HTN, prior history of heart attack, status post stenting, on 2 liters of oxygen, chronic wound status, post removal of hardware with application of integra bilayer to the right foot. R3 is here because of worsening wound infection. Patient currently stays at (Long Term Care Facility) and goes to the wound care clinic once a week. Patient says that the nursing home ought to have been changing wound dressings daily but says that wasn't done. Patient says she would feel pain more on her right ankle, radiating to the upper part of her legs. She has been feeling nauseated for several days. Endorses chills but says she can't tell if she had a fever. Assessment and Plan: Wound infection, PAD (Peripheral Artery Disease), history of MRSA (Methicillin Resistant Staph Aureus), stage 3 pressure injury to the sacral region, and ulcers of both feet with necrosis of muscle. Multiple wounds in both feet with significant purulent drainage and evidence of necrosis. On 5/28/26 at 9:37 AM, V22, Wound Care Provider, stated she saw R3 at the wound clinic on 5/26/26, R3's right foot wound had purulent drainage, she was worried that R3 had osteomyelitis, so she sent R3 to the emergency room. V22 stated R3 was admitted to the hospital with osteomyelitis of the right foot and the hospital physician is saying that R3 might need an amputation, but there haven't been any final decisions made as of yet. V22 stated she had concerns that the facility was not completing the dressing changes as ordered to R3's foot so she attempted to contact nursing management at the facility multiple times, but no one would call her back. V22 stated when she saw R3 last week, R3 had maceration to her buttocks, when she saw her on 5/26/26, she had full skin breakdown on her buttocks, and she doesn't think the facility was turning and positioning R2 leading to the further breakdown. V22 stated when she gives orders, she expects the facility to follow them. 2) R4's Face Sheet, undated, documents R4 has the following diagnoses, in part: Type 2 DM, Stage 4 CKD, Anemia, and HTN.R4's MDS, dated [DATE], documents R4 has a BIMS score of 15. R4's Care Plan, dated 2/9/26, documents R4 is at risk for skin complications.R4's POS documents the following orders: 1/27/26 Cleanse wound with wound cleaner, pat dry. Apply Medi honey to sacrum area with bordered gauze one time a day for wound care. 1/27/26 Cleanse wound with wound cleaner, pat dry. Apply Medi honey to right heel and with bordered gauze one time a day.R4's Nursing admission Observation, dated 12/31/25, has no documentation that R4's skin was assessed.R4's Nursing admission Assessment, dated 2/19/26, documents R4 has skin conditions that require monitoring/treatment, however there were no measurements, locations, or description documented.R4's Skin Assessment, dated 2/19/26, documents there were no new findings. There wasn't any documentation of the current areas.There wasn't any documentation in R4's records that the facility had documented measurements or a description of the wounds from 1/15/26 through her discharge to the hospital on 2/25/26.On 5/28/26 at 1:06 PM, V3, DON (Director of Nurses), stated the treatments should be completed as ordered and would be documented on the TAR or in the progress notes.The Skin Management: Pressure Injury, Lower Extremity Ulcer Evaluation, and Documentation, policy, dated 6/2015, documents, in part, pressure injuries will be evaluated, a picture taken and the following areas documented weekly: location, stage, size, depth, presence and location of undermining/tunneling/sinus tract, exudate, pain, wound bed, and wound edges. Wounds will be measured on a weekly basis. If a wound shows no signs of healing after three weeks, a reevaluation of the wound will be done. Reevaluation of the treatment plan including determining whether to continue or modify the current treatment interventions.

Based on interview and record review, the facility failed to provide showers to 4 of 6 residents (R2, R5, R7, R15) reviewed for Activities of Daily Living (ADL) care in a sample of 15.Findings Include:Findings Include:1.) R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has medical diagnoses of Aphasia, Hemiplegia, Weakness, Abnormal Posture, Contracture of the Right and Left Knee, Contracture of the Right and Left Ankle, and Dementia.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is rarely/never understood, has a memory problem, has an upper and lower extremity impairment on both sides, uses a wheelchair, needs supervision or touching assistance with eating, is dependent on staff for toileting hygiene, showering/bathing, personal hygiene, rolling left and right, lying to sitting on side of bed, chair/bed to chair transfers, and is always incontinent of bladder and bowel.R2's Care Plan Date Initiated 11/19/23 documents R2 has Activities of Daily Living (ADL) Self Care Performance Deficit related to Cerebrovascular Accident (CVA).R2's Shower Sheets document R2 last received a shower on 4/16/26.On 5/26/28 at 9:00 AM R2 observed in bed wearing a hospital gown, R2's hair appears matted and greasy.On 5/27/28 at 12:28 PM R2's hair appeared unkept, matted, and greasy.2.) R5's Undated Face Sheet documents R5 was originally admitted to the facility on [DATE] with medical diagnoss of Rheumatoid Arthritis of Left Hip, Post-Traumatic Stress Disorder, Unsteadiness on Feet, and Need for Assistance with Personal Care.R5's MDS dated [DATE] documents R5 is cognitively intact, has a lower extremity impairment of both sides, uses a wheelchair, needs substantial/maximal assistance with toileting hygiene, showering/bathing, need partial/moderate assistance with sitting to standing and chair/bed to chair transfers, is frequently incontinent of bladder, and occasionally incontinent of bowel.R5's Care Plan Date Initiated 12/16/24 documents ADL: R5 requires assist with daily care needs related to need for assistance with ADLs.R5's Physician Order dated 6/13/25 at 11:40 PM documents patient requesting assistance with daily showers in the morning for showering and hygiene- requesting morning time showers, assist with showering.On 5/26/26 at 8:46 AM R5 stated she received a shower about two weeks ago and has not been offered or received a shower since.R5's Shower Sheets document R5 last received a shower on 5/15/26.3.) R7's Undated Face Sheet documents R7 was admitted to the facility on [DATE] with medical diagnoses of Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease, and Muscle Weakness.R7's MDS dated [DATE] documents R7 is cognitively intact, needs partial/moderate assistance with toileting hygiene, showering/bathing, needs supervision or touching assistance with chair/bed to chair transfers, and is occasionally incontinent of bladder.R7's Care Plan Date Initiated 1/27/26 documents ADL: R7 requires assist with daily care needs related to muscle weakness.On 5/26/26 at 9:21 AM R7 stated she has been in the facility since January and has only received 1 shower. R7 stated she is not offered a shower or bed bath weekly.R5's Shower Sheets document R5 last received a shower on 3/26/26.4.) R15's Undated Face Sheet documents R15 was admitted to the facility on [DATE] with medical diagnosis of Cerebral Infarction, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Unsteadiness on Feet, Weakness, and Hypertension.R15's MDS dated [DATE] documents R15 is cognitively intact, uses a wheelchair, needs supervision or touching assistance with toileting hygiene, showering/bathing, chair/bed to chair transfers.R15's Care Plan Date Initiated 11/29/25 documents ADL: R15 requires assist with daily care needs related to use of wheelchair and broken right clavicle.On 5/27/26 at 10:27 AM R15 stated very seldom does she receive a shower and is unsure when the last time she received one. R15 stated she filed a grievance regarding showers, and nothing has changed.R15's Shower Sheets documents R15 last received a shower on 5/13/26.The Facility's Grievance Form dated 3/2/26 documents Description: (R15) states that when she gets her showers, which is rare, that the staff will let her into the shower room and leave her unattended. (R15) states that she is unable to wash herself properly and that the staff does not help her. Steps of Investigation: Spoke with resident shower days is Wednesday and Saturdays. Need assistance would like to have showers everyday and need standby assistance, to wash back and dry back. Summary/Findings: showers not given.R15's Grievance Form dated 3/16/26 documents Description: would like to shower daily prior to bedtime with staff standby assistance. Summary/Findings: Resident only had one shower last week.The Facility's Grievance Form dated 1/21/26 documents Resident reported not getting shower twice a week or weekly at times.The Facility's Grievance Form dated 5/4/26 documents Issue with getting showers.On 5/28/26 at 1:06 PM V3, Director of Nursing, stated the shower sheets she has provided are the only shower sheets and documentation she has that showers were given and done.On 5/28/26 at 4:00 PM V1, Administrator, stated showers are to be given at least weekly, they try to give them twice weekly, it depends on the resident's preference, some request it more often.The Facility's Activities of Daily Living Dependent Residents Policy Date Revised 1/2023 documents Purpose: to ensure that dependent residents in the facility receive regular, safe, and respectful bathing assistance as part of their Activities of Daily Living (ADLs), in alignment with their care plan, preferences, and clinical needs.

Based on interview and record review, the facility failed to properly notify 4 (R5, R7, R12, and R14) of 6 residents prior to a room change reviewed for notification of room changes in a sample of 15.Findings Include:1.) R5's Undated Face Sheet documents R5 was originally admitted to the facility on [DATE] with diagnoses of Rheumatoid Arthritis of Left Hip, Post-Traumatic Stress Disorder, Unsteadiness on Feet, and Need for Assistance with Personal Care.R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact.On 5/26/26 at 8:46 AM R5 stated she is currently in room [ROOM NUMBER]xx. R5 stated she was not informed of her room change prior to moving, and the facility did not inform her family.R5's Census List documents on 12/27/25 R5 resided in room [ROOM NUMBER]xx-B and on 1/15/26 a room change was completed and R5 moved to room [ROOM NUMBER]xx-B.2.) R7's Undated Face Sheet documents R7 was admitted to the facility on [DATE] with medical diagnoses of Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease, and Muscle Weakness.R7's MDS dated [DATE] documents R7 is cognitively intact.On 5/27/26 at 1:10 PM R7 observed in room [ROOM NUMBER]xx. R7 stated she was not notified by the facility before her room was changed.R7's Census List documents on 1/21/26 R7 resided in room [ROOM NUMBER]xx-A and on 2/1/26 a Liability change was made and R7 was moved to room [ROOM NUMBER]xx-A. R7's Census List documents on 3/9/26 R7's room was changed to 4xx-B and on 4/1/26 R7's room was changed to 3xx-A.3.) R12's Undated Face Sheet documents R12 was admitted to the facility on [DATE] with medical diagnoses of Pulmonary Embolism without Acute Cor Pulmonale, Prediabetes, and Personal History of Other Venous Thrombosis and Embolism.R12's MDS dated [DATE] documents R12 is cognitively intact.On 5/27/26 at 8:48 AM, R12 observed in room [ROOM NUMBER]. R12 stated he was not notified prior to his room move.R12's Census List documents on 2/1/26 R12 resided in room [ROOM NUMBER]xx-B, had a room change on 3/25/26 to room [ROOM NUMBER]-B, had a room change on 4/20/26 to room [ROOM NUMBER]xx-A, and had another room change on 5/17/26 to room [ROOM NUMBER]xx-C.4.) R14's Undated Face Sheet documents R14 was originally admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Abnormalities of Gait and Mobility, Muscle Weakness, Hypertension, End Stage Renal Disease, and Chronic Diastolic Congestive Heart Failure.R14's MDS dated [DATE] documents R14 is moderately cognitively impaired.On 5/27/26 at 2:50 PM R14 observed in room [ROOM NUMBER]xx. R14 stated he was not informed that his room would be changing by the facility and when he went to his room his belongings were gone, and he was told his room had been moved.R14's Census List documents on 4/1/26 R5 resided in room [ROOM NUMBER]xx-A and on 4/10/26 R14 had a room change to 4xx-C.R14's Grievance Form dated 3/10/26 documents Description: Resident was not notified about moving to a different room. Resident was not present during moving of personal items. Resident would like to return to previous room. Steps of Investigation: Administer talked with (R14), explained room move was necessary related to insurance and him being in correct bed to bill correctly. Explained going forward he would be notified prior to moving his belongings.On 5/28/26 at 8:40 AM, V1, Administrator, stated they were not doing the room move notifications properly and she has educated the staff. V1 stated R14 was out of the facility and staff moved his belongings to a different room and did not notify him. V1 stated R14 was upset and filed a grievance.The Facility's Room Change/Transfer within Facility Policy Dated 12/2017 documents When a resident is being moved to a new room at the request of the facility, the residents, family or resident representative shall receive an explanation in writing of why the move is required. The resident will be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. Resident will be notified by a staff representative of room transfer request including reasons for the transfer, and will notify the resident regarding the proposed location of the new room and the potential new roommate(s).

Based on interview and record review, the facility failed to implement their Abuse Prevention Policy by not reporting an injury of unknown origin for 1 (R2) of 7 residents, reviewed for abuse, neglect, and injuries of unknown origin in the sample of 15.Findings Include:R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] with medical diagnoses of Aphasia, Hemiplegia, Weakness, Abnormal Posture, Contracture of the Right and Left Knee, Contracture of the Right and Left Ankle, and Dementia.R2's Care Plan Date Initiated 11/19/13 documents R2 has a communication problem related to Cerebrovascular Accident (CVA). [NAME] is nonverbal and only able to make unintelligible sounds and is unable to communicate effectively with verbal and non-verbal gestures.R2's Care Plan Date Initiated 3/2/17 documents R2 is considered at risk for abuse/neglect due to mood cognition, weakness, behavioral/physical deficits.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is rarely/never understood, has a memory problem, has an upper and lower extremity impairment on both sides, uses a wheelchair, needs supervision or touching assistance with eating, is dependent on staff for toileting hygiene, showering/bathing, personal hygiene, rolling left and right, lying to sitting on side of bed, chair/bed to chair transfers, and is always incontinent of bladder and bowel.R2's Nurses Notes dated 5/13/26 at 10:09 AM documents This nurse was called into the resident's room at 6am and informed that the resident had an area on her chest and wanted to know if I was aware. When the nurse entered the resident's room and accessed the area this nurse noted a large raised, firm, warm to touch, dried popped blistered area that extends from right arm pit, and severely painful area to right upper chest and shoulder. Nurse checked progress notes, and nothing had been documented and there was not risk management completed. So, the nurse called (V1) Administration and notified her of the findings. This nurse informed (V1) that a staff Certified Nursing Assistant (CNA) said that the areas were noticed by a night nurse on Sunday night. Head to toe assessment completed and the following was also noted bruising and swelling on the chest area, bruising on the right side, scattered bruises, scabs, and discoloration on bilateral lower extremities (BLE). The right elbow is very swollen and painful. Buttocks skin is intact. Pedal, brachial, and radial pulses noted to be weak on the right side. The administrator informed the nurse that a police officer would be coming to the facility to see the resident. Female Officer came 0745 and evaluated the resident and took pictures of some of her areas. Officer asked when this first notice and nurse informed her that CNA said that Sunday night nurse was aware and had taken pictures and notified the other nurse that night.R2's Hospital Records dated 5/13/26 documents Chief Complaint: patient presents with bruising. History of Present Illness (HPI): Per staff member, bruising reportedly noted Sunday and Monday to patient's chest and right shoulder, with no documentation of any injuries. She is unable to provide any history about what happened due to be nonverbal. Exam concern described for significant bruising and swelling of the right chest wall, right axilla, and right upper arm, with an associated scrape in the armpit/axilla.The Facility's Initial Report dated 5/13/26 documents Staff reported to administrator while performing care noticed a dark discoloration under right armpit. Medical Director (MD) notified, and order received to send to emergency room (ER) for evaluation. Investigation initiated. Final report to follow.R2's Local Police Department Incident Report Dated 5/13/26 documents On 05/13/26 at approximately 0728 hours, I was dispatched to (Nursing Facility), in regards to (R2) having a large amount of bruising and unknown injuries. I arrived on scene and contacted Nurse (V26), (V26) advised she was working nights last night when she was advised of an issue with (R2). (V26) advised she did an assessment on (R2) after being told about some bruising on (R2's) right side. (V26) advised she reviewed (R2's) paperwork and was unable to locate any previous documentation of this injury, but was advised the night nurse on Sunday, 05/10/26, verbally stated she noticed bruising. During (V26's) assessment, she observed yellow discoloration on (R2's) right arm, both breasts, and the right side under (R2's) arm. (V26) advised she observed what appeared to be a large, red and purple blister near (R2's) right armpit, and purple bruising down her side and underneath her right breast. (V26) advised the right side of (R2's) body near her injuries was cold to the touch and the skin was tight. (V26) advised she noticed (R2's) right leg was cold to the touch compared to the left, and all of the pulses on her right side were much weaker than the left. (V26) advised during her assessment, although (R2) is nonverbal, she noticed (R2) to be in excruciating pain when touching the right side of her body and the right extremities.On 5/27/26 at 11:10 AM V26, Registered Nurse (RN), stated she was asked by a CNA if she was aware of R2's shoulder and chest area being swollen. V26 stated she did not see anything noted in R2's report sheets or nurses notes. V26 stated when she assessed R2, she noticed a large, raised area under R2's breast and bruising with discoloration to R2's arm and under arm, V26 stated she does not remember what side of R2's body this was on. V26 stated she was not informed of any bruising of discoloration when she received report on R2. V26 stated she called V1, Administrator, regarding the bruising and V1 stated she was not aware. V26 stated V1 informed V26 to start an investigation and interview staff. V26 stated the local police department was notified and R2 was sent to the local hospital for evaluation.On 5/28/26 at 12:18 PM V30, RN, stated she noticed some bruising on the night of 5/10/26 when she worked with R2. V30 stated she observed bruising under R2's right arm by R2's breast, to the top and middle of R2's right breast that extended to R2's left breast. V30 stated the worst bruise was on R2's right side and it extended to R2's bend of her arm. V30 stated the bruises were green and yellow in color, in different stages of healing, and looked as though they had been there awhile. V30 stated she is not sure if she documented the bruising and if she did not, she meant to. V30 stated she did not report the bruising to V1, Administrator, because she assumed another staff member already did.On 5/28/26 at 2:03 PM V24, CNA, stated she was not working on R2's hall on the night of 5/10/26, but remembers V30 coming to the nurse's station showing pictures of bruises on R2. V24 stated V30 asked if any staff knew of the bruises on R2 and no staff members were aware. V24 stated she asked V30 what the next step was regarding the bruises and V30 mentioned contacting V1. V24 stated she knows staff is supposed to report any bruising or injuries to V1 immediately, but she was not going to tell V30 what to do, since V30 is the nurse and was in charge. V24 stated V30 did not report the bruises to V1 that night.On 5/28/26 at 4:00 PM V1 stated allegations of abuse, neglect, or injuries of unknown origin, are to be reported to her immediately.On 5/29/26 at 9:16 AM V1, Administrator, stated she was first notified of the bruising to R2 on 5/13/26. V1 stated she expects her staff to follow the facility policy on reporting any allegation of abuse, neglect, or injury of unknown origin. V1 stated she was not aware of any staff member noticing the bruising on R2 on 5/10/26, and if she was notified then, she would have reported it right away.The Facility's Abuse Prevention Program Date Reviewed 9/2017 documents Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Internal Reporting Requirement and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual. Following the discovery of any suspicious bruises, lacerations, or other abnormalities of unknown source the nurse shall complete a full assessment of the resident for other bruises, laceration, or pain.

Based on interview and record review, the facility failed to report an injury of unknown origin immediately to Administration for 1 (R2) of 7 residents reviewed for abuse in a sample of 15.Findings Include:R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of Aphasia, Hemiplegia, Weakness, Abnormal Posture, Contracture of the Right and Left Knee, Contracture of the Right and Left Ankle, and Dementia.R2's Care Plan Date Initiated 11/19/13 documents R2 has a communication problem related to Cerebrovascular Accident (CVA). [NAME] is nonverbal and only able to make unintelligible sounds and is unable to communicate effectively with verbal and non-verbal gestures.R2's Care Plan Date Initiated 3/2/17 documents R2 is considered at risk for abuse/neglect due to, mood cognition, weakness, behavioral/physical deficits.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is rarely/never understood, has a memory problem, has an upper and lower extremity impairment on both sides, uses a wheelchair, needs supervision or touching assistance with eating, is dependent on staff for toileting hygiene, showering/bathing, personal hygiene, rolling left and right, lying to sitting on side of bed, chair/bed to chair transfers, and is always incontinent of bladder and bowel.R2's Nurses Notes dated 5/13/26 at 10:09 AM documents This nurse was called into the residents room at 6am and informed that the resident had an area on her chest and wanted to know if I was aware. When the nurse entered the residents room and accessed the area this nurse noted a large raised, firm, warm to touch, dried popped blistered area that extends from right arm pit, and severely painful area to right upper chest and shoulder. Nurse checked progress notes and nothing had been documented and there was not risk management completed. So, the nurse called (V1) Administration and notified her of the findings. This nurse informed (V1) that a staff Certified Nursing Assistant (CNA) said that the areas were noticed by a night nurse on Sunday night. Head to toe assessment completed and the following was also noted bruising and swelling on the chest area, bruising on the right side, scattered bruises, scabs, and discoloration on bilateral lower extremities (BLE). The right elbow is very swollen and painful. Buttocks skin is intact. Pedal, brachial, and radial pulses noted to be weak on the right side. The administrator informed the nurse that a police officer would be coming to the facility to see the resident. Female Officer came 0745 and evaluated the resident and took pictures of some of her areas. Officer asked when this first notice and nurse informed her that CNA said that Sunday night nurse was aware and had taken pictures and notified the other nurse that night.R2's Hospital Records dated 5/13/26 documents Chief Complaint: patient presents with bruising. History of Present Illness (HPI): Per staff member, bruising reportedly noted Sunday and Monday to patient's chest and right shoulder, with no documentation of any injuries. She is unable to provide any history about what happened due to be nonverbal. Exam concern described for significant bruising and swelling of the right chest wall, right axilla, and right upper arm, with an associated scrape in the armpit/axilla.The Facility's Initial Report dated 5/13/26 documents Staff reported to administrator while performing care noticed a dark discoloration under right armpit. Medical Director (MD) notified and order received to send to emergency room (ER) for evaluation. Investigation initiated. Final report to follow.R2's Local Police Department Incident Report Dated 5/13/26 documents On 05/13/26 at approximately 0728 hours, I was dispatched to (Nursing Facility), in regards to (R2) having a large amount of bruising and unknown injuries. I arrived on scene and contacted Nurse (V26), (V26) advised she was working nights last night when she was advised of an issue with (R2). (V26) advised she did an assessment on (R2) after being told about some bruising on (R2's) right side. (V26) advised she reviewed (R2's) paperwork and was unable to locate any previous documentation of this injury, but was advised the night nurse on Sunday, 05/10/26, verbally stated she noticed bruising. During (V26's) assessment, she observed yellow discoloration on (R2's) right arm, both breasts, and the right side under (R2's) arm. (V26) advised she observed what appeared to be a large, red and purple blister near (R2's) right armpit, and purple bruising down her side and underneath her right breast. (V26) advised the right side of (R2's) body near her injuries was cold to the touch and the skin was tight. (V26) advised she noticed (R2's) right leg was cold to the touch compared to the left, and all of the pulses on her right side were much weaker than the left. (V26) advised during her assessment, although (R2) is nonverbal, she noticed (R2) to be in excruciating pain when touching the right side of her body and the right extremities.On 5/27/26 at 11:10 AM V26, Registered Nurse (RN), stated she was asked by a CNA if she was aware of R2's shoulder and chest area being swollen. V26 stated she did not see anything noted in R2's report sheets or nurses notes. V26 stated when she assessed R2, she noticed a large, raised area under R2's breast and bruising with discoloration to R2's arm and under arm, V26 stated she does not remember what side of R2's body this was on. V26 stated she was not informed of any bruising of discoloration when she received report on R2. V26 stated she called V1, Administrator, regarding the bruising and V1 stated she was not aware. V26 stated V1 informed V26 to start an investigation and interview staff. V26 stated the local police department was notified and R2 was sent to the local hospital for evaluation.On 5/28/26 at 12:18 PM V30, RN, stated she noticed some bruising on the night of 5/10/26 when she worked with R2. V30 stated she observed bruising under R2's right arm by R2's breast, to the top and middle of R2's right breast that extended to R2's left breast. V30 stated the worst bruise was on R2's right side and it extended to R2's bend of her arm. V30 stated the bruises were green and yellow in color, in different stages of healing, and looked as though they had been there awhile. V30 stated she is not sure if she documented the bruising and if she did not, she meant to. V30 stated she did not report the bruising to V1, Administrator, because she assumed another staff member already did.On 5/28/26 at 2:03 PM V24, CNA, stated she was not working on R2's hall on the night of 5/10/26, but remembers V30 coming to the nurse's station showing pictures of bruises on R2. V24 stated V30 asked if any staff knew of the bruises on R2 and no staff members were aware. V24 stated she asked V30 what the next step was regarding the bruises and V30 mentioned contacting V1. V24 stated she knows staff is supposed to report any bruising or injuries to V1 immediately, but she was not going to tell V30 what to do, since V30 is the nurse and was in charge. V24 stated V30 did not report the bruises to V1 that night.On 5/28/26 at 4:00 PM V1 stated allegations of abuse, neglect, or injuries of unknown origin, are to be reported to her immediately.On 5/29/26 at 9:16 AM V1, Administrator, stated she was first notified of the bruising to R2 on 5/13/26. V1 stated she was not aware of any staff member noticing the bruising on R2 on 5/10/26, and if she was notified then, she would have reported it right away.The Facility's Abuse Prevention Program Date Reviewed 9/2017 documents Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Internal Reporting Requirement and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual. Following the discovery of any suspicious bruises, lacerations, or other abnormalities of unknown source the nurse shall complete a full assessment of the resident for other bruises, laceration, or pain.

Based on interview and record review the facility failed to initiate the process to timely obtain prescription medication for 2 of 6 residents (R1, R3) reviewed for medications in the sample of 10. This failure resulted in R1 experiencing unnecessary severe pain and suffering. Findings Include:1.R1's admission Record, print date of 11/17/25, documented R1 has diagnoses including acquired absence of right leg above the knee, peripheral vascular disease, cellulitis of left lower limb, type 2 diabetes mellitus, COPD (chronic obstructive pulmonary disease), hereditary and idiopathic neuropathy, hyperlipidemia, anxiety disorder, depression, heart failure, and hypertension. R1's MDS (Minimum Data Set), dated 8/21/25, documented R1 is cognitively intact, and requires partial/moderate assistance with transfers. R1's progress note, dated 11/10/25 and authored by V11 Nurse Practitioner, documented R1 was hospitalized from [DATE] - 11/10/25 for acute worsening of chronic left lower extremity venous ulcers with cellulitis and MRSA (methicillin resistant staphylococcus aureus) history; she received IV antibiotics and wound care. On return, she reports mild baseline leg pain (2/10). It continues, Past Surgical History: Right above-knee amputation (AKA) for compartment syndrome and foot infection (recent) - surgical wound debridement (left foot, recent). R1's Lyrica medication order, print date of 11/18/25, documented R1's Lyrica order was initiated on 1/21/25. This order documented Lyrica capsule 75 MG (Pregabalin) *controlled drug*, give 1 capsule by mouth three times a day for nerve pain. On 11/17/25 at 10:15 AM R1 stated the facility has been out of her Lyrica for 5 days. R1 stated when she asks the nurses about it, they just reply it has been ordered. On 11/17/25 at 10:53 AM V5 RN (Registered Nurse) stated (R1) is out of her Lyrica. V5 stated she is not sure how long she has been out. Surveyor asked V5 if the issue is with R1's physician not being notified in time to re-new her Lyrica prescription and V5 replied I think so because most of the agency nurses don't go through the cart to see what needs re-ordered. V5 then stated she went through the med cart this am and made a list of re-fills that are coming due for the nurse practitioner to send in. Surveyor asked V5 if R1's Lyrica will be delivered this evening and V5 replied it might come in this evening.On 11/17/25 at 2:13 PM V5 RN stated R1 is still out of her Lyrica and didn't receive her noon dose. Surveyor asked what the #9 on R1's MAR indicates for R1's Lyrica that was supposed to be administered today at noon and V5 replied 9 means it's on order from the pharmacy.R1's November 2025 MAR (Medication Administration Record) documented a #9 rather than a check mark for R1's Lyrica capsule 75 MG on the following dates and times R1 was supposed to receive her scheduled Lyrica: 11/15/25 at 6 AM, 11/15/25 at 9 PM, 11/16/25 on all 3 scheduled doses at 6 AM, 12 PM, and 9 PM, on 11/17/25 on all 3 scheduled doses at 6 AM, 12 PM, and 9 PM, and on 11/18/25 at 6 AM. This MAR documented chart codes #9 = other/see nurse notes.R1's progress note, dated 11/15/25 at 6:16 AM, documented e-MAR administration notes, Lyrica capsule 75 MG, give 1 capsule by mouth three times a day for nerve pain, med not available, reorder sent to pharmacy. R1's progress note, dated 11/15/25 at 9:43 PM, documented Lyrica capsule 75 MG, give 1 capsule by mouth three times a day for nerve pain, med not available, reorder sent to pharmacy. R1's progress note, dated 11/16/25 at 5:21 AM, documented Lyrica capsule 75 MG, give 1 capsule by mouth three times a day for nerve pain, med not available, reorder sent to pharmacy. R1's progress note, dated 11/16/25 at 5:24 PM, documented Lyrica capsule 75 MG, unavailable, reordered, awaiting new. R1's progress note, dated 11/16/25 at 10:16 PM, documented Lyrica capsule 75 MG, med not available. R1's progress note, dated 11/17/25 at 5:45 AM, documented Lyrica capsule 75 MG, med not available. R1's progress note, dated 11/17/25 at 12:45 PM, documented Lyrica capsule 75 MG, on order. On 11/18/25 at 8:00 AM V5 RN stated R1's Lyrica did not come in last night. Surveyor asked V5 if she knows the reason the Lyrica did not come in and V5 replied the Nurse Practitioner doesn't have a NPI (National Provider Identifier) number yet.On 11/18/25 at 8:05 AM R1 stated her Lyrica manages her nerve pain especially the phantom pain she experiences due to her leg amputation. R1 stated today is day 6 without the medication and her phantom pain rating has been between a 7 and 10 on a scale of 0 to 10. R1 stated when she receives her Lyrica as ordered her phantom pain averages a 3 on the pain scale.On 11/18/25 at 9:18 AM Surveyor asked V2 DON (Director of Nursing) if she knows why R1 has not been receiving her Lyrica medication. V2 stated no and she would find out what is going on with the medication because every Wednesday she goes to all the nurses and asks them what residents need narcotic drug refills from the Physician. Surveyor asked V2 if she feels it is acceptable for R1 not to receive her Lyrica as ordered for the last 4 days and V2 replied no. Surveyor then asked V2 if she can find out why R1's Lyrica order has not been refilled and if it is because the Nurse Practitioner does not have a NPI number yet. V2 stated she would check into it. On 11/18/25 at 9:42 AM V11 APRN (Advanced Practice Registered Nurse) stated she does have a NPI number, or she couldn't practice at the facility. V11 stated she just received her DEA (Drug Enforcement Administration) number this week and the nurse must be referring to that although the Physicians have been signing off on the controlled drug orders. Surveyor asked V11 if it is acceptable for R1 to go without her Lyrica for over 4 days and V11 replied it is never okay for a patient to go without their scheduled medication.On 11/18/25 at 10:32 AM Surveyor asked V2 DON and V5 RN if R1's Medication Monitoring/Control Record documented R1's last Lyrica was administered at 9 PM on 11/14/25 if that means that is the last time R1 received her scheduled Lyrica. V2 replied not necessarily because the nurses should get one from the E-kit. Surveyor asked V5 in the presence of V2 if she pulled a Lyrica from the E-Kit on 11/17/25 for R1 and V5 replied no. V5 then confirmed again to Surveyor that she did not administer R1's Lyrica as scheduled on 11/17/25.On 11/18/25 at 3:20 PM surveyor asked R1 if her pain has been at a zero since she has not been receiving her scheduled Lyrica and R1 replied my pain is never a zero and you are the only nurse who has asked me about my pain in the last 3 days. R1 stated her phantom pain was between a 7 - 10 this am and since the facility got her Lyrica back in stock and she received her noon dose today her pain is back down to a 3.On 11/18/25 at 3:32 PM surveyor asked V2 DON if R1's most recent count sheet documenting R1's last dose of Lyrica was administered on 11/14/25 at 9 PM is the last time R1 received her Lyrica until today at noon. V2 stated as far as she knows it was because pharmacy has not sent any documentation showing it was administered from the E-kit and that V13 ADON stated they couldn't have got any Lyrica for R1 out of the E-kit without a new order because the E-kit does not have R1's required dosage.On 11/19/25 at 9:33 AM V13 ADON (Assistant Director of Nursing) presented an incident report to surveyor for R1 not receiving her Lyrica as ordered. V13 stated the incident says the Lyrica was to be on hold until it came in stock. Surveyor asked why the order was never placed on hold and V13 stated when he was called on 11/14/25 about R1 being out of her Lyrica he told the nurse to call the doctor and put the order on hold, but the nurse must not have followed through on that.R1's incident report, dated 11/15/25 at 6:15 AM and authored by V13, documented this writer was notified by the floor nurse that resident's Lyrica is out of stock. Resident assessed for pain. No c/o pain or discomfort voiced. Physician notified. New order obtained to place the medication on hold until the medication becomes available from the pharmacy. R1's progress notes do not document anything regarding this incident report. On 11/19/25 at 10:16 AM V11 Nurse Practitioner stated she checked the physician notification records for R1 and there is nothing documented regarding R1's physician and/or clinician who was on call being notified of R1 being out of Lyrica nor was an order implemented to hold R1's Lyrica until it was delivered to the facility.2.) R3's admission Record, print date of 11/17/25, documented R3 has diagnoses including cerebral infarction, type 2 diabetes mellitus, COPD, hypokalemia, anemia, coagulation defect, hypothyroidism, hyperlipidemia, anxiety disorder, obstructive sleep apnea, hypertension, nonrheumatic mitral valve insufficiency, generalized osteoarthritis, and depression. R3's MDS, dated [DATE], documented R3 is cognitively intact and is dependent on staff and a mechanical lift for transfers to and from her wheelchair. R3's care plan, undated, documented R3 is diabetic, resident is at risk for hypo/hyperglycemia related to diagnosis of diabetes mellitus with interventions including administer medication as ordered. On 11/17/25 at 11:35 AM R3 stated she has not been receiving her Ozempic injection every week as ordered, and the nurses tell her they can't find it when she asks them about it. R3's physician order, print date of 11/19/25 and order date of 10/16/25, for Ozempic documented order summary: Ozempic (2 MG/dose) subcutaneous solution pen-injector 8 MG/3ML (semaglutide), inject 2 mg subcutaneously one time a day every Thursday for diabetes give 2 mg dose, pen should last 28 days - 4 doses. R3's MAR, dated 11/2025, documented Ozempic (2 MG/dose) subcutaneous solution pen-injector 8 MG/3ML (semaglutide). Inject 2 mg subcutaneously one time a day every Thursday for diabetes, give 2 mg dose, pen should last 28 days, 4 doses. Administration date of 11/6/25 at 6 PM documented #9 (other/see nurse's note).R3's progress note, dated 11/6/25 at 5:35 PM documented Ozempic (2 MG/dose), inject 2 mg subcutaneously every Thursday for diabetes give 2 mg dose pen should last 28 days, 4 doses, medication not in. On 11/19/25 at 11:06 AM V1 Administrator stated she expects residents to receive their medications as ordered.The facility's Pharmacy Services policy, dated 9/2017, documented pharmacy services are provided by a licensed pharmacy. The role of the pharmacy, as well as pharmacy policies are outlined in the pharmacy policy manual. Responsible Party: DON, Administrator. Guideline: 1. Pharmaceutical services are available to ensure that resident's medications and biologicals are provided as ordered. 2. The facility does not accept money, goods, or services free or below cost from any pharmacy. 3. Pharmaceutical services provide appropriate methods and procedures for the procurement, dispensing and administration of drugs and biologicals per the individual pharmacy policy. 4. Pharmacy services are monitored to assure that the drug distribution system, to include the ordering, labeling and administering of drugs and biologicals, in is compliance with established policies and procedures. 5. Pharmacy services are provided on a 24-hour basis.

Based on interview and record review, the facility failed to provide Physician prescribed medication for 2 of 7 (R2, R9) reviewed for medications in the sample of 20. This failure resulted in R9 missing 6 doses of pain medication leaving her in pain.Findings include:1. On 9/17/25 at 10:00 AM, R9 stated I ran out of my pain medication oxy (oxycodone). I went for 3 days without pain medication. I wanted to cut my leg off it hurt so bad. I take it for my phantom pain in my right leg and the wound infection in my left leg. I don't know why I ran out either they didn't reorder it, or pharmacy didn't deliver it.R9's Minimum Data Set, dated [DATE], documents R9 is cognitively intact.On 9/25/25 at 1:47 PM, V4 LPN, stated R9 did run out of her oxycodone. Her prescription had run out, and I think she was changing providers or something. R9's Physician Order, dated 9/13/25, documents, oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 4 hours for Pain.R9's September 2025 Medication Administration Record documents R9 did not receive her prescribed 5 mg of Oxycodone on 9/15/25 the 9 AM dose, 1 PM dose, 5 PM dose, 9 PM dose, 9/16/25 1 AM dose, and the 5 AM dose.2. R2's Physician Order, documents, oxyCODONE HCl Oral Tablet 15 MG (Oxycodone HCl) (Oxycodone HCl) Give 7.5 mg (milligrams) by mouth six times a day for pain start date of 5/8/25.R2's Nurses Note, dated 8/29/2025 06:32, documents, Call out to (pharmacy) to obtain the status of order for pain medication. Per pharmacy a quantity of 4 was ordered and 2 sent. Remaining 2 will be sent this morning. New order from MD (Medical Doctor) will be needed.R2's Medication Administration Record (MAR), dated August 2025, documents R2 did not receive the prescribed oxycodone 7.5 mg on 8/28/25 10 PM dose, 8/29/25 2 AM dose, and 6 AM dose.R2's Minimum Data Set, dated [DATE], documents R2 is cognitively intact.On 9/16/25 at 11:27 AM, R2 stated about a month or so ago I ran out of my pain medication, but it is better now.On 9/25/25 at 1:16 PM, V2, Director of Nurses stated that R2 missed 3 doses of oxycodone.On 9/24/25 at 10:02 AM, V4, Licensed Practical Nurse, stated, sometimes we do run out of pain medication for the residents. I will call the doctor and get them to send over a prescription to the pharmacy if a new prescription needed to be written. If their order needs to be rewritten, you can't get the medication from the (emergency medicine dispensing machine).On 9/24/25 at 9:01 AM, V2, Director of Nurses, stated, we are in the middle of changing pharmacies. The nurses should be calling pharmacy when the resident is down to a weeks' worth of pills. If the resident needs a new prescription, the pharmacy will call the doctor, and the doctor will send a prescription. If the resident does run out of medication, we have the (emergency medicine dispensing machine) which the staff can pull medications from. Most narcotics are in there.The policy medication Administration, dated 4/25, documents, 26. If medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain from the contingency or convenience box. 27. If the physician's order cannot be followed for any reason, the physician should be notified in a timely manner, and a note should reflect the situation in the resident's medical record.

Based on interview, observations, and record review, the facility failed to arrange a specialty Physician appointment for 1 of 3 residents (R2) reviewed for doctor appointments in the sample of 7. This failure resulted in R2 not receiving treatment for his poor vision, worsening vision, and only being able to see shadows.Findings include:R2's admission Record, print date of 7/2/25, documents R2 was admitted on [DATE] with diagnoses of Blindness one eye, low vision other eye, and Cortical age - related cataract right eye.R2's Minimum Data Set, dated [DATE], documents R2 is cognitively intact and has severely impaired vision.R2's Minimum Data Set, dated [DATE], documents R2 is cognitively intact, has severely impaired vision and requires supervision/ touching assistance with walking.R2's Hospital Transfer Orders For The Receiving Facility, dated 7/18/24, documents, Follow Up Instructions and Future Appointments: Referred to SLUCARE Physician Group - Ophthalmology.R2's Physician Order, dated 10/17/24, documents, Refer to ophthalmology for evaluation and treatment of bilateral cataracts.R2's Physician Order, dated 2/12/25, documents, refer to ophthalmologist r/t (related to) cataracts.R2's Physician Order, dated 5/15/25, documents, Referral to Ophthalmologist. Worsening vision.R2's eMAR (electronic Medications admission Record)- Medication Administration Note, dated 2/20/2025 19:54, documents, I also see a note that he has a referral for an eye doctor. Can we confirm or make a referral for an ophthalmologist? Thank you, STAT (urgent) Referral, printed and provided to Transportation to set appointment.R2's Care Plan, dated 7/26/24, documents, (R2) is at risk for falls due to Functional Deficits, Visual Impairments. Intervention: 6/9/25 Educate resident on being more aware of surroundings and ensuring clear pathway when walking.R2's Care Plan, dated 7/26/24, documents, VISION: Resident has impaired Vision as evidenced by sign. vision loss, Cataract right eye. Interventions: Orient to surroundings PRN (as needed) Interventions: Place items within easy reach and orient to placement. Provide the following environmental adaptations: -adequate lighting -avoid clutter, avoid obstructed pathways -avoid glares, shadows -braille markings as indicated.On 6/30/25 at 10:09 AM, V3, Social Worker, stated R2 let me know last week that he wanted to see an eye doctor since I know exactly what insurance he has now, I will send out referrals.On 6/30/25 at 9:48 AM, R2 stated, I have never seen the eye doctor since I have been here. I have a cataract on the right eye. I got bit by a dog last April/May and it caused me to get an infection. After that I could only see shadows. I could see someone come in and take my body wash. Since I don't see that well, I couldn't tell you who it was.On 6/30/25 at 1:21 PM, V12, Licensed Practical Nurse, stated, R2 only sees shadows.On 7/2/25 at 9:40 AM, R2 stated, Since I have been here my vision has gotten worse in my right eye and better in my left eye. My right eye hurts too when I open and close my eye.On 7/2/25 at 10:00 AM, V19, Transport, stated she is the person that makes all of the appointments. V19 stated, I had (R2) set up with (eye doctor) in November but his insurance was not active at that time, so they canceled the appointment, and it was rescheduled. When the rescheduled appointment came up, they canceled it because they did not take his insurance. I kept trying to find him a doctor that took his insurance and treated cataracts. I just found one and he goes on 6/18/25. V19 stated that she just has notebooks to keep track of appointments and who was called. At this time, V19 provide one undated note about referring R2 to an eye doctor who does cataracts.On 7/3/25 at 10:10 AM, V21, Nurse Practitioner, stated, Cataracts only get worse over time. I don't know how many doctors they reached out to find him care. That is something I would like to know. V21 was informed the facility had no proof of reaching out to eye doctors for R2.On 6/30/25 at 9:48 AM, R2 was observed ambulating in his room. R2 walks with a slow gait, slightly hunched over, with his hands out in front of him to touch objects with.On 7/2/25 at 9:20 AM, R2 was informed that the facility was able to get him into an eye doctor on 6/18/25. R2 became visibly emotional with happiness and thanked surveyor for all of the help.The policy Physician Orders, dated 9/24, documents, Physician orders are followed as written; if there is a question about the order, contact the physician for clarifications.

Based on interview and record review the facility failed to ensure residents were not asserting dominance over other residents for 2 of 6 residents (R1, R6) reviewed for abuse in the sample of 12. Due to this failure, R1 became tearful, scared, and embarrassed about a sexual abuse allegation, refusing to be seen by a provider due to being afraid of what may happen, refused therapy, and reported he lived in fear, confining himself to his room since (R6) resided across the hall from (R1). Findings include: 1-R1's Face sheet dated 5/13/25, documents R1 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Cerebral Palsy, Epilepsy, Schizophrenia, and Major Depressive Disorder. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires the use of a wheelchair. R1's Care Plan, dated 2/14/25, documents R1 is at risk for abuse and neglect. R1's Care Plan, dated 3/18/25: Alleged sexual assault. R1's Care Plan, dated 5/12/25: Recipient of alleged sexual assault. Interventions: 3/18/25 Social Service Director had conversation with resident about inappropriate behavior. Residents not able to sit together in dining room, if seen together to separate. R1's Care Plan, dated 3/18/25: placed on enhanced supervision. R1's Care Plan, dated 5/12/25 notified abuse coordinator, observe the resident for signs of fear and insecurity during delivery of care, take steps to calm the resident and help him feel safe, 1:1 Supervision, Social Services to meet with resident as needed, assess resident for abuse and neglect upon admission and quarterly. It continues R1 has diagnosis of Schizophrenia and may display symptoms that include but are not limited to being out of touch with reality (delusional or hallucinations), may have disorganized speech or erratic behavior, decrease in activities. Diagnosis of mental illness. It continues R1 requires assistance with daily care needs. R1's Care Plan does not address R1 being bullied and/or any resident asserting dominance over him. On 5/28/2025 at 10:02 R1's Behavior Tracking was requested. No behavior tracking was provided to the surveyor for R1. The Facility's Identified Offender lists document R1 and R6 both as Identified Offenders with R6 being convicted of second-degree murder in 1990. On 5/28/2025 at 2:03 PM, R1 was lying in bed. R1 appeared very thin in appearance and his body was leaning to the right side. On 5/14/25 at 10:20 AM, R1 stated I usually sleep naked, and the other night (R6) came into my room and asked me if I wanted some pizza. I said yes and told him to put it on the table. I thought that (R6) had left the room but then I felt my blanket being pulled off me. The next thing I know, (R6) had me by the back of my neck and was pushing my head into my pillow. That's when I felt someone playing with my a** and then he put a finger up my a**. I yelled at him and told him to get off me. I know it was him because I recognized his voice and when I turned over, I saw him walking out of my room. I did tell some staff about it. I did not want to go to the hospital to get checked because I was embarrassed and afraid of what might happen. (R6) was in the same penitentiary that I was in, and he is still picking on me. There are times I can be in the hall or outside and he will grab me by my neck and say bad things to me. I know what it was like in prison, so I am scared of him here. R1 appeared upset and teary eyed while discussing this incident. On 5/29/2025 at 3:01 PM, R1 stated, (R6) and him were alright, but he would not call them friends. (R6) does buy him food at times, candy and soda. He stated (R6) still thinks they are in prison and treats him like they are still in prison. R1 stated he (R6) has always bullied him, and he is constantly telling him he is going to mess him up and stab him or fuc* him over if he does not do what he tells him to do. I can't do much anyway, so it does not matter. Things changed for me when he came into my room, woke me up and was playing with my butt and stuck something up my butt. I want a lawyer. I am not sure why he did it, I think he wants me to know he is the boss of me. I know I am not in prison anymore and (R6) abuses me like we are still in prison. I see him mostly during smoke breaks. I don't like to leave my room now. R1 appeared upset and teary eyed while discussing this incident and his voice was shaky while he was talking about (R6). On 5/14/25 at 10:55 AM, R7 stated I always see (R6) trying to dominate (R1). (R6) grabs (R1) by the back of his neck or pinches his shoulders and will tell him things like 'I'm going to play with you like a fidget [NAME]'. I know they were both in prison together and some things might have started there. The look on (R1's) face and the tear in his eyes showed me he was clearly upset over this. I totally believe that incident happened in (R1's) room because I've seen him treating (R1) like that before. I know that since that incident, they have put both on 1:1 supervision and they moved (R1) out of his room to another hall. It seems like they are punishing (R1) while protecting (R6). There is no doubt in my mind that (R6) is abusing (R1). On 5/29/2025 at 10:03 AM, R7 stated, I have seen (R6) during smoke breaks harass (R1) and I know staff have seen it too, but everyone is afraid to speak up because nobody wants to get in trouble and/or lose their job, but (R1) is not in prison anymore and should not have to live in fear and be bullied. Like I told the other surveyor, (R6) tries to dominate (R1) and I don't think it is right. I have heard him tell him he is going to hurt him and/or play him like a fidget [NAME]. I know since the incident occurred (R1) has been staying in his room more. On 5/14/25 at 10:40 AM, V5, Restorative Certified Nursing Assistant (CNA), stated I work with (R1) all the time for therapy, and we have a really good relationship. I also heard a while back that (R1) and (R6) have had things going on for a long time, because (R7) stated that (R6) is always picking on (R1) and flicking his ear and telling (R1) he is going to treat him like he was treated in the joint. I told the previous Administrator about all of this at that time, and she brushed it off and acted like it never happened. Then this happened to (R1) and he cannot really defend himself. This is terrible and very serious and hope that something gets done. On 5/14/25 at 11:35 AM, V4, Director of Rehab, stated I have overheard (R6) has been victimizing (R1) and bullies and picks on him all the time, and that they were in prison together and (R6) victimized him in prison too. (V7, Nurse Practitioner (NP) told me that (R6) threatened to kill her and that she was surprised that (R6) is still in the facility. It's awful for (R1) to be treated like that. On 5/14/25 at 11:45 AM, V7, Nurse Practitioner (NP), stated, I, myself, was threatened by (R6). (R6) really likes his pain medications and his insurance was declining his Oxycodone, so I had to change him to Percocet, and he hysterically flipped on me and told me I had to watch my back. I talked to my fiancée because I was scared, and I cried every time I would have to come to the facility for a good two weeks. He gets passes out to the community and then comes back so who knows what he is getting out there, drugs or weapons. (R6) scares me, and he doesn't need to be here. He is a threat to everyone in here, residents and staff. On 5/30/2025 at 1:48 PM, V7 stated, (R6) was upset with me because of his medication change and he said several things to me and told me to watch my back and threatened me. I told V34, the former Administrator. (R1) came into the therapy room and made an allegation that he had been sexually abused by (R6). At that time staff started talking and they were saying (R6) had a history with (R1) and he had been bullying (R1). (V34) was aware of it. I am not sure what their policy is regarding abuse. I can only go by my experience, and I think (R6) is dangerous and at times can be unhinged. If a resident was being bullied by another resident, I would not expect the other resident to ever be alone with that resident. R1's Progress Notes R1's Nurses Note, dated 5/12/25 at 12:15 PM, documents Resident reported that he was sexually assaulted by resident (R6) in his bedroom while laying [SIC] in his bed. Resident stated that resident (R6) entered his room, sexually assaulted him, then exited the room. Resident stated he did not see the resident's face but, he did recognize who the resident was because he knows his voice and noticed him while he was walking out the door. Nursing staff attempted to assess resident, but resident refused. Administrator, Director of Nursing (DON), and NP notified and made aware. (Local Police Department) notified and resident interviewed. Residents separated; Resident placed on 1:1 supervision; Resident relocated; All previous interventions in place; Care plan updated. On 5/28/2025 at 9:34 AM, V1, Administrator stated, I started working as the Administrator here at the end of March. I have been here almost two months now. The DON (Director of Nursing) is also new to the position. Staff stated (R6) and (R1) were incarcerated together at (V32, Correctional Facility). They do have a history. From my understanding they were both in the same gang in prison, so they were not rivals. I am not aware of any issues they had when they were in prison. They are both identified offenders. (R1) initially reported to the CNA (certified nursing assistant) that he was sexually assaulted by (R6). (R1) told me (R6) came into his room and held his head down and he was sexually abused. But the stories were conflicting and kept changing. I was not able to substantiate it. On 5/30/2025 at 12:54 V34, Former Administrator at facility stated, I don't recall anything related to (R1) and (R6) but I was only at the facility for a few months. I did not really know either of them. On 5/30/2025 at 3:48 PM, V32, Certified Nursing Assistant stated, she was currently doing one on ones with (R1). He usually goes out in the morning and smokes, then he will go into the dining room and eat breakfast then he will go back to his room, and he will stay there until the next day. His routine changed and he stays in his room a lot more now. I am not sure why, but his routine had definitely changed, and he is in his room more. 2- R6's Progress Notes dated 8/15/2024 at 3:37 PM document he was admitted to the facility. R6's Physician Order Sheet (POS) dated May 2025 documents a diagnosis of Aftercare following joint replacement surgery, Chronic Obstructive Pulmonary Disease unspecified, Unspecified lack of coordination, Difficulty in walking, Unsteadiness on feet, Weakness, Major Depression, Chronic Pain, Chronic Kidney Disease Stage 2, Periprosthetic Fracture Around Internal Prosthetic Right Shoulder Joint, Displayed Fracture of Glenoid Cavity Scapula. R6's Mnium Data Set (MDS) dated [DATE] document he is cognitive intact for decision making for activities of daily living and has no impairment on his upper and/or lower extremities. R6's Care Plan document dated 4/12/2024 documents AMBULATION: has a self-care deficit in ambulation related to (r/t) inability to walk independently/ history of unsteady gait/ walks for short distances but uses the w/c for longer distances, with guided practice has the opportunity for continued progress. R6's Care Plan does not document anything related to abuse. R6's Care Plan, dated 4/7/25, documents R6 is at risk for abuse and neglect. 5/12/25 Alleged sexual assault. It continues R6 has a history of aggressive, inappropriate behavior, but has demonstrated stability during the admission screening process and is therefore considered appropriate for admission. R6's Progress Notes does not document anything related to him being on one on ones and/or the allegation of sexual abuse made against him by R1. The Facility's Resident Rights policy, dated 8/1/22, documents The facility strives to consistently and fully comply with the various laws and regulations, including but not limited to 42 CFR 483, pertaining to the treatment, services and needs of residents to attain or maintain residents' highest practicable physical, mental and psychosocial well-being. The facility shall: Not engage in verbal, mental, or physical abuse, corporal punishment and involuntary seclusion. The Facility's Abuse Prevention Program policy, dated 9/2017, documents in part The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault by a licensee, employee or agent. Sexual abuse is non-consensual sexual contact of any type with a resident. IV. Establishing a Resident Sensitive Environment: This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis, and update as necessary. For residents who are identified offenders, the facility shall incorporate the Identified Offender Report and Recommendations Report into the identified offender's plan of care including security measures listed. VI. Protection of Residents: Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents.

Based on record reviews and interviews the facility failed to complete the admission process and transcribe medications to Physician Order Sheet, the Medication Administration Record, obtain medications from the pharmacy and administer medications as ordered by the physician for 1 of 3 (R3) residents reviewed for significant medication errors. This failure resulted in R3 experiencing shortness of breath, heart palpitations, elevated blood glucose levels, untreated Urinary Tract Infection (UTI), R3 feeling like he was going to die, hospitalized and received critical care for untreated Urinary Tract Infection. Findings include: R3's Census Report, not dated, documents that R3 was admitted to the facility on [DATE] with the following diagnoses: AKI on CKD IV non anion gap metabolic acidosis prostatomegaly, Complicated UTI bladder stents, Fracture of left Humerus, Pacemaker, Accelerated Hypertension, Ataxia, Coronary Artery Disease status post CABG, Chronic Diastolic Congestive heart failure, Anemia of Chronic Disease, Paroxysmal Atrial Fibrillation Mobitz second degree block, Prolonged QTc interval, Non-insulin dependent Diabetes Mellitus, uncontrolled diabetes, Hyperglycemia, paraspinal disease, CVA, TIA, PVD status post Stents, CAD status post CABG, Hypertension, Hyperlipidemia, GERD, Hypotension. R3's Minimum Data Set, dated dated [DATE], documents that R3 is cognitively intact. R3's Hospital Discharge Orders, dated 4/2/2025 at 9:52 AM, documents the following 1. Isosorbide Dinitrate Oral Tablet 30 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) 2. Aspirin Oral Tablet Delayed Release 81 MG: by mouth one time a day. Give 1 tablet by mouth one time a day related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (I25.10) 3. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for supplement. 4. Levothyroxine Sodium Oral Tablet 50 MCG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for thyroid. 5. glipizide Oral Tablet 10 MG: 1 tablet by mouth two times a day. Give 1 tablet by mouth two times a day for DM before meals. 6. Cephalexin Oral Tablet 500 MG: 1 tablet by mouth two times a day. Give 1 tablet by mouth two times a day for infection. 7. hydralazine HCl Oral Tablet 25 MG: 1 tablet by mouth three times a day. Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) every 8 hours. 8. Metoprolol Tartrate Tablet 50 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) 9. Simvastatin Oral Tablet 40 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for cholesterol. 10. Xarelto Oral Tablet 15 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ATRIOVENTRICULAR BLOCK, FIRST DEGREE (I44.0) R3's Progress Notes, dated 4/2/2025 at 7:39 PM, documents that Nurses Notes Note Text: Resting in bed color pale skin w/d warm/dry denies pain sling to left arm in place resident states he can't walk unable to get resident up to br (bathroom) or have access to a bsc (bedside commode). R3's Physician Order Sheet(POS) and Medication Administration Record (MAR), dated April 2025, documents that R3's Hospital discharge orders were transcribed to the POS and the MAR on 4/5/2925. The E-Rc Message Log, not dated, documents that R3's medication orders were received on 4/5/2025 and processed on 4/6/2025. R3's Medication Administration Record (MAR), dated April 2025, documents no orders for 4/2, 4/3, and 4/4. R3's MAR documents orders transcribed 4/5/2025, 4/7/2025 and 4/8/2025. R3's MAR documents that R3 received 1 dose of Glipizide on 5/5/2025. 1 dose of Xarelto, Simvastatin, Cephalexin, Glipizide, Cyanocobalamin, Metoprolol, Pantoprazole, Isosorbide on 5/6/2025. R3 did not receive Hydrochlorothiazide, Aspirin, Ascorbic Acid, and hydralazine. R3's Progress Notes, dated 4/5/2025 at 8:02 PM, documents that eMAR- Medication Administration Note Text: Cephalexin Oral Tablet 500 MG Give 1 tablet by mouth two times a day for infection awaiting from pharmacy R3's Progress Notes, dated 4/5/2025 9:03 PM, documents that eMAR- Medication Administration Note Text: hydralazine HCl Oral Tablet 25 MG Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) every 8 hours awaiting from pharmacy. R3's Progress Notes, dated 4/6/2025 6:04 AM, documents that eMAR- Medication Administration Note Text: hydralazine HCl Oral Tablet 25 MG Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) every 8 hours awaiting from pharmacy. R3's Progress Notes, dated 4/6/2025 6:05 AM, documents that eMAR- Medication Administration Note Text: Levothyroxine Sodium Oral Tablet 50 MCG Give 1 tablet by mouth one time a day for thyroid awaiting from pharmacy. R3's Progress Notes, dated 4/6/2025 1:12 PM, documents that eMAR- Medication Administration Note Text: hydrALAZINE HCl Oral Tablet 25 MG Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) every 8 hours meds not here from pharmacy. R3's Progress Notes, dated 4/6/2025 16:54 eMAR- Medication Administration Note Note Text: glipiZIDE Oral Tablet 10 MG Give 1 tablet by mouth two times a day for DM before meals not available R3's Progress Notes, dated 4/6/2025 10:11 PM, documents eMAR- Medication Administration Note Text: hydrALAZINE HCl Oral Tablet 25 MG Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) every 8 hours to arrive within hour and bp 120/85, hr 58, 93%spo2 room air. no sob. R3's Progress Notes, dated 4/6/2025 10:13 PM, eMAR- Medication Administration Note Text: Cephalexin Oral Tablet 500 MG Give 1 tablet by mouth two times a day for infection not avail/available. take until gone to arrive am, this nurse called pharm x3 no answer. data entry R3's Progress Notes, dated 4/6/2025 11:04 PM, documents that Nurses Notes Note Text: pt bp 120/85, 58 hr. this nurse called pharm x3 to request med pulls. R3's Progress Notes, dated 4/6/2025 at 11:35 PM, documents that Nurses Notes Note Text: pt hr 56, 20/78. pt spso2 92%, ra, 2 Lo2 applied prn for pt. R3's Progress Notes, dated 4/7/2025 at 1:30 AM, documents that Nurses Notes Note Text: Resident continues to c/o chest discomfort. He called his wife and stated that he felt like he was going to die. This nurse returned a call to his wife, and she was frantic because she is so far away from the resident. This nurse was able to calm her down and talk to her. Previous nurse put the resident on 2 L of 02. Resident stated he hasn't had any meds in 3 days. He wanted to go to the hospital for evaluation. Resident sent to (Local Hospital). Report given to ER (emergency room ) nurse. VS stable. HR 66. Resident took his hearing aids. R3's Progress Notes, dated 4/7/2025 5:12 AM, documents that Nurses Notes Note Text: Resident went to (Local Hospital) instead of (Local Hospital) that was mentioned during transfer. Report from ER nurse that resident has a chronic UTI and is possibly being admitted . Waiting for call back . Wife is aware. The Pharmacy Manifest, dated 4/7/2025, documents that R3's ISOSORB DIN TAB 30MG, PANTOPRAZOLE TAB 40MG, SIMVASTATIN TAB 40MG, XARELTO TAB 15MG, glipiZIDE-10MG-TABS, CEPHALEXIN CAP 500MG, HYDRALAZINE TAB 25MG, LEVOTHYROXIN TAB 50MCG, was delivered at 1:12 AM. Signed by V5, LPN. R3's Metoprolol 50mg was delivered at 7:04 PM. Signed by V9, LPN. The (Local Hospital) Progress Notes, dated 4/7/2025, documents that Chief Complaint: Patient presents with Palpitations. Patient is an [AGE] year-old male with history of Coronary Artery Disease, Diabetes, hyperlipidemia, COPD/Chronic Obstructive Pulmonary Disease, Hypertension, for 4 hour disease, chronic kidney disease, atrial fib, and recent fracture of his left humerus who brought to emergency room for evaluation of palpitations. Patient was recently transferred to (Nursing Facility) from Decatur for rehabilitation 4 days ago. Patient states he has not received any of his routine medications presents coming to this facility. Tonight, he began having palpitations of his heart feeling like it was racing. He denies any chest pain or shortness of breath. He denies any nausea vomiting diarrhea or fever. Critical Care: Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Renal failure (Urinary tract Infection secondary to Enterococcus, Atrial Fib). It also documents that Patient reports emergency room from (Nursing Facility) after being transferred there from Decatur. Patient has multiple medical problems and has been without medical treatment for the past 4 days. He was diagnosed with an Enterococcus Faecalis Urinary Tract Infection at Decatur for which he has not been receiving medications for either. Labs came back with a urinalysis showing 51-150 white blood cells per high-power field. Troponin was negative TSH/Thyroid Stimulating Hormone was negative magnesium was normal CMP/Complete Metabolic Panel normal except for 2.02 creatinine. CBC/Complete Blood Count normal except for 8.4 hemoglobin. Chest x-ray was unremarkable. Went over these results with the patient. Also reviewed his hospital record from Decatur. Patient has multiple medical problems for which he is not being treated currently. I felt he would benefit from coming in and receiving IV antibiotics for his Urinary Tract Infection and he agreed. Also documents Pt/patient to ER 3 via EMS/Emergency Medical Service with c/o/complaints of palpitations starting 4 hours PTA/prior to admission. States he is newly at (Nursing Facility) and has not had his medication in 4 days. Pt is a diabetic, cardiac hx/history with a pacemaker. Denies any chest pain. Cardiac protocol initiated. Blood sugar 570 per EMS. It continues at 5: 12 AM V5 from (Nursing Facility) called at this time also requesting an update. Informed her that patient will possibly be admitted for medication management and urinary tract infection. Facility nurse states the reason patient has not received his daily medications in 4 days is because (Nursing facility) does not have a local pharmacy. She states their pharmacy is based in Chicago and they have not received his medications yet. ERP (emergency room physician) notified. On 5/1/2025 at 12:12 PM V4, Previous DON, stated that his last day was 4/3/2025 and he is not familiar with R3. V4 stated that the process for new admission is that the admitting nurse will transcribe the orders in PCC (Point Click Care) so that it can be sent to pharmacy. The orders are sent to the pharmacy through the PCC (Point Click Care). There is a triple check system that is in place to assure that the admission is completed correctly. On 5/1/2025 at 12:41 PM, V3, Assistant Director of Nursing (ADON), stated that she was the interim Director of Nursing after V4 left. V3 stated that the admission process is completed by the floor nurse regardless of if they work for the facility or agency. V3 stated that this includes medication and assessments. V3 stated that neither were completed timely. V3 stated that she became aware of R3 not receiving his medications on the Sunday prior to his transfer to hospital. V3 stated that the medication should have been transcribed upon admission. V3 stated that it takes 24 hours for an admission to be completed but the medications are to be transcribed within the first couple of hours of the admission. V3 stated that she is not sure why the medications were not transcribed and assessments completed. V3 stated that the admitting nurse was from an agency. V3 stated that the agency nurses can and are expected to complete the admission. V3 stated that there is a triple check system that is in place but was not done either. V3 stated that if the triple check would have been completed this would have prevented R3 from missing his medications that he needed, transfer to hospital and assessment would have been completed. V3 stated that the floor nurse regardless of if she works for the facility or agency is knowledgeable and capable of completing the admission. V3 stated that the medications are a priority and should have been taken care of. V3 stated that they only have 4 facility staffed nurses and they are all scheduled on the other side of the building. V3 stated that the nurses that provided care for R3 was agency. V3 stated that nurse mangers are to audit the admission and make sure it is completed, this was not done either. This includes medications and assessments. On 5/1/2025 at 2:33 PM V5, LPN, stated that she works for an agency and was in the facility when R3 was admitted , and V5 sent R3 to the hospital on 4/7/2025. V5 stated that the night of the admission she worked on the other hall and the nurse had 3 admissions. V5 stated that she took an admission, V8, RN, took one and V3, ADON, took one. V5 stated that V3 took R3's hospital records home so she could work on them remotely. V5 stated that the orders did not get transcribed until the 5th. V5 stated that when she started her shift, she was informed by the previous nurse that R3 wasn't feeling well and O2 had been applied. V5 stated that she went down to the room to check on R3 and perform assessment. V5 stated that R3 complained of not feeling well. O2 was in place at 2 liters. V5 stated that at that time R3 did not appear to be in any distress. V5 stated that R3 voiced concern about not receiving his medication. V5 stated that she went to the cart and R3 had orders but no medication. V5 stated that she did receive a delivery shortly after that. V5 stated that she continued to monitor R3. V5 stated that she received a call from V16, R3's wife, who voiced concern about R3. V5 stated that R3 had called his wife and informed her that he was not feeling well. V5 stated that she went down to R3's room and he complained of feeling pressure in his chest and feeling like he was going to die. V5 stated that she performed her assessment and called to transfer resident to hospital because he was having chest discomfort. V5 stated that she called V16 back and told her that she was sending R3 to the hospital. On 5/1/2025 at 2:50 PM V6, LPN, verified that she worked at the facility 4/3/2025 and 4/4/2025. V6 stated that she doesn't remember R3 and not aware of the admission. V6 stated that she is an agency nurse and is responsible for admitting resident to the facility. V6 stated that she gets the hospital documentation, put them (patient) in the system, then verify the orders and transcribe them into the computer. The orders are sent to the pharmacy after transcribed. V6 stated that during the admission process the resident is assessed and oriented to the facility. On 5/1/2025 at 2:42 PM V7, RN, verified that she worked on 4/5/2025. V7 stated that she did not administer medication to R3 and did not access the EKit to obtain medications for R3. On 5/5/2025 at 12:06 PM V10, Pharmacist, stated that R3 not receiving his Cephalexin, Metoprolol, Xarelto, hydralazine, glipizide, Imdur was not administered per the physician orders were significant med errors. On 5/5/2025 at 2:00 PM V12, Medical Director, stated that R3 not receiving his Cephalexin as directed was a significant med error with significant results as R3 was hospitalized and treated for a urinary tract infection. On 5/7/2025 at 12:22 PM V8, RN, stated that she was on duty when R3 was admitted . V8 stated that there were 3 admissions that night. V8 stated that she is not sure who did the admission, but she did not. V8 stated that when she returned on 4/5/2025 she went to give R3 his meds and noticed that there were none. V8 stated that she did not have access to the EKit and did not obtain medications from there. V8 stated that she called the pharmacy, and they stated that they would send the medications out. V8 stated that she did not administer any medication to R3. V8 stated that she checked them off in the computer but had not administered any and put in a note that the medications were not there to give. V8 stated that R3 informed her that he had not received any of his medication since being admitted to the facility. V8 stated that she called the pharmacy multiple times trying to get the medication. On 5/7/2025 at 3:24 PM V9, LPN, stated that she was on vacation when R3 was admitted . V9 stated that when she returned, she worked the floor, 4/5/2025. V9 stated that R3 informed her that he had not received his medication since being at the facility. V9 stated that she noticed that R3 did not have any medications or orders. V9 stated that she went to look through the chart and found the discharge orders in the miscellaneous section of the chart. V9 stated that she entered the medication in the computer and notified the pharmacy. V9 stated that the admission process has many steps. V9 stated that the admitting nurse completes the orders, skin check and oriented to facility. The next nurse will complete the rest. The admission is then reviewed by the managers. This is to prevent this from happening. V9 stated that V3 would have been the one to follow up because she (V9) was on vacation. V9 stated that she asked how this happened. V9 stated that she was concerned because it went for such a long time and through so many people. V9 stated that she asked what happened and received no answer. On 5/7/2025 at 4:50 PM V13, RN, stated that she worked on 5/6/2025. V13 stated that she worked a 4-hour shift. V13 stated during her shift R3's medications had not come into the facility. V13 stated that she called the pharmacy and was informed that they would be out that night. V13 stated that R3 was complaining of not feeling well. V13 stated that she assessed R3 and noted that his pulse was low. V13 stated that R3 did not complain of shortness of breath but thought she should get a concentrator just in case. V13 stated that the oxygen was applied and R3 seemed stable. V13 stated that she notified the nurse in report. The facility's Admission/Re-Admission policy, dated 4/2024, documents that GENERAL: The facility will ensure that all residents have necessary assessments completed in a timely manner at the point of admission in order to provide the best possible, person-centered care. Responsible Party: All Staff POLICY: I. All new and re-admissions that have been out of the facility for longer than 24 hours should be assessed within 1 hour of arriving to the facility by a licensed nurse to ensure stability and safety of resident. Within 24 hours of admission, the following PCC Forms should be completed: a. NRSG: Admission Observation b. NRSG: Interim Baseline Care Plan c. NRSG: Fall Risk Evaluation d. Braden's Scale for Predicting Pressure Sore Risk e. Comprehensive Pain Evaluation f. Call Light Ability Screen g. All medications should be reconciled with the resident/resident representative and verified with the primary physician or nurse practitioner. h. Physician order sheet should reflect any standing orders specific to the resident as well as medications and treatments that are ordered throughout the stay. 2. All consents that are applicable to the resident, including but not limited to; influenza vaccine. pneumonia vaccine, psychotropic medications, and COVID-19 vaccine and testing should be obtained throughout the admission process. 3. All necessary admission information discussed above will be documented in the resident's clinical record. The facility's Physician Order policy, dated 2/2024, documents that GENERAL: Drugs will be administered only upon a clean, complete, and signed order of a person lawfully authorized to presc1ibe. Verbal orders will be received only by licensed nurses or pharmacists and confirmed in writing by the physician. Electronic orders transmitted via NCPDP Script 10.6 will be accepted. RESPONSIBLE PARTY: Nursing POLICY: Documentation of the Medication Order: I. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet in PCC and the Medication Administration Record (MAR) or Treatment Administrative Record (TAR). 2 The following steps are initiated to complete documentation: a. Clarify the order b. Enter the orders with administration schedule in PCC and transmit to pharmacy.

Based on record reviews and interviews the facility failed to transcribe medications to Physician Order Sheet, the Medication Administration Record, obtain medications from the pharmacy and administer medications as ordered by the physician according to standards of practice for 1 of 3 (R3) residents reviewed for significant medication errors. This failure resulted in R3 experiencing shortness of breath, heart palpitations, untreated Urinary Tract Infection and R3 feeling like he was going to die. Findings include: 1. R3's Census Report, not dated, documents that R3 was admitted to the facility on [DATE] and discharged from the facility on 4/7/2025 with the following diagnoses: AKI on CKD IV non anion gap metabolic acidosis prostatomegaly, Complicated UTI bladder stents, Fracture of left Humerus, Pacemaker, Accelerated Hypertension, Ataxia, Coronary Artery Disease status post CABG, Chronic diastolic congestive heart failure, Anemia of chronic disease, Paroxysmal Atrial Fibrillation Mobitz second degree block, Prolonged QTc interval, Non-insulin dependent diabetes mellitus, uncontrolled diabetes, Hyperglycemia, paraspinal disease, CVA, TIA, PVD status post Stents, CAD status post CABG, Hypertension, Hyperlipidemia, GERD, Hypotension R3's Minimum Data Set, dated dated [DATE], documents that R3 is cognitively intact. R3's Hospital Discharge Orders, dated 4/2/2025 at 9:52 AM, documents the following 1. Isosorbide Dinitrate Oral Tablet 30 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) 2. Aspirin Oral Tablet Delayed Release 81 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (I25.10) 3. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for supplement. 4. Levothyroxine Sodium Oral Tablet 50 MCG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for thyroid. 5. glipizide Oral Tablet 10 MG: 1 tablet by mouth two times a day. Give 1 tablet by mouth two times a day for DM before meals. 6. Cephalexin Oral Tablet 500 MG: 1 tablet by mouth two times a day. Give 1 tablet by mouth two times a day for infection. 7. hydralazine HCl Oral Tablet 25 MG: 1 tablet by mouth three times a day. Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) every 8 hours. 8. Metoprolol Tartrate Tablet 50 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) 9. Simvastatin Oral Tablet 40 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for cholesterol. 10. Xarelto Oral Tablet 15 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ATRIOVENTRICULAR BLOCK, FIRST DEGREE (I44.0) R3's Physician Order Sheet (POS) and Medication Administration Record (MAR), dated April 2025, documents that R3's Hospital discharge orders were transcribed to the POS and the MAR on 4/5/2925. R3's Medication Administration Record (MAR), dated April 2025, documents no orders for 4/2, 4/3, and 4/4. R3's MAR documents orders transcribed 4/5/2025, 4/7/2025 and 4/8/2025. R3's MAR documents that R3 received 1 dose of Glipizide on 5/5/2025. 1 dose of Xarelto, Simvastatin, Cephalexin, glipizide, Cyanocobalamin, Metoprolol, Pantoprazole, Isosorbide on 5/6/2025. R3 did not receive Hydrochlorothiazide, Aspirin, Ascorbic Acid, and hydralazine. On 5/1/2025 at 12:12 PM V4, Previous DON, stated that his last day was 4/3/2025 and he is not familiar with R3. V4 stated that the process for new admission is that the admitting nurse will transcribe the orders in PCC (Point Click Care) so that it can be sent to pharmacy. The orders are sent to the pharmacy through the PCC. There is a triple check system that is in place to assure that the admission is completed correctly. On 5/1/2025 at 12:41 PM, V3, Assistant Director of Nursing (ADON), stated that she was interim Director of Nursing after V4 left. V3 stated that the admission process is completed by the floor nurse regardless of if they work for the facility or agency. V3 stated that this includes medication and assessments. V3 stated that neither were complete timely. V3 stated that she became aware of R3 not receiving his medications on the Sunday prior to his transfer to hospital. V3 stated that the medication should have been transcribed upon admission. V3 stated that it takes 24 hours for an admission to be completed but the medications are to be transcribed within the first couple hours of the admission. V3 stated that she is not sure why the medications were not transcribed. V3 stated that the admitting nurse was from an agency. V3 stated that the agency nurses can and are expected to complete the admission. V3 stated that there is a triple check system that is in place but was not done either. V3 stated that if the triple check would have been completed this would have prevented R3 from missing his medications that he needed, and assessment would have been completed. V3 stated that the floor nurse regardless of if she works for the facility or agency is knowledgeable and capable of completing the admission. V3 stated that the medications are a priority and should have been taken care of. V3 stated that they only have 4 facility staffed nurses and they are all scheduled on the other side of the building. V3 stated that the nurses that provided care for R3 was agency. V3 stated that nurse mangers are audit the admission and make sure it is completed. This includes medications and assessments. On 5/1/2025 at 2:33 PM V5, LPN, stated that she was in the facility when R3 was admitted , and V5 sent R3 to the hospital. V5 stated that the night of the admission she worked on the other hall and the nurse had 3 admissions. V5 stated that she took an admission, V8, RN, took one and V3, ADON, took one. V5 stated that V3 took R3's hospital records home so she could work on them remotely. V5 stated that the orders did not get transcribed until the 5th. On 5/5/2025 at 12:06 PM V10, Pharmacist, stated that R3 not receiving his Cephalexin, Metoprolol, Xarelto, Hydralazine, Glipizide, Imdur was not administered per the physician orders were significant med errors. On 5/5/2025 at 2:00 PM V12, Medical Director, stated that R3 not receiving his Cephalexin as directed was a significant med error with significant results as R3 was hospitalized and treated for a urinary tract infection. On 5/7/2025 at 12:22 PM V8, RN, stated that she was on duty when R3 was admitted . V8 stated that there were 3 admissions that night. V8 stated that she is not sure who did the admission, but she did not. V8 stated that when she returned on 4/5/2025 she went to give R3 his meds a noticed that there were none. V8 stated that she did not have access to the EKit/emergency kit and did not obtain medications from there. V8 stated that she called the pharmacy, and they stated that they would send the medications out. V8 stated that she did not administer any medication to R3. V8 stated that she checked them off in the computer and put in a note that the medications were not there to give. V8 stated that R3 informed hr that he had not received any of his medication since being admitted to the facility. V8 stated that she called the pharmacy multiple times trying to get the medication. The facility's Physician Order policy, dated 2/2024, documents that GENERAL: Drugs will be administered only upon a clean, complete, and signed order of a person lawfully authorized to presc1ibe. Verbal orders will be received only by licensed nurses or pharmacists and confirmed in writing by the physician. Electronic orders transmitted via NCPDP Script 10.6 will be accepted. RESPONSIBLE PARTY: Nursing POLICY: Documentation of the Medication Order: I. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet in PCC and the Medication Administration Record (MAR) or Treatment Administrative Record (TAR). 2 The following steps are initiated to complete documentation: a. Clarify the order b. Enter the orders with administration schedule in PCC and transmit to pharmacy.

Based on record reviews and interviews the facility failed to transcribe medications to Physician Order Sheet, the Medication Administration Record, obtain medications from the pharmacy and administer medications as ordered by the physician for 1 of 3 (R3) residents reviewed for significant medication errors. This failure resulted in R3 experiencing shortness of breath, heart palpitations, untreated urinary tract infection and R3 feeling like he was going to die. Findings include: 1.x R3's Census Report, not dated, documents that R3 was admitted to the facility on [DATE] and discharged from the facility on 4/7/2025 with the following diagnoses: AKI on CKD IV non anion gap metabolic acidosis prostatomegaly, Complicated UTI bladder stents, Fracture of left Humerus, Pacemaker, Accelerated Hypertension, Ataxia, Coronary Artery Disease status post CABG, Chronic diastolic congestive heart failure, Anemia of chronic disease, Paroxysmal Atrial Fibrillation Mobitz second degree block, Prolonged QTc interval, Non-insulin dependent diabetes mellitus, uncontrolled diabetes, Hyperglycemia, paraspinal disease, CVA, TIA, PVD status post Stents, CAD status post CABG, Hypertension, Hyperlipidemia, GERD, Hypotension. R3's Minimum Data Set, dated dated [DATE], documents that R3 is cognitively intact. R3's Hospital Discharge Orders, dated 4/2/2025 at 9:52 AM, documents the following 1. Isosorbide Dinitrate Oral Tablet 30 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) 2. Aspirin Oral Tablet Delayed Release 81 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (I25.10) 3. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for supplement. 4. Levothyroxine Sodium Oral Tablet 50 MCG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for thyroid. 5. glipizide Oral Tablet 10 MG: 1 tablet by mouth two times a day. Give 1 tablet by mouth two times a day for DM before meals. 6. Cephalexin Oral Tablet 500 MG: 1 tablet by mouth two times a day. Give 1 tablet by mouth two times a day for infection. 7. hydralazine HCl Oral Tablet 25 MG: 1 tablet by mouth three times a day. Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) every 8 hours. 8. Metoprolol Tartrate Tablet 50 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) 9. Simvastatin Oral Tablet 40 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for cholesterol. 10. Xarelto Oral Tablet 15 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ATRIOVENTRICULAR BLOCK, FIRST DEGREE (I44.0) R3's Physician Order Sheet (POS) and Medication Administration Record (MAR), dated April 2025, documents that R3's Hospital discharge orders were transcribed to the POS and the MAR on 4/5/2925. R3's Medication Administration Record (MAR), dated April 2025, documents no orders for 4/2, 4/3, and 4/4. R3's MAR documents orders transcribed 4/5/2025, 4/7/2025 and 4/8/2025. R3's MAR documents that R3 received 1 dose of Glipizide on 5/5/2025. 1 dose of Xarelto, Simvastatin, Cephalexin, glipizide, Cyanocobalamin, Metoprolol, Pantoprazole, Isosorbide on 5/6/2025. R3 did not receive Hydrochlorothiazide, Aspirin, Ascorbic Acid, and hydralazine. On 5/1/2025 at 12:12 PM V4, Previous DON, stated that his last day was 4/3/2025 and he is not familiar with R3. V4 stated that the process for new admission is that the admitting nurse will transcribe the orders in PCC (Point Click Care) so that it can be sent to pharmacy. The orders are sent to the pharmacy through the PCC. There is a triple check system that is in place to assure that the admission is completed correctly. On 5/1/2025 at 12:41 PM, V3, Assistant Director of Nursing (ADON), stated that she was interim Director of Nursing after V4 left. V3 stated that the admission process is completed by the floor nurse regardless of if they work for the facility or agency. V3 stated that she became aware of R3 not receiving his medications on the Sunday prior to his transfer to hospital. V3 stated that the medication should have been transcribed upon admission. V3 stated that it takes 24 hours for an admission to be completed but the medications are to be transcribed within the first couple hours of the admission. V3 stated that she is not sure why the medications were not transcribed. V3 stated that the admitting nurse was from an agency. V3 stated that the agency nurses can and are expected to complete the admission. V3 stated that there is a triple check system that is in place but was not done either. V3 stated that this would have been completed by the following nurses which were agency nurses as well. V3 stated that they only have 4 facility staffed nurses and they are all scheduled on the other side of the building. V3 stated that the nurses that provided care for R3 was agency. On 5/1/2025 at 2:33 PM V5, LPN, stated that she was in the facility when R3 was admitted , and V5 sent R3 to the hospital. V5 stated that the night of the admission she worked on the other hall and the nurse had 3 admissions. V5 stated that she took an admission, V8, RN, took one and V3, ADON, took one. V5 stated that V3 took R3's hospital records home so she could work on them remotely. V5 stated that the orders did not get transcribed until the 5th. On 5/5/2025 at 12:06 PM V10, Pharmacist, stated that R3 not receiving his Cephalexin, Metoprolol, Xarelto, Hydralazine, Glipizide, Imdur was not administered per the physician orders were significant med errors. On 5/5/2025 at 2:00 PM V12, Medical Director, stated that R3 not receiving his Cephalexin as directed was a significant med error with significant results as R3 was hospitalized and treated for a urinary tract infection The facility's Physician Order policy, dated 2/2024, documents that GENERAL: Drugs will be administered only upon a clean, complete, and signed order of a person lawfully authorized to presc1ibe. Verbal orders will be received only by licensed nurses or pharmacists and confirmed in writing by the physician. Electronic orders transmitted via NCPDP/National Council for Prescription Drug Programs Script 10.6 will be accepted. RESPONSIBLE PARTY: Nursing POLICY: Documentation of the Medication Order: I. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet in PCC and the Medication Administration Record (MAR) or Treatment Administrative Record (TAR). 2 The following steps are initiated to complete documentation: a. Clarify the order b. Enter the orders with administration schedule in PCC and transmit to pharmacy.

Based on interview and record review, the facility failed to prevent physical and sexual abuse for 5 of 5 (R17, R18, R19, R20, R21) reviewed for abuse in the sample of 21. This failure resulted in R17 being sexually inappropriately touched by another resident. Findings Include: 1. R17's Face Sheet, print date of 3/24/25, documents R17 was admitted on [DATE] and has diagnoses of Type 2 Diabetes Mellitus, cocaine abuse, and mood disorder. R17's Minimum Data Set (MDS), dated [DATE], documents R17 is severely cognitively impaired. R17's Nurses Note, dated 3/18/2025 13:14, documents, This nurse was notified that this resident was inappropriately touched by another resident. Both residents involved were separated and (R16) put on 1:1 Upon investigation and questioning resident said nothing happened. Admin (Administrator) DON (Director of Nurses) and NP (Nurse Practitioner) notified. Police called and reported to IDPH (Illinois Department of Public Health). Skin check completed and resident has no skin issues and has no trauma from event. No complaints of pain or discomfort. R17's and R16's facility Final Serious Injury Incident and Communicable Disease Report, dated 3/18/25, documents, 2 staff members reported in the dining the two residents sitting close at the same table. they noted that (R17) had her pants down and stated that (R16) had his hand in her vaginal area. Staff intervened and removed (R17) from the area to help redress her. Police called, with MD. (R16) put on enhanced monitoring until future investigation. (R17) denied any sexual activity and stated that she does feel safe in the facility. (R16) denied any sexual activity and did state that (R17) did have her pants down, but he did not touch her. All other staff in the dining room did not witness incident. The police did not do a report as (R17) denied the incident and she stated that she felt safe. The nurse did complete a head to toe assessment and noted that resident had no noted skin impairment. (R17) denied pain or trauma. IDT (Interdisciplinary) intervention is for Staff to monitor the residents in the dining room and keep (R17) and (R16) separate at all times. R16's Face Sheet, print date of 3/25/25, documents R16 was admitted on [DATE] and has diagnoses of Major Depressive Disorder, Schizophrenia, Epilepsy, and Cerebral Palsy. R16's MDS, dated [DATE], documents R16 is cognitively intact. R16's Electronic Medical Record fails to document any Nurses Notes or Social Service Notes related to the allegation of sexual abuse. On 3/21/25 at 12:20 PM, V1, Administrator, stated she reported the incident to IDPH (Illinois Department of Public Health) and completed the investigation. The resident who it happened to is currently in the hospital at (hospital) for psychiatric issues. She was homeless, has schizophrenia and is relatively new here. We just found out her daughter is the POA (Power of Attorney). She has a BIMS (Brief Interview of Mental Status) of 6 and the man has a BIMS around 12. The incident was witnessed by two of the kitchen workers who reported it. It happened in the dining room where she took off her pants and he had his hand in her (vaginal) area. The residents were separated immediately. The lady denied it, said she felt safe in the facility. He denied it too. There were no other witnesses. All staff who may have been coming or going through the dining room were interviewed. We called the police but they did not file a report because the resident was denying it. The same day the lady threw a phone at another resident and that is why we sent her out. She is aggressive and having behaviors. She went out because she was a danger to others. On 3/24/25 at 2:10 PM, R16 stated, (R17) took her clothes off. I didn't fondle that woman. On 3/24/25 at 10;42 AM, V19, Dietary Aide, stated, R16 and R17 were sitting next to each other. R17 was in her wheelchair. R17 had her pants down and was showing R16 her private area. R16 put his hand on her pubic area. I yelled for V20 the Dietary Manager because we are not allowed to touch the residents. When I yelled at him to stop, he stopped. V20 told R17 not to do that. R17 started to yell we shouldn't be looking at us. V20 told the Administrator. On 3/24/25 at 1:55 PM, V20, Dietary Manager, stated, I was in the back of the kitchen V19 and V23 hollered at me to come out. R17 was sitting next to R16 she had her pants down. R16 was being taken away and staff were covering R17 up. I went to tell V2 immediately. On 3/25/25 at 10:49 AM, V23, Dietary Aide, stated, I was in the kitchen doing dishes. The kitchen staff were saying look at that man. V23 was questioned who were saying look at that man, V23 stated, (V19) and (V25, Dietary Aide). So, I went to the door window and saw (R16) rubbing (R17's) pubic area, then her thigh, and butt. I walked away because there is nothing I could do. There was no staff in the dining room. The door was opened to tell him to go to his room but he must have heard the door open because then he moved his hand. We called for (V20 Dietary Manager) but by that time (R16) was propelling himself away from the dining room. R17 didn't say anything. Her pant were off. We are contracted staff, and we cannot touch the residents. On 3/25/25 at 11:55 AM, V28, Business Office Manager, stated I was in the kitchen I heard hey they are way to close. I went out and separated R16 an R17. I draped R17's gown back over her legs lap area. I took R16 away from the dining room in his wheelchair and someone took R17 out of the dining room. On 3/26/25 at 10:30 AM, V2, Director of Nurses, stated, someone came to my office and told me we have a situation going on in the dining room by the time I got there residents R16 and R17 had been separated. It all happened very quickly. After that V1 was handling the situation. I would never allow abuse in this facility. 2. R18's Face Sheet, print date of 3/24/25, documents R18 was admitted on [DATE] and has diagnoses of recent stroke and End Stage Renal Disease. R18's MDS, dated [DATE], documents R18 is cognitively intact. The facility Final Serious Injury Incident and Communicable Disease Report, dated 3/18/25, documents, (R17) was sitting at the nurse's station when (R18 approached (R17) and she hit him with the phone on the head. They were immediately separated. (R18) was assessed by the nurse and noted to have a small red mark on forehead. He denied any pain at the time. police and ambulance called to send (R17) to (hospital) for evaluation. R18's Skin Condition Report, dated 3/18/25, documents R18 has a red area on the top of his scalp and he stated R17 hit him with the phone. R17's Face Sheet, Print date of 3/24/25, documents R17 was admitted on [DATE] and has diagnoses of Type 2 Diabetes Mellitus, cocaine abuse, and mood disorder. R17's MDS, dated [DATE], documents R17 is severely cognitively impaired. R17's Nurses Note, dated 3/18/2025 3:37 PM, documents, This nurse was attempting to remove resident from behind the desk when resident got upset at just being asked to come from behind the desk that she started to toss the phone about the nurses desk. (R18) was on the phone at the time, and this caused the receiver to be pulled from his hands, and he reported that it hit him in the head. R17's Nurse Note, dated 3/18/25, documents, this nurse was attempting to remove resident from behind the desk when resident got upset at just being asked to come from behind the desk that she started to toss the phone about the nurse's desk. (R18) was on the phone at the time, and this caused the receiver to be pulled from his hands, and he reported that it hit him in the head. Resident stayed aggressive by trying to pull stuff off the walls at the nurse's station and very abusive to staff. Removed resident from area and away from victim. (Nurse Practitioner) notified and orders to send out for eval. (evaluation) Involuntary admission to (Psychiatric Hospital) given to resident for being a threat to the residents and staff, 10-day bed hold sent with resident as well. Report called to (Psychiatric Hospital) ED (Emergency Department). On 3/25/25 at 9:18 AM, V13, Wound Nurse, stated, R17 wanted to get behind the desk. I was trying to get her out from behind it because of the privacy issue. She started shaking her arms and hands and ripped the phone out of R18's hands and it hit him in the head. She had only been here for 3 or 4 days. She was refusing her medications. She was hard to keep calm. 3. R20's Face Sheet, print date of 3/24/25, documents R20 was admitted on [DATE] and has diagnoses of Dementia and Schizoaffective Disorder. R20's MDS, dated [DATE], documents R20 is moderately cognitively impaired. R20's Final Serious Injury Incident and Communicable Disease Report, dated 3/16/25, documents, (R20) has a diagnosis of dementia with a BIMS of 6. He is noted to wander around in his wheelchair going to other resident's rooms. He wandered into (R19's) room. (R19) asked him to leave and when he did not, he hit him in the chest. The residents were immediately separated. The nurse performed a head-to-toe assessment on (R20) and noted no change in condition. R20's Nurses Note, dated 3/15/2025 10:00 PM, documents, Resident entered resident (R19's) room, causing (R19) to get upset at resident and got punched in the chest. Admin (Administrator) was notified, and investigation started. Skin check, and pain assessment completed. R19's Face Sheet, print date of 3/24/25, documents R19 was admitted on [DATE] and has diagnosis of Diabetes Mellitus. R19's MDS, dated [DATE], documents R19 is cognitively intact. R19's Nurses Note, dated 3/15/2025 10:14 PM, documents, Resident was upset that another resident (R20) entered his room and took it upon his self to take care of the situation by punching (R20). in the chest. CNA (Certified Nurse's Aide) witnessed it and removed (R20) out of resident's room. Resident was educated on not taking matters into his own hands and putting his hands on residents in such a manner. On 3/24/25 at 2:10 PM, R19 was questioned if he ever hit another resident, R19 stated, (R20) came in my room. He comes in and gets in my bed and steals stuff. I got him out of my bed, but I never put knuckles on him. I just used my open hand. On 3/25/25 at 10:37 AM, V22 LPN, stated, R19 is pretty non-confrontational. He is blind. R20 is truly our only geriatric patient. he has dementia and is alert to himself only. He wanders around with no intent. He will go into others rooms. He is like a toddler. On 3/25/25 at 12:59 PM, V13 LPN, stated, I was working the hall the evening R19 hit R20. R20 wanders into other people's rooms. 4. R19's and R21's Pintail Serious Injury Incident and Communicable Disease Report, incident report of 2/7/25, dated 2/7/25, documents, it was reported that a possible altercation happened between (R19) 58 yr (year) year old male and (R21) [AGE] year-old male. Assessments completed, no injuries to note. Residents were separated immediately. R19's Nurses Note, dated 2/7/25 at 1:13 PM, documents, Resident was involved in an altercation with another resident. Coffee was thrown on patient. No obvious scars or blisters to be noted at this time. Both residents denied the altercation. Eyewitness from the dietary department claims to have seen this resident hitting the other. Administrator aware. Patient is his own responsible party. Resident denies pain and discomfort. Resident remains in the dining room eating lunch. R21's Nurses Notes, dated 2/7/2025 14:19, documents, It was reported to this writer that resident had an altercation with another resident (R21) in the dining room, this resident was reported to had thrown coffee at another resident. It was stated by nursing staff that the two-resident started swinging at each other, but they didn't witness any physical contact, dietary staff stated that the other resident had hit this resident, and she had physically pulled the other resident off of him. Statements from both residents were obtained and both parties denied any physical altercation. Assessment completed upon this resident; no injury noted at this time. resident denies any pain or discomfort. Vs: T-97.1 P (pulse)-81, R-16, BP- 163/93, O2 (oxygen saturation)-97% RA. resident is now sitting up by the nurses station , will continue to monitor. Resident is his own responsible party, Emergency contact call (V21 R21's Power of Attorney) with no answer voicemail left, Admin made aware. On 3/24/25 at 2:07 PM, R19 is in his room. He states that he is blind and does not see well at all. On 3/24/25 at 2:07 PM, R19 was questioned if he has ever been hurt by other residents, R19 stated, Somebody threw hot coffee on me. R19's and R21's Final Serious Injury Incident and Communication Disease Report, incident report date of 2/9/25, dated 2/9/25, documents, resident to resident altercation. Both residents were in dining room and started to argue. (R19) hit (R21) in chest. staff immediately separated them. nurse assessed (R21). no injuries noted. R19's Nurses Note, dated 2/9/2025 08:45, documents, At approximately 8:30 am, I heard a commotion in the dining room and a CNA was almost there in DR (dining room) when she witnessed a resident from 200 hall wiped his hand across the table to push his dishes to the floor as this was happening this resident had already stood up and was heading to the microwave to heat up his oatmeal and this resident in turn hit him in his chest. R21's Nurses Note, dated 2/9/2025 14:54, documents, This resident had an altercation with another resident in the DR during breakfast. According to the CNA on duty, this resident attempted to throw his breakfast tray at another resident but missed. However, the other resident (R19) retaliated by striking this resident with his fist in his left upper chest region. The resident was unable to describe the events that led up to this incident. Denied pain/discomfort. The two residents were separated. Full body assessment was performed. No apparent injuries noted. ROM (range of motion) and V.S. (vital signs) are WNL (within normal limits). Administration, DON and ADON (Assistant Director of Nurses) were all made aware. POA (power of Attorney) and MD (Medical Director) to be notified. Q (every) 15-minute checks were implemented. Observation continues. Will pass on to oncoming staff. R19's Face Sheet, print date of 3/24/25, documents R19 was admitted on [DATE] and has diagnosis of Diabetes Mellitus. R19's MDS, dated [DATE], documents R19 is cognitively intact. R21's Face sheet, print date of 3/24/25, documents that R21 was admitted on [DATE] and has a diagnosis of Dementia. R21's MDS, dated [DATE], documents that R21 is severely cognitively impaired. On 3/25/25 at 10:37 AM, V22 Licensed Practical Nurse, stated, I was just told about the alteration between R19 and R21. I do not remember who the CNA was. R21 was not injured. He is alert to himself only. He is blind and has psychiatric issue. He will hit and yell at whoever when he is in the mood. On 3/25/25 at 11:11 AM, V24, Certified Nurse Aide, stated I just put R21's tray on the table and R21 immediately knocked it off. R19 was not in his chair he had just gotten up or the tray would have hit him. R19 walked around and hit R21 in the chest. They were immediately separated and R19 went back to his room. The Abuse Policy and Prevention Program, dated 10/22, documents, The facility affirms the right to our residents to be free from abuse. It continues, Abuse: Abuse mean any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.

Based on interview and record review, the facility failed to send a resident for evaluation and treatment after multiple refusals for dialysis for 1 of 3 residents (R6) reviewed for change of condition in the sample of 21. This failure resulted in R6 being sent to the emergency room , being admitted to the Intensive Care Unit, and having a Central Line placed. Findings Include: R6's Face Sheet, print date of 3/20/25, documents R6 was admitted on [DATE] and has diagnoses of Schizophrenia, Dementia, Alzheimer's Disease, and Dependence on Renal Dialysis. R6's Minimum Data Set, dated dated [DATE], documents R6 is severely cognitively impaired. R6's Physician Order, dated 1/30/25, documents, Dialysis: 5 days a week. R6's Hemodialysis Treatment Times, dated 2/3/25 - 3/17/25, documents the last dialysis treatment was on 3/11/25. R6's Nurses Note, dated 3/19/25 at 1:05 PM, documents, Res/resident appeared lethargic, not responding to verbal stimuli. Provider at facility assessed and N.O. (new order) received to send res to ER (emergency room ) for eval (evaluation). Attempted to obtain vitals and res (resident) became combative, hitting at staff. Call placed to POA (Power of Attorney) who agrees with plan of care and wanted res sent to (local hospital). EMS (Emergency Medical Services) notified, report called to (local hospital), resident currently on way to ED (Emergency Department). R6's HOSPITALIST ADMISSION HISTORY & PHYSICAL EXAM, dated 3/19/25, documents, (R6) is a 73 y.o.(year of) female with a PMHx (past medical history) of Alzheimer's dementia, Parkinson's disease, ESRD (End Stage Renal Dialysis) on dialysis, CHF (Congestive Heart Failure), GERD (Gastroesophageal Reflux Disease), HTN (Hypertension), HLD (Hyperlipidemia), OSA (Osteoarthritis), Anemia, and Schizophrenia who presented to the ED (Emergency Department) with complaints of altered mental status. HPI (History of Present Illness) limited due to underlying Alzheimer's dementia. Information obtained per chart review. The patient presented to the ED earlier today from (facility) skilled nursing facility with report per staff of refusing all care for the past week. The patient has a history of ESRD and is supposed to receive dialysis 5 days a week (Monday through Friday). Per staff, the patient has been refusing dialysis all week, with her last completed dialysis treatment on 3/13. No further details surrounding the presenting illness are available. Per chart review, the patient has underlying Alzheimer's dementia and is oriented times 1-2 at baseline. During the ED evaluation, the patient was hemodynamically unstable with bradycardia and hypotension. Central venous access was obtained, and the patient was subsequently started on dopamine and Levophed. Per chart review, nephrology was consulted by the ED provider for dialysis management. Additionally, the intensivist was also consulted in the emergency department. Patient was subsequently admitted to ICU (Intensive Care Unit) for further management. On 3/19/25 at 12:35 PM, V2, Director of Nurses, stated, V14, Dialysis Nurse, spoke with V15, Nephrologist, and I spoke with V15, Medical Director. We are going to send her to the hospital because she needs dialysis and here I cannot chemically restrainer her to be able to do it. I know V3 doesn't want her to go out, but we have no choice. On 3/19/25 at 12:50 PM, V14, Dialysis Nurse, stated, R6 would refuse dialysis. If they could get her down here, she would refuse to transfer from the wheelchair to the dialysis chair. If she would agree to sit for dialysis when she would say she was done she was done. She would hit, kick, scream, and spit. She hit one of the technicians in the head with the blood pressure machine. One time we had to call (V3) to come because she was to agitated to take her off of the machine. It was just too unsafe to try and pull her dialysis needles. I was letting (V15 Nephrologist) know that she was refusing, and he told me to do what I could. Today I did call him and let him know that she has not had dialysis in 8 days, and he said to send her out because that has been too long. Usually if they miss 3 treatments in a week, we send them out. On 3/19/25 at 2:20 PM, V15, stated, R6 should have been sent to the hospital on her 3rd missed treatment. I spoke with V14 and told her that and told her to have the nursing home sent out. After missing 3 treatments the electrolytes are off and at that point it is not even safe to dialysis them without new lab work. That is why they go to hospital, get the labs drawn, and then they can get dialysis. When V14 called me today and said she still hadn't been to dialysis I told her if the nursing home won't send her out, I will give you an order to do it. On 3/19/25 at 2:27 PM, V2 stated V14 never came to me and told me that R6 needed to be sent out before today. On 3/19/25 at 3:30 PM, V14 stated, on 3/14/25 the nurse came down and told me that R6 was not coming for dialysis. I then told her that R6 needs to be sent to the emergency room . I do not remember who the nurse was. I personally could not send her out to the emergency room because she was not in the dialysis clinic but over on the nursing home side. On 3/25/25 at 10:40 AM, V22 Licensed Practical Nurse stated, I took care of R6 only a few times. Dialysis never told me that since she missed dialysis again, she needed to go to the hospital. If I was told that I would have notified the Doctor and let him know. The policy change in Resident Condition, dated 10/2024, documents, It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change of condition. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physical, mental or emotional status. c. There is a pattern of refusing treatments or medications. d. the resident wants to be discharged AMA (against medical advice). e. It is deemed necessary or appropriate in the best interest of the resident. 2. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. 3. Communication with the resident and their responsible party as well as the physician will be documented in the resident's medial record or other appropriate documents.

Based on interview and record review, the facility failed to provide the Physician prescribed pain medication for 1 of 5 residents (R5) reviewed for pain in the sample of 21. This failure resulted in R5 having pain requiring him to stay in bed all day, feeling frustrated, and enjoy his normal daily activities. Findings include: R5's Face Sheet, print date of 3/19/25, documents R5 was admitted on [DATE] and has diagnoses of Spina Bifida, Anxiety, and Bipolar Disorder. R5's Minimum Data Set, dated dated [DATE], documents R5 is cognitively intact. R5's Physician Order, dated 6/26/24, documents, Oxycodone HCL Oral Tablet 10 MG (milligrams) give 1 tablet by mouth every 4 hours related to osteomyelitis of vertebra, lumbar region. R5's Medication Administration Record documents R5 did not receive the scheduled doses of Oxycodone 10 mg on 3/18/25 the 9 AM, 1 PM, 5 PM, an 9 PM schedule doses. On 3/19/25 the 1 AM and 5 AM scheduled doses. The 3/18/25 5 PM dose has a pain level of 6 charted. On 3/18/25 at 9:05 AM, R5 stated that he did not get his morning dose of Oxycodone because they ran out of it. On 3/18/25 at 2:00 PM, V13, Licensed Practical Nurse, stated R5 did run out of his Oxycodone, and it supposed to come on the pharmacy delivery tonight. Our pharmacy is in Chicago, so we have to wait for the delivery. V13 stated that she was unable to pull it out of the (automatic medication dispensing machine) because there was none in the (automatic medication dispensing machine). R5 has a lot of abdominal pain due to multiple hernias and he has been on this pain medication for a long time. On 3/19/25 at 9:40 AM, R5 stated I received by Oxycodone this morning. R5 was questioned what his pain level was without his pain medication on the 0-10 scale, R5 stated, It got up to about a 7. I have a lot of abdominal pain from hernias. I pretty much had to lay in bed all day because of it. It makes me frustrated they know I need my medication. The policy Pain Management, dated 10/23, documents, General: to facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhanced dignity and life involvement.

Based on interview and record review, the facility failed to provide the Physician prescribed pain medication for 1 of 5 residents (R5) reviewed for medications in the sample of 21. This failure resulted in R5 having pain requiring him to stay in bed all day, feel frustrated, and not enjoy his normal daily activities. Findings include: R5's Face Sheet, print date of 3/19/25, documents R5 was admitted on [DATE] and has diagnoses of Spina Bifida, Anxiety, and Bipolar Disorder. R5's Minimum Data Set, dated dated [DATE], documents R5 is cognitively intact. R5's Physician Order, dated 6/26/24, documents, Oxycodone HCL Oral Tablet 10 MG (milligrams) give 1 tablet by mouth every 4 hours related to osteomyelitis of vertebra, lumbar region. R5's Medication Administration Record documents R5 did not receive the scheduled doses of Oxycodone 10 mg on 3/18/25 the 9 AM, 1 PM, 5 PM, and 9 PM. On 3/19/25 the 1 AM and 5 AM scheduled doses. On 3/18/25 at 9:05 AM, R5 stated that he did not get his morning dose of Oxycodone because they ran out of it. On 3/18/25 at 2:00 PM, V13, Licensed Practical Nurse, stated R5 did run out of his Oxycodone and it supposed to come on the pharmacy delivery tonight. Our pharmacy is in Chicago, so we have to wait for the delivery. V13 stated that she was unable to pull it out of the (automatic medication dispensing machine) because there was none in the (automatic medication dispensing machine). R5 has a lot of abdominal pain due to multiple hernias and he has been on this pain medication for a long time. On 3/19/25 at 9:40 AM, R5 stated I received by Oxycodone this morning. R5 was questioned what his pain level was without his pain medication on the 0-10 scale, R5 stated, It got up to about a 7. I have a lot of abdominal pain from hernias. I pretty much had to lay in bed all day because of it. It makes me frustrated they know I need my medication. The policy Medication Administration, dated 2/24, documents, If medication is ordered, but not present, check to see if it was misplaced and then call pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box.

Based on observation, interview, and record review the facility failed to provide toileting to promote resident's dignity for 1 of 3 residents (R3) reviewed for dignity in a sample of 8. This failure caused R3 to be incontinent and feel helpless, ashamed, embarrassed, depressed, and demeaned. Findings include: R3's Care Plan, dated 9/3/2024, does not address R3's toileting. R3's Minimum Data Set, dated dated [DATE], documents that R3 is cognitively intact, frequently incontinent of urine and bowel and independent with toileting. On 9/17/2024 at 12:14 PM V17, R3's sister, stated that R3 is her brother. V17 stated that she is his power of attorney but that R3 makes his own decisions. V17 stated that her brother has called her and told her of the horrible conditions of his care. V17 stated that R3 was embarrassed. V17 stated that R3 wants to go to the bathroom but the facility had no way to get him on a toilet. V17 stated that R3 had to lay in his own body fluids. V17 stated that this had to be humiliating. V17 stated that it's one thing to have to go on yourself because you can't control it but to have to because they have no way to take you to the toilet is unacceptable. On 9/17/2024 at 1:56 PM R3 stated that he was originally at home. R3 stated that he became ill and was in the hospital for some time. R3 stated that he was then transferred to a rehab facility. R3 stated that at that facility he received Therapy almost daily. R3 stated that he had regained some of his strength back. R3 stated that at the facility they had a handicap accessible bathroom, and he was able to hold on to the rail and get on the toilet. R3 stated that once his insurance ran out and he became Medicaid he was then transferred to this facility. R3 stated that the staff would not help him. R3 stated that he is a large and wide man. R3 stated that he is obese and weighs close to 400lbs (pounds). R3 stated that he can't get into the bathroom at this facility. R3 stated that his wheelchair won't go through the bathroom door. R3 stated that he was given an adult bried and told to go in it. R3 stated that they brought in a commode but because he was not trained, he couldn't use it. R3 stated that he did not like going to the bathroom on himself. R3 stated that this is ridiculous. R3 stated I need help that's why I came there, and they did not want to help me. R3 stated that he was transferred in a lift and because of this he could not use a toilet. R3 stated that the shower room on the hall is big but there isn't a toilet. R3 stated that he felt embarrassed, and it was demeaning. R3 stated that I know I'm a big man, but they should have a place where I can use the bathroom. R3 stated that they didn't even try. R3 stated How do you fight that. I felt helpless and ashamed.'' R3 stated that he is disgusted with himself that this is now his life. R3 stated To be told to use the diaper and then have to. I'm not sure how to handle that. R3 stated that he would put his call light on, and they never come. R3 stated that he would go on himself. R3 stated Ridiculous. R3 stated that the website says they have all these things and services, but they don't. R3 stated I want to get better and go home. How am I supposed to do that. On 9/17/2024 at 12:07 PM V11, Certified Nurse's Assistant (CNA), stated that she did not take R3 to the bathroom or use the bedside commode. V11 stated that R3 was incontinent. V11 stated that R3 would tell them when he was wet. On 9/18/2024 at 9:40 AM V10, CNA, stated that R3 had a commode in his room but it was not used. V10 stated that it still had the plastic on it. On 9/19/2024 at 3:47 PM V18, CNA, stated that she took care of R3, and he was a full body mechanical lift. V18 stated that R3 was incontinent and not taken to the bathroom. V18 stated that R3 did not use a urinal or bedpan. V18 stated that R3 uses a full body mechanical lift to transfer. V18 stated that residents that use the full body mechanical lift are usually incontinent. V18 stated that R3's wheelchair could not fit through the bathroom. On 9/19/2024 at 3:49 PM V19, CNA, stated that she did not care for R3 but was familiar with R3 and his care. V19 stated that he used a full body mechanical lift. V19 stated that the full body mechanical lifts do not fit in the bathroom, they are too big. V19 stated that they give the residents urinals and bed pans. On 9/24/2024 3:37 PM V1, Administrator, stated that she expects her staff to assist residents to the toilet. V1 stated that she expects if the resident can't use the toilet to be provided with a urinal and bedpan. The facility's Resident Rights policy, dated 2/2024, documents The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference. It continues PROCEDURE: I. The facility will assess and interview resident for the need to make reasonable accommodations such as: Room set-up and Adaptive devices necessary to maintain/restore resident at their highest level of functioning. The facility's Activity of Daily Living policy, dated 9/2023, documents GUIDELINE: 2. A program of assistance and instructions in ADL skills is care planned and implemented. 3. Assistive devices and adaptive equipment are provided by Occupational Therapy. It also documents D. Elimination: b. Adaptive equipment, assistance and instruction are given as required.

Based on interview and record review the facility failed to arrange a medically necessary appointment transport for 1 of 3 (R16) residents reviewed for dialysis in the sample of 18. This failure resulted in R16 missing his appointment to treat a clogged dialysis shunt, which in turn created ineffective dialysis procedures. Findings include: R16's Care Plan, dated [DATE], documents Dialysis: Resident has potential for impaired renal function secondary to Dialysis due to ESRD (End Stage Renal Disease); Assist with arranging transportation to and from dialysis center, check arteriovenous fistula/shunt for bruit and thrill to assess for arterial blood flow every shift, inspect access site dressing after dialysis and apply pressure if bleeding occurs. If bleeding does not stop or restarts, contact MD (Medical Doctor) and/or dialysis clinic, Notify MD and/or dialysis clinic PRN (as needed) of complications, Notify MD of weight gain, and/or fluid volume excess ( sudden, weight gain, increased BP(blood pressure), full bounding pulse, jugular vein distention, SOB (shortness of breath), moist cough, abnormal breath sounds, and edema), Observe access site for s/s (signs/symptoms) of infection: redness, drainage, swelling, pain and displacement every shift. Report changes in neurological status (E.g.: altered LOC (level of consciousness), headache, visual or pupillary changes, restlessness, seizures), Review post treatment sheets. R16's Minimum Data Set, dated dated [DATE], documents that R16 is cognitively intact. R16's Dialysis progress note, dated [DATE] at 9:11 AM, documents AVF (arteriovenous fistula) RUA (right upper arm)- primary cannulation without difficulties/issues. Secondary & Tertiary cannulation, both times there was a flash, blood moved down the line by itself, unable to push or pull, needles were readjusted without success. RN (registered nurse) called Vascular Institute, advised that access be rested and try again tomorrow, if no success will have to come in, possible re-insert CVC (Central Venous Catheter). R16's Progress Note, dated [DATE] at 10:22 AM, documents Nurses Notes Note Text: resident has an appointment at (Regional hospital) with the vascular unit at 8am tomorrow to have his fistula unclogged. transportation is aware. R16's Progress Note, created date [DATE] at 1:10 PM and effective date [DATE] 1:08 PM, documents Nurses Notes Late Entry: Note Text: Resident attended appointment at Vascular Institute at (Regional Hospital) New cath (catheter) put in due to infiltration of fistula. Waiting for the edema to subside and will have a fistulagram on [DATE] to see if it has remedied itself. R16's (Regional Hospital) History and Physical, dated [DATE], documents reason for admission: Pt (patient) is a [AGE] year-old who has a past medical history of Anemia, Chronic obstructive pulmonary disease, Cognitive communication deficit, ESRD (end stage renal disease) on dialysis, ESRD on dialysis, Essential hypertension, and Hyperlipidemia was transferred from (local hospital) for evaluation by vascular surgery for his non-working dialysis AV fistula. He gets his dialysis daily except Saturday. He had his full dialysis on Wednesday. Yesterday when he was having his dialysis his AV fistula stopped working and he couldn't complete his dialysis. As per Dialysis nurse his fistula was clotted. For which he went to (local) ER (emergency room ) for evaluation today and was transferred to (hospital). R16's Progress Note, dated [DATE] at 9:07 PM, documents Nurses Notes Note Text: Resident was readmitted to the facility at 7:30 pm. from (Regional Hospital). Arrived via stretcher and accompanied by 2 EMT (Emergency Medical Technicians). Returned to room. Resident is alert and oriented and able to make needs known. No respiratory distress noted. Assessed resident and noted his new fistula in his RUE. No s/sx (signs and symptoms) of pain or discomfort. No irritation noted. Resident is afebrile. (,d+[DATE]-97XXX[DATE]-96% RA (room air). Resident able to move about independently. Resting at this time. R16's Progress Note, dated [DATE] at 12:17 PM, documents Nurses Notes Note Text: pt (patient) appt (appointment) by dialysis nurse at (Vascular Clinic) will be rescheduled. pt being sent out to (local hospital) NPO (nothing by mouth) for eval of lt (left) chest fistula for an eval and possible intervention to function properly. pt up ad lib, ,d+[DATE] last bp (blood pressure) at noon. picked up via (local hospital) ambulance to (local hospital) via x2 staff members. pt took his phone charger and his wallet with him. R16's Progress Note, dated [DATE] at 4:40 PM, documents Nurses Notes Note Text: Resident returned to the facility in good spirits. No c/o (Complaints of) voiced, denies pain. Resident had lab work while there. Looks like he has some up and coming appointments. On [DATE] at 9:40 AM V27, Registered Nurse, stated that R16 catheter was clogged and had been sent to the emergency room . V27 stated that there was an attempt to unclog without success. V27 stated at that time R16 was evaluated and an appointment was made with the vascular clinic. V27 stated that a week later R16 was sent back to the hospital because the facility did not have transportation to send him to his appointment that would have fixed the clog. V27 stated that the hospital could not do anything because R16 was not admitted . V27 stated that R16 was assessed and sent back to the facility. The catheter remained clogged. V27 stated that it is inappropriate to send a patient to the emergency room because you don't have transportation for his doctor's appointment. V27 stated that the facility sent the patient to the ER to handle it. V27 stated that this is R16's lifeline and not having appropriate dialysis can lead to his death. V27 stated that this is inappropriate level of care and neglectful. On [DATE] at 10:40 AM V25 stated that R16 is a dialysis patient of theirs. V25 stated that R16 has two access points, and both are compromised. V25 stated that this is a big concern because they can't dialyze R16 appropriately. V25 stated that R16 had an appointment at the vascular clinic and that appointment was missed due to transportation issues. V25 stated that R16's kidneys don't filter blood the way they should. As a result, wastes and toxins build up in his bloodstream. Dialysis removes waste products and excess fluid from the blood because his kidneys can't. V25 stated that this is a serious problem and can be life threatening. On [DATE] at 12:00 PM V4, Nurse Practitioner, stated that she was made aware of R16 access being clogged. V4 stated that they are able at this time to perform dialysis. V4 stated that they are not able to remove all of the fluid but believes that may be due to R16's blood pressure. V4 stated that it is important that R16 has his CVC fixed. V4 stated that she has informed V26 to continue to communicate with V4 about R16's dialysis and the facility is in the process of getting an appointment. V4 stated that the residents on dialysis have such a high acuity. V4 stated that she can't do much if they don't get them to the appointment. On [DATE] at 12:12 PM V2, Director of Nursing, stated that R16 was having some problems with his access. V2 stated that R16 had been out to the hospital and had a new catheter placed. V2 stated that at some point the dialysis staff made an appointment for R16 to be seen at clinic in Missouri. V2 stated that the dialysis staff did not communicate the appointment appropriately to the V23 so that transportation could be set up. V2 stated that when he became aware that R16 missed the appointment he notified V4 and R16 was sent to the hospital for evaluation. V2 stated that the appointment was cancelled due to transportation issue. On [DATE] at 1:09 PM V24, dialysis Registered Nurse, stated that R16 is a patient of theirs. V24 stated that there have been issues with R16 missing appointments. V24 stated that currently R16's ability to remove waste and toxins from his body is compromised. V24 stated that R16 has a shunt in right arm that has been clogged and no access at this time. V24 stated that she is aware that R16 has gone to the hospital. V24 stated that the problem with that is the hospital will not do anything with the graft to the shunt. V24 stated that hospital prefer to leave that to those that specializes in this. V24 stated that so sending R16 to the hospital may not help. V24 stated that R16 has not been to the institute since [DATE]. V24 stated that R16 went to the hospital. V24 stated that they share the hospital but is a separate entity. V24 stated that R16 had catheter placed while there. V24 stated that they were informed by the dialysis that this is not working and that they are getting less and less results. V24 stated that this is a serious problem because this is his only lifeline. V24 stated the appointment was set for replacement and R16 did not show. V24 stated that this is a problem because if this continues R16 could die. On [DATE] at 7:45 AM R16 stated that he is aware of the issues with his shunt site. R16 stated that it is blocked and can't be used. R16 stated that he was supposed to go to the clinic but was not able to because of transportation. R16 stated that V23 takes him if she doesn't have any appointments, or he goes by ambulance. R16 stated that the facility sent him to the hospital and the hospital did not do anything for him. R16 stated that he was told that this is a specialty and must be handled by the right people. R16 when he went to (Regional Hospital) they didn't address the clog at all. R16 stated that the put a line in him and told him this was temporary and that he has to get to the clinic to get his access fixed. R16 stated that when he was to go to his appointment the facility sent him to (local hospital) instead. R16 stated that they didn't do anything there either. R16 stated that the catheter that he has in now doesn't work well either. On [DATE] at 2:10 PM V26, Dialysis RN, stated that R16 previously had a CVC in his right chest for dialysis. V26 stated that CVCs are acute and temporary. V26 stated that they are not usually chronic because of the need to be changed. V26 stated that R16 then got a AV shunt in his right arm and the CVC in Right chest was removed. V26 stated that R16 started having problems with his shunt ,d+[DATE] and the shunt was clogged. V26 stated that this was communicated to the vascular institute, and they suggested a rest for the day and try the next day. V26 stated that they attempted to perform dialysis the following day and was not successful. V26 stated that on [DATE] R16 had dialysis using the CVC to the left chest, which was newly placed. V26 stated that the problem is that the CVC to the left chest is not working correctly. V26 stated that this has been sometime. V26 stated that this is R16's only access at this time and it can be a medical emergency if it stops working all together. V26 stated that previously they were able to remove about 70 Liters but they are only able to remove about half of that maybe 30 to 35. CVC catheter so that R16 can be dialyzed appropriately. V26 stated that if R16 is not able to remove the toxins and waste in R16's blood it will build up and be life threatening. On [DATE] at 2:15 PM V28, dialysis Tech, stated that they have been having problems with it since it was placed. The facility did not provide a policy for appointment transportation.

Based on interview and record review the facility failed to timely assess, timely notify physician of resident's increased pain, and timely treat a fracture for of 1 of 3 residents (R3) reviewed for quality of care in the sample of 4. This failure resulted in R3 having leg pain from at least 1/23 through 1/28/24 and being admitted to hospital for right femur fracture requiring surgery. Findings include: R3's Face Sheet, undated, documented she had diagnoses of other lack of coordination, abnormal posture, muscle weakness, hemiplegia (paralysis on one side of body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following unspecified cerebrovascular disease affecting right dominant side. R3's Care Plan, dated 10/24/22, documents (R3) has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Hemiplegia. Her primary mode of locomotion is wc (wheelchair). She is incontinent of B&B (bowel and bladder). She requires assist with adl care tasks. (R3) has been provided with a reacher to assist with safely reaching personal items. It continues: TRANSFER: (R3) requires Mechanical Aid (full body mechanical lift) for transfers. Imitation date of 9/4/2019 R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact, and dependent on staff for transfers. R3's Nursing Progress Notes, dated 1/27/2024 at 4:52 AM, documents resident complains of right knee pain. resident states the pain is a 10 on a 1-10 pain scale. resident states she is unable to attend dialysis this am because she can't move her right leg because the pain is so severe. this nurse asked the resident if anything had happened causing the pain in her right knee. resident states a few nights ago while being put in bed, her right leg was accidentally injured in a twisting motion. m.d. (Doctor of Medicine) made aware, poa (Power of Attorney) made aware and orders were received to order an xray of her right knee. R3's Nursing Progress Notes, dated 1/28/2024 at 7:28 AM, documents call placed to md xray to shift, care continues. R3's Nursing Progress Notes, dated 1/28/2024 at 12:19 PM, documents (Emergency Medical Transportation Company) is en (in) route to take resident to (Local Hospital) related to right knee xray. R3's Nursing Progress Notes, dated 1/28/2024 at 11:56 PM, documents this nurse called (local hospital) and spoke with (V4), RN (Registered Nurse), patient was transferred to Regional Hospital from (local hospital) with a dx (diagnosis): fractured femur. This nurse called and spoke with (V5), RN, at Regional Hospital resident is currently admitted with a fracture of the right femur with surgical intervention pending. m.d, poa and management made aware. R3's Computer Tomography (CT) of Right Femur from (local hospital), dated 1/28/2024, documents IMPRESSION: There is an oblique fracture (bone is broken at an angle) through the distal (furthest away from the center of the body) diaphysis (middle) of the right femur with mild posterior displacement of the distal fracture fragment and mild overlap. This is primarily in oblique fracture with mild comminution (broken in more than two pieces). A subtle component of the fracture extends distally into the distal fracture fragment along the more medial aspect (toward the middle or center) of the distal medial femoral diaphysis just above the medial femoral condyle (area located on the end of the femur/thigh bone, covered by cartilage and work as a shock absorber). R3's Nursing Progress Notes, dated 1/29/2024 at 11:31 AM, documents This (V7), RN, called (V6, R3's POA), (listed as POA and emergency contact). (V6) told this RN that (R3) is out of surgery this morning and is currently recovering. Family is at hospital with resident at this time. Family given this RN's information and educated to reach out with updates or if they need anything. R3's Post Fall Huddle, not dated, documents that the date of the Fall/transfer, was 1/27/2024 evenings. It documents that R3 was being transfer assisted by staff. It documents that that R3 is alert and oriented. Documents that assisted devices wheelchair was in use and device not in use. It also documents that R3 said that her leg was twisted during transfer. It documents What appears to be the initial root cause of the fall? Resident stated while she was being put to bed her right leg was twisted 0 (no) initial pain. The facility's Reported Incident Form Initial Report documents the date and time when the alleged incident occurred is unknown at this time. The Report documented the incident occurred in the resident's room. It documents that the serious bodily injury occurred was a right femur fracture. It documents that the Resident had increasing complaints of pain to the right leg, that was unrelieved with pharmacological intervention. The Facility's Final Report, submitted on 2/5/24, documented the conclusion of the investigation as After complete and thorough investigation, resident and staff interviews, the facility has concluded that the resident sustained a right femur fracture during a transfer from the resident's wheelchair to her bed. The resident states that during her transfer, the right leg became twisted. Pain was voiced in the days following the incident unrelieved. The physician was notified and the resident was sent to the emergency room and was diagnosed with fracture of the right femur. In conclusion, it is verified that the resident sustained an injury to the right femur during transfer. R3's Medication Administration Record, dated 1/1/2024-1/31/2023, documents on 1/23/2024 at 1:30 PM R3's pain level was #6 (1-10 with 10 being the most severe pain) and Tramadol 50, milligrams (mg) given. On 1/26/24 at 4:44 PM R3's pain level was #8. R3's Controlled Drug Receipt Record/Disposition Form, dated 8/8/2023, documents that R3 received Tramadol 50mg tabs: 1/23/24 12 PM, 1/25/24 4:30 PM, 1/26/24 5 PM, 1/27/2023 at 5 AM and 9 PM. On 2/6/2024 at 10:40 AM V27, Dialysis Registered Nurse, RN, stated that when R3 came to dialysis on 1/23/24 she was complaining of pain to her right leg. V27 stated that this is unusual because R3 doesn't usually complain of pain. V27 stated that she gave R3 some Tylenol. V27 stated that R3 stated that her leg was hurting because it got bent. V27 stated that R3 did not elaborate at that time. V27 stated that R3 is alert and reliable. V27 stated that at times her words may come out jumbled or garbled. V27 stated that there wasn't any bruising at the time but that there was swelling but not a large amount. On 2/8/2024 at 1:56 PM V20, Licensed Practical Nurse, LPN, stated that on 1/23/2024 R3 complained of knee pain. V20 stated that she asked R3 what caused her pain. V20 stated that R3 reported that her leg had been bent or twisted during a transfer. V20 stated that this was new for R3. V20 stated that R3 had never complained of pain before that day to V20. V20 stated that she did not look at or assess R3's knee at that time. V20 stated that she did not notify the doctor because R3 had prn (as needed) medication already ordered. On 2/5/2024 at 3:54 PM V12, LPN, stated that R3 is alert and oriented. V12 stated that R3 is reliable. V12 stated that R3 may get the days mixed but is not confused. V12 stated that she was notified of R3 having pain in her knee. V12 stated that R3 is dependent on staff for transfers. V12 stated that R3 requires the mechanical lift. V12 stated that a couple of Fridays ago R3 said her leg was hurting and felt like it was twisted. V12 stated that she gave her Tylenol. V12 stated that this was new and R3 had not complained of pain to her leg before this. V12 stated that she did an assessment of R3's leg and it was swollen. V12 stated that she did not notify the doctor because she contributed the swelling to the usual edema. V12 stated that she gave R3 Tylenol. V12 stated that she was not notified by the staff that R3's leg being twisted during a transfer. On 2/5/2024 at 3:23 PM V15, Certified Nurse's Assistant, CNA, stated that he works 2 days a week at the facility. V15 stated R3 was dependent on staff for care. V15 stated that R3 has dialysis on Tuesday, Thursday, and Saturday. V15 stated that when he went in to get R3 up for Dialysis R3 refused. V15 stated that this is unlike her. V15 stated that R3 never wants to miss dialysis. V15 stated that R3 was complaining of pain. V15 stated that R3 was complaining that her leg hurt. V15 stated that this is not normal for R3. V15 stated that R3 doesn't complain of pain and that she does not miss dialysis. V15 stated that he told V10, RN. V15 stated that the same day or day after R3 went to the hospital. On 2/6/2024 at 2:30 PM V10, RN, stated that she works the night shift and on Saturday morning R3 was complaining of pain to her leg. V10 stated the leg was swollen and bruised. V10 stated that R3 was refusing to go to dialysis because of the pain. V10 stated that this was new for R3. V10 stated that she asked R3 what happened. V10 stated that R3 informed her that a few nights ago her leg was twisted. V10 stated that she called V29, Doctor, and received an order for an x ray. V10 stated that she gave R3 a pain pill about 5:00 AM. V10 stated that at 7 AM the pain had not been relieved. V10 stated that R3 was still in pain. V10 stated that she notified the oncoming nurse. On 2/5/2024 at 3:36 PM V9, LPN, stated that she came in on Saturday at 7 PM. V9 stated that she was told in report that they were waiting for xray and that R3 had swelling and bruising to her knee. V9 stated that she went down and assessed the knee, and it was puffy and bruised. V9 stated that R3 was complaining of pain. V9 stated that R3 does have chronic edema to her leg but this was different. V9 stated that R3 is alert and reliable. V9 stated that R3 does not have any history of making false allegations. V9 stated because the x ray technician hadn't been out there, she called. V9 stated that they returned her call close to 11 PM and said they were not able to get someone out to facility and rescheduled x ray to the following day. On 2/5/2024 at 9:17 AM V6, R3's daughter, stated that her husband had come to visit R3. R3 at that time complained of pain to her right knee to him. V6 stated R3 said she was being transferred either from bed to chair or chair to bed and she was dropped. V6 stated that her husband reported this to V18, CNA. V6 stated that V18 asked R3 at that time if she was dropped or hurt during the transfer, which we found kind of odd. V6 stated that the leg was swollen and bruised that day. V6 stated that she came on the following day and R3's leg was swollen and bruised and R3 was continuing to complain of pain. V6 stated she talked with the nurse and was told that x-rays were ordered but had not come yet. V6 stated at that time she and her sister requested R3 be sent to the hospital because R3 was in so much pain. V6 stated that she spoke with V1, Administrator, after R3 was admitted to the hospital for a broken femur and was informed that V1 was not aware of the issue until Monday morning. V6 stated that she was told by V1 that she would be investigating and would return a call to her. V6 stated that she has not received a call as of yet. V6 stated that her mother initially was transferred to (local hospital) and was then transferred to (Regional Hospital) where R3 underwent surgery for a broken femur. V6 stated that R3 told her that a large black woman with braids transferred her on the evening or night shift. V6 stated that R3 told her that her leg got twisted and that it hurts. V6 stated that she was not sure if R3 said she was dropped or not. V6 stated that R3 will not return to this facility and is currently at another facility. On 2/6/2024 at 10:48 AM R3 stated that her leg got bent and twisted. R3 stated that it was dark. R3 stated that 2 girls came in and got her up. R3 stated that she was lifted by the girls and when they turned her, (R3), her leg got twisted and bent back. R3 stated that this caused her to sit down hard, and it hurt. R3 stated that it was a lot of pain when it happened and then less. R3 stated that she went to dialysis that day and it started hurting worse. R3 stated that she told the nurse and that she got Tylenol. R3 stated that it helped but the pain never went away. R3 stated that the pain never went away and that she was always in pain. R3 stated that she kept telling the staff. R3 stated that she would tell anyone she could because it hurt so bad. R3 stated that when they moved her it hurt worse. R3 stated that even though she told them they continued to transfer her without the lift. R3 stated that this caused more pain. R3 stated that she remembers her son in law coming to visit and then her daughters. R3 stated that they were supposed to use the lift and didn't. R3 stated that she told the nurse. R3 stated that she was in a lot of pain. R3 stated that she doesn't remember the day but knows it was before she went to dialysis. R3 stated that she told the nurse. On 2/8/2024 at 1:19 PM V29, Doctor, stated that he was notified of R3 having pain, swelling and bruising to her right knee and leg on 1/27/2024 and ordered x rays at that time. V29 stated that was unable to follow R3 after that as the facility went with a different physician. V29 stated that up to that point R3 was his patient. V29 stated that he would have expected to be notified of R3's new pain when it occurred. V29 stated that he would have expected the nurse to assess the patient and notify him. V29 stated at that time he would have ordered the x ray and the results of femur fracture would have been found and treatment would have started at that time, including send R3 to the hospital. V29 stated that if the staff were aware of R3 having new pain and stating that she was hurt, leg twisted or bent he would have expected to be notified of this when the nurse became aware of it. V29 stated not being notified of R3's complaints of pain and an initial assessment being performed by the nurse caused a delay in treatment. On 2/9/2023 at 10:10 AM V2, Director of Nursing, stated that per their investigation the injury occurred on the 1/22/24. V2 stated that the first complaint of pain was on 1/23/24. V2 stated that she would have expected the nurse to assess R3 and notify the physician at that time. V2 stated that R3's complaint of new pain and reporting of her leg being hurt was a change in condition. V2 stated that R3 reporting that her leg was twisted or bent causing her pain is an accident or incident and the physician should have been notified at that time. The facility's Pain Management policy, dated 9/2022, documents Policy: 5. Licensed Nursing may notify Health Care Provider of any new development of pain, change in pain, change in condition that could cause pain, for pharmacological interventions based on the individual pain factors. The facility's Change in Resident Condition policy, dated 9/2023, documents It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident and although it's not an emergency it was an acute medical condition. The facility's Physician Notification policy, dated 9/2023, documents Guideline: In a non-emergent, but acute medical situation the physician will be paged and if there is no return call in 15 minutes, the physician will be notified again. If there is no return call in 15 additional minutes (30 minutes total), the Medical Director will be notified.

Based on interview and record review the facility failed to notify the physician of residents continued leg pain for 1 of 3 residents (R3) reviewed for physician notification in the sample of 4. This failure resulted in R3 having unrelieved pain and a delay in treatment for a right femur fracture that required surgical intervention. Findings include: R3's Minimum Data Set, dated dated [DATE], documents that R3 is cognitively intact, and dependent on staff for transfers. R3's Nursing Progress Notes, dated 1/27/2024 at 4:52 AM, documents resident complains of right knee pain. resident states the pain is a 10 on a 1-10 pain scale. resident states she is unable to attend dialysis this am because she can't move her right leg because the pain is so severe. this nurse asked the resident if anything had happened causing the pain in her right knee. resident states a few nights ago while being put in bed, her right leg was accidentally injured in a twisting motion. m.d. (Doctor of Medicine) made aware, poa (Power of Attorney) made aware and orders were received to order an xray of her right knee. R3's Nursing Progress Notes, dated 1/28/2024 at 7:28 AM, documents call placed to md xray to shift, care continues. R3's Nursing Progress Notes, dated 1/28/2024 at 12:19 PM, documents (Emergency Medical Transportation Company) is en (in) route to take resident to (Local Hospital) related to right knee xray. R3's Nursing Progress Notes, dated 1/28/2024 at 11:56 PM, documents This nurse called (local hospital) and spoke with (V4), RN (Registered Nurse), patient was transferred to Regional Hospital from (local hospital) with a dx (diagnosis): fractured femur. This nurse called and spoke with (V5), RN, at Regional Hospital resident is currently admitted with a fracture of the right femur with surgical intervention pending. m.d, poa and management made aware. R3's Computer Tomography (CT) of Right Femur from (local hospital), dated 1/28/2024, documents IMPRESSION: There is an oblique fracture (bone is broken at an angle) through the distal (furthest away from the center of the body) diaphysis (middle) of the right femur with mild posterior displacement of the distal fracture fragment and mild overlap. This is primarily in oblique fracture with mild comminution (broken in more than two pieces). A subtle component of the fracture extends distally into the distal fracture fragment along the more medial aspect (toward the middle or center) of the distal medial femoral diaphysis just above the medial femoral condyle (area located on the end of the femur/thigh bone, covered by cartilage and work as a shock absorber). R3's Nursing Progress Notes, dated 1/29/2024 at 11:31 AM, documents This (V7), RN, called (V6, R3's POA), (listed as POA and emergency contact). (V6) told this RN that (R3) is out of surgery this morning and is currently recovering. Family is at hospital with resident at this time. Family given this RN's information and educated to reach out with updates or if they need anything. R3's Post Fall Huddle, not dated, documents that the date of the Fall/ transfer, was 1/27/2024 evenings. It documented R3 stated while she was being put to bed her right leg was twisted No initial pain. The Facility's Final Report, submitted on 2/5/24, documented the conclusion of the investigation as After complete and thorough investigation, resident and staff interviews, the facility has concluded that the resident sustained a right femur fracture during a transfer from the resident's wheelchair to her bed. The resident states that during her transfer, the right leg became twisted. Pain was voiced in the days following the incident unrelieved. The physician was notified and the resident was sent to the emergency room and was diagnosed with fracture of the right femur. In conclusion, it is verified that the resident sustained an injury to the right femur during transfer. R3's Medication Administration Record, dated 1/1/2024-1/31/2023, documents on 1/23/2024 at 1:30 PM R3's pain level was #6 (1-10) and Tramadol 50 mg given. On 1/26/24 at 4:44 PM R3's pain level was #8. R3's Controlled Drug Receipt Record/Disposition Form, dated 8/8/2023, documents that R3 received Tramadol 50mg tabs: 1/23/24 12 PM, 1/25/24 4:30 PM, 1/26/24 5 PM, 1/27/2023 at 5 AM and 9 PM. On 2/6/2024 at 10:40 AM V27, Dialysis Registered Nurse, RN, stated that when R3 came to dialysis on 1/23/24 she was complaining of pain to her right leg. V27 stated that this is unusual because R3 doesn't usually complain of pain. V27 stated that she gave R3 some Tylenol. V27 stated that R3 stated that her leg was hurting because it got bentV27 stated that there wasn't any bruising at the time but that there was swelling but not a large amount. On 2/8/2024 at 1:56 PM V20, Licensed Practical Nurse, LPN, stated that on 1/23/2024 R3 complained of knee pain. V20 stated that she asked R3 what caused her pain. V20 stated that R3 reported that her leg had been bent or twisted during a transfer. V20 stated that this was new for R3. V20 stated that R3 had never complained of pain before that day to V22. V22 stated that she did not look at or assess R3's knee at that time. V20 stated that she did not notify the doctor because R3 had prn (as needed) medication already ordered. On 2/5/2024 at 3:54 PM V12 LPN stated that R3 is alert and oriented. V12 stated that a couple of Fridays (1/26/24) ago R3 said her leg was hurting and felt like it was twisted. V12 stated that she gave her Tylenol. V12 stated that this was new and R3 had not complained of pain to her leg before this. V12 stated that she did an assessment of R3's leg and it was swollen. V12 stated that she did not notify the doctor because she contributed the swelling to the usual edema. V12 stated that she gave R3 Tylenol. V12 stated that she was not notified by the staff that R3's leg being twisted during a transfer. On 2/5/2024 at 3:23 PM V15, Certified Nurse Assistant, CNA, stated that when he went in to get R3 up for Dialysis R3 refused. V15 stated that this is unlike her. V15 stated that R3 never wants to miss dialysis. V15 stated that R3 was complaining of pain. V15 stated that R3 was complaining that her leg hurt. V15 stated that this is not normal for R3. V15 stated that R3 doesn't complain of pain and that she does not miss dialysis. V15 stated that he told V10, RN. V15 stated that the same day or day after R3 went to the hospital. On 2/6/2024 at 2:30 PM V10, RN, stated that she works the night shift and on Saturday morning (1/27/24) R3 was refusing to go to dialysis because of the pain. V10 stated that this was new for R3. V10 stated that R3 informed her that a few nights ago her leg was twisted. V10 stated that she called V29, Doctor, and received an order for an x ray. V10 stated that she gave R3 a pain pill about 5:00 AM. V10 stated that at 7 AM the pain had not been relieved. V10 stated that R3 was still in pain. V10 stated that she notified the oncoming nurse. On 2/5/2024 at 3:36 PM V9, LPN, stated that she came in on Saturday (1/27/24) at 7 PM. V9 stated that she went down and assessed the knee, and it was puffy and bruised. V9 stated that R3 was complaining of pain. V9 stated that R3 does have chronic edema to her leg but this was different. V9 stated because the x ray technician hadn't been out there, she called. V9 stated that they returned her call close to 11 PM and said they were not able to get someone out to facility and rescheduled x ray to the following day. On 2/5/2024 at 9:17 AM V6, R3's daughter, stated that her husband had come to visit R3. R3 at that time complained of pain to her right knee to him. R3 said she was being transferred either from bed to chair or chair to bed and she was dropped. V6 stated that her husband reported this to V18, CNA. V6 stated that V18 asked R3 at that time if she was dropped or hurt during the transfer, which we found kind of odd. V6 stated that the leg was swollen and bruised that day. V6 stated that she came on the following day and R3's leg was swollen and bruised and R3 was continuing to complain of pain. V6 stated she talked with the nurse and was told that x-rays were ordered but had not come yet. V6 stated at that time she and her sister requested R3 be sent to the hospital because R3 was in so much pain. On 2/6/2024 at 10:48 AM R3 stated that her leg got bent and twisted. R3 stated that it was dark. R3 stated that 2 girls came in and got her up. R3 stated that she was lifted by the girls and when they turned her, (R3), her leg got twisted and bent back. R3 stated that this caused her to sit down hard, and it hurt. R3 stated that it was a lot of pain when it happened and then less. R3 stated that she went to dialysis that day and it started hurting worse. R3 stated that she told the nurse and that she got Tylenol. R3 stated that it helped but the pain never went away. R3 stated that the pain never went away and that she was always in pain. R3 stated that she kept telling the staff. R3 stated that she would tell anyone she could because it hurt so bad. R3 stated that when they moved her it hurt worse. R3 stated that even though she told them they continued to transfer her without the lift. R3 stated that this caused more pain. R3 stated that she remembers her son in law coming to visit and then her daughters. R3 stated that she was in a lot of pain. R3 stated that she doesn't remember the day but knows it was before she went to dialysis. R3 stated that she told the nurse. On 2/8/2024 at 1:19 PM V29, Doctor, stated that he was notified of R3 having pain, swelling and bruising to her right knee and leg on 1/27/2024 and ordered x rays at that time. V29 stated that he would have expected to be notified of R3's new pain when it occurred. V29 stated that he would have expected the nurse to assess the patient and notify him. V29 stated at that time he would have ordered the x ray and the results of femur fracture would have been found and treatment would have started at that time, including send R3 to the hospital. V29 stated that if the staff were aware of R3 having new pain and stating that she was hurt, leg twisted or bent he would have expected to be notified of this when the nurse became aware of it. V29 stated not being notified of R3's complaints of pain and an initial assessment being performed by the nurse caused a delay in treatment. On 2/9/2023 at 10:10 AM V2, Director of Nursing, stated that per their investigation the injury occurred on the 1/22/24. V2 stated that the first complaint of pain was on 1/23/24. V2 stated that she would have expected the nurse to assess R3 and notify the physician at that time. V2 stated that R3's complaint of new pain and reporting of her leg being hurt was a change in condition. V2 stated that R3 reporting that her leg was twisted or bent causing her pain is an accident or incident and the physician should have been notified at that time. The facility's Change in Resident Condition policy, dated 9/2023, documents It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident and although it's not an emergency it was an acute medical condition. The facility's Physician Notification policy, dated 9/2023, documents Guideline: In a non-emergent, but acute medical situation the physician will be paged and if there is no return call in 15 minutes, the physician will be notified again. If there is no return call in 15 additional minutes (30 minutes total), the Medical Director will be notified.

Based on interview and record review the facility failed to safely transfer a resident per plan of care for 1 of 3 residents (R3) reviewed for supervision to prevent accidents in the sample of 4. This failure resulted in R3's sustaining a right femur fracture which required surgical repairment. Findings include: R3's Face Sheet, undated, documented she had diagnoses of other lack of coordination, abnormal posture, muscle weakness, hemiplegia (paralysis on one side of body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following unspecified cerebrovascular disease affecting right dominant side. R3's Care Plan, dated 10/24/22, documents (R3) has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Hemiplegia. Her primary mode of locomotion is wc (wheelchair). She is incontinent of B&B (bowel and bladder). She requires assist with adl care tasks. (R3) has been provided with a reacher to assist with safely reaching personal items. It continues: TRANSFER: (R3) requires Mechanical Aid (full body mechanical lift) for transfers. Imitation date of 9/4/2019 R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact, and dependent on staff for transfers. R3's Nursing Progress Notes, dated 1/27/2024 at 4:52 AM, documents resident complains of right knee pain. resident states the pain is a 10 on a 1-10 pain scale. resident states she is unable to attend dialysis this am because she can't move her right leg because the pain is so severe. this nurse asked the resident if anything had happened causing the pain in her right knee. resident states a few nights ago while being put in bed, her right leg was accidentally injured in a twisting motion. m.d. (Doctor of Medicine) made aware, poa (Power of Attorney) made aware and orders were received to order an xray of her right knee. R3's Nursing Progress Notes, dated 1/28/2024 at 7:28 AM, documents call placed to md xray to shift, care continues. R3's Nursing Progress Notes, dated 1/28/2024 at 12:19 PM, documents (Emergency Medical Transportation Company) is en (in) route to take resident to (Local Hospital) related to right knee xray. R3's Nursing Progress Notes, dated 1/28/2024 at 11:56 PM, documents this nurse called (local hospital) and spoke with (V4), RN (Registered Nurse), patient was transferred to Regional Hospital from (local hospital) with a dx (diagnosis): fractured femur. This nurse called and spoke with (V5), RN, at Regional Hospital resident is currently admitted with a fracture of the right femur with surgical intervention pending. m.d, poa and management made aware. R3's Computer Tomography (CT) of Right Femur from (local hospital), dated 1/28/2024, documents IMPRESSION: There is an oblique fracture (bone is broken at an angle) through the distal (furthest away from the center of the body) diaphysis (middle) of the right femur with mild posterior displacement of the distal fracture fragment and mild overlap. This is primarily in oblique fracture with mild comminution (broken in more than two pieces). A subtle component of the fracture extends distally into the distal fracture fragment along the more medial aspect (toward the middle or center) of the distal medial femoral diaphysis just above the medial femoral condyle (area located on the end of the femur/thigh bone, covered by cartilage and work as a shock absorber). R3's Nursing Progress Notes, dated 1/29/2024 at 11:31 AM, documents This (V7), RN, called (V6, R3's POA), (listed as POA and emergency contact). (V6) told this RN that (R3) is out of surgery this morning and is currently recovering. Family is at hospital with resident at this time. Family given this RN's information and educated to reach out with updates or if they need anything. R3's Post Fall Huddle, not dated, documents that the date of the Fall/transfer, was 1/27/2024 evenings. It documents that R3 was being transfer assisted by staff. It documents that that R3 is alert and oriented. Documents that assisted devices wheelchair was in use and device not in use. It also documents that R3 said that her leg was twisted during transfer. It documents What appears to be the initial root cause of the fall? Resident stated while she was being put to bed her right leg was twisted 0 (no) initial pain. The facility's Reported Incident Form Initial Report documents the date and time when the alleged incident occurred is unknown at this time. The Report documented the incident occurred in the resident's room. It documents that the serious bodily injury occurred was a right femur fracture. It documents that the Resident had increasing complaints of pain to the right leg, that was unrelieved with pharmacological intervention. The Facility's Final Report, submitted on 2/5/24, documented the conclusion of the investigation as After complete and thorough investigation, resident and staff interviews, the facility has concluded that the resident sustained a right femur fracture during a transfer from the resident's wheelchair to her bed. The resident states that during her transfer, the right leg became twisted. Pain was voiced in the days following the incident unrelieved. The physician was notified and the resident was sent to the emergency room and was diagnosed with fracture of the right femur. In conclusion, it is verified that the resident sustained an injury to the right femur during transfer. V11's, Licensed Practical Nurse,LPN, written statement, not dated, documents On 1/26/2024 this writer was on 400 hall doing treatments when (R3) called this writer to her room. Resident stated her leg was hurting and that it was twisted when they were getting her up. Resident unable to tell this writer what day it happened. This writer immediately went to resident's nurse (V12, Licensed Practical Nurse, LPN), and let her know of the situation. (V12) stated she would give her something for the pain and notify the doctor. V7's, Certified Nurse's Assistant (CNA), written statement regarding the incident, not dated, documents We did a 2 person transfer on (R3). (R3) never complained of pain. V14's, CNA, written statement, not dated, documents I worked with another CNA named (V15) over on the women side. (R3) had her call light on to go to bed. When we brought the (mechanical lift) in there she said to be careful of her right leg that midnights 2 maned her and she twisted her leg. I informed the nurse (V12) on what (R3) said. She (V12) said she already looked at it. That it was the side she had her stroke on. She didn't say anything about what I told her about midnights 2 manning her (R3). On 2/5/2024 at 12:39 PM V16, Scheduler, stated that the interviews and statements were from the date of 1/31/2024. V16 stated that the night that V13 transferred R3 was 1/22/24. On 2/5/2024 at 4:14 PM V3, Assistant Director of Nursing, (ADON), stated that the investigation concluded that R3's leg was injured during a transfer. V3 stated that on 1/22/23, V22 and V23 were observed entering R3's room and transferred R3 to bed. V3 stated that V22 and V23 transferred R3 using the lift and somehow twisted R3's leg. V3 stated that watching the camera they could see them enter the room and shortly after exit. V3 stated after this transfer R3 started to complain of pain to her knee. V3 stated that there aren't cameras in the room so the exact technique she is not sure of. When asked how she knew it was a transfer with a lift, V3 stated that because R3 requires a mechanical lift she assumed the transfer was with the lift. V3 stated that R3 is alert and able to tell you what happened. V3 stated that they did Inservice on how to use the mechanical lift. V3 stated that this is the only in-service performed because of R3's incident and injury. On 2/5/2024 at 3:11 PM V14, CNA, stated that she believes she took care of R3 the day after it happened. V14 stated that she worked 3 to 11PM that night. V14 stated that R3 had her call light on. V14 stated that when she answered it R3 wanted to go to bed. V14 stated that R3 told her that she must get the lift. V14 stated that she was going to go get. V14 stated that R3 then said that they dropped her (R3) this morning. V14 stated that when they transferred R3 to the bed in lift and R3 was yelling out in pain. V14 stated that R3's leg was swollen. V14 stated that she told V12 and V12 response was that she already knew and that its R3's flaccid leg. V14 stated that it is not like R3 to complain of pain and to yell was different and new. V14 stated that R3 is alert and able to respond correctly. R3 stated that if R3 said she was hurt or dropped than its accurate. On 2/5/2024 at 3:18 PM V11, Wound Nurse, stated that she worked the floor as an aide on 1/22/24 because of the ice storm. V11 stated that she assisted R3 with repositioning and care and R3 did not complain of any pain. V11 stated that R3 leg had some edema. V11 stated that this is not unusual for her because of her right side being flaccid. V11 stated that she did not see any bruising. V11 stated on the following Friday (1/26/24) R3 yelled for V11 to her room. V11 stated that R3 stated I'm in pain. They twisted my leg when getting me up. V11 stated that she reported this to V12. V11 stated that she informed V12 of the pain and of R3 saying that her leg was twisted when staff got her up. V12 stated that she will assess her and call the doctor. V11 stated that she did not look at R3's leg at that time. V11 stated that R3 is very alert. V11 stated she believes R3's statements are accurate. V11 stated that R3 can remember things from a week before. V11 stated that R3 does not have a history of making false allegations. V11 stated that if R3 said she would believe it to be accurate. On 2/5/2024 at 10:36 PM V26, CNA, stated that she works at the facility fulltime. V26 stated that she is familiar with R3 and provides care for her routinely. V26 stated that R3 is dependent with care. When asked how does R3 transfer, V26 responded that she was told to use 2 people, but she uses the mechanical lift because R3 doesn't stand. V26 stated that about 2 weeks ago V26 was getting ready to get R3 up. V26 stated that V13 was working the shift as well. V26 stated that because she did not feel comfortable with transferring R3 by herself V13 showed her. V26 stated that she would never do that because R3 didn't stand and didn't help at all. V26 stated that V13 grabbed a hold of R3 in a bear hug and lifted her off the bed and down in the chair. V26 stated that the transfer was not smooth and R3 didn't move her feet. V26 stated that R3's feet did not move during the transfer. V26 stated that she is not sure if R3's leg hit anything or twisted. V26 stated that V13 just picked R3 up and put her in the chair. On 2/5/2024 at 10:49 PM V13, CNA, stated that she provides care to R3. V13 stated that they changed R3's transfers. V13 stated that R3 was a 2 person transfer and now she is a lift. V13 stated that she doesn't know when it changed. V13 stated that she has in the past transferred R3 alone. V13 stated that she was out sick and is now returning. V13 stated that it's been about 2 weeks. On 2/6/2024 at 10:48 AM R3 stated that her leg got bent and twisted. R3 stated that it was dark. R3 stated that 2 girls came in and got her up. R3 stated that she was lifted and when they turned her, (R3), her leg got twisted and bent back. R3 stated that this caused her to sit down hard, and it hurt. R3 stated that it was a lot of pain when it happened and then less. R3 stated that she went to dialysis that day and it started hurting worse. R3 stated that she told the nurse and that she got Tylenol. R3 stated that it helped but the pain never went away. R3 stated that the pain never went away and that she was always in pain. R3 stated that she kept telling the staff. R3 stated that she would tell anyone she could because it hurt so bad. R3 stated that when they moved her it hurt worse. R3 stated that even though she told them they continued to transfer her without the lift. R3 stated that this caused more pain. R3 stated that she remembers her son in law coming to visit and then her daughters. R3 stated that they were supposed to use the lift and didn't. R3 stated that she told the nurse. R3 stated that she was in a lot of pain. R3 stated that she doesn't remember the day but knows it was before she went to dialysis. R3 stated that she told the nurse. On 2/8/2024 at 9:00 AM V1, Administrator, stated that she was made aware of the incident the day before R3 went out to the hospital. V1 stated that an investigation was performed. V1 stated that her findings were that 2 aides transferred R3 without using the mechanical lift. V1 stated that R3 did not complain of pain at that time. V1 stated that R3 started to complain of pain and was given pain medication. V1 stated that R3's pain continued, the doctor was notified, and x rays were ordered. V1 stated that the x ray technician did not come on initial day and was rescheduled for the following day. V1 stated that R3 continued to complain of pain and was sent out to the hospital. V1 stated that she feels that the nurses did what needed to be done in this situation. V1 stated that they were able to identify the staff involved in the incident. V1 stated that the aides admitted to the transfer. V1 stated that V26 and V7 performed the transfer. V1 stated that V22 and V23 were on that shift as well. V1 stated that there has been some changes and staff have been terminated and in serving was performed on the mechanical lift. The facility's Reporting of Unusual Occurrences Policy, effective date of 6/2015 and reviewed date of 9/2022, documents the purpose is to provide a process for the reporting and reviewing unusual occurrences. The Policy documents 4. The resident will be evaluated after the incident/occurrence to determine the injury. The evaluation that is done is based on the occurrence and documented in the EHR (Electronic Health Record). If the incident involves a visitor or staff, then a note is made and placed in a file for the Administrator. 5. The provider, as well as the family is notified of the incident. The Policy documents 9. The investigation for falls, skin tears and unknown injury will begin immediately and will be entered into the risk management portal.

Based on interview, observation and record review, the facility failed to adequately supervise a resident to prevent an elopement of 1 of 3 residents (R2) reviewed for supervision. This failure resulted in R2 eloping from the facility. R2 was gone from the facility for approximately 14 hours and sustained a fractured right tibia while out of the facility. On 11/07/23 at 2:50pm V1 Administrator and V2 Don was in room when V1 signed IJ Template. The Immediate Jeopardy began on 10/10/23 approximately 11:00 PM-12:00AM, When R2 eloped from the facility, and was found out in the rain under a tree with a broken leg. The staff was unaware of R2 had exited the facility. Findings include: On 11/3/23 at 2:35 PM, R2 was observed in his room with the privacy curtain pulled all the way around him. R2 stated he left the faciity on [DATE] at approximately 11:00 PM - 12:00 AM. R2 stated he went out the front door as two people were going out the door. R2 stated he did not know who they were, but he doesn't think they were staff members. R2 stated he told those two people that he was leaving too. R2 stated he signed himself out and went and sat under a tree, never climbed, or got into the tree and as he was sitting down, he heard a pop in his right knee, and it started hurting. R2 stated he did not go anywhere else just to sit under the tree. R2 stated sometime in the afternoon on 10/11/23 the facility staff found him and was watching him but never came to him. R2 stated the ambulance came and took him to the hospital. R2 stated it was raining during the morning on 10/11/23 and the tree was keeping him out of the rain. R2 stated he's not sure how far away from the facility he was. R2's Release of Responsibility for Leave of Absence, documents R2 signed himself out on 10/10 (no year documented) at 7:15 PM and was signed back in by staff on 10/10 (no year documented) at 7:27 PM and 10/11 (no year or time documented). R2's Face Sheet, undated, documents R2 has a diagnosis of Schizophrenia, Adjustment Disorder and Visual Hallucinations. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact and is ambulatory. R2's Care Plan, dated 1/3/22, documents R2 is at risk for wandering/elopement, on 5/21/23, resident left hospital emergency room (ER/ED) without supervision. R2's Community Survival Skills Evaluation, dated 7/17/23, documents R2 is not capable unsupervised outside pass privileges at this time. R2's Elopement Assessment, dated 5/1/23 and 10/11/23, documents R2 is at high risk for elopement. R2's Progress Notes, document the following: 5/1/2023 at 1:41 PM, resident left via facility transportation with paperwork. Transportation will transport resident to Psychiatric Hospital per MD orders for Evaluation & treatment. 5/1/2023 3:58 PM, Call placed to Psychiatric Hospital to follow-up on resident status. Spoke with ER Nurse. Per ER Nurse resident was not seen by ER for care. ER Nurse transferred my call to the hospital psychiatric Intake Nurse. Per Intake Nurse Resident has not been admitted and was not evaluated. Resident was last treated for Psychiatric care on March 9th. ADON, (Assistant Director of Nurses), was notified that resident was not at Hospital. Awaiting further instructions. 5/1/2023 21:00 Hospital House Supervisor contacted facility and writer asking about the whereabouts of the resident, that the police had no information on what was going on and asked for writer to give a face sheet to the police, writer contacted the ADON, she stated that the police were notified, a missing person report was put into effect and that they found resident and 911 was picking him up and taking him to the psychiatric hospital. The ADON stated she contacted the hospital and she had given report to the ER nurse in regard to the resident and his condition, will follow up with hospital on time of arrival and nurse treating. 5/2/2023 04:32 Resident returned to facility via ambulance. Resident educated on call light usage and importance of letting staff know when he needed anything. Resident verbalized agreement. Resident can make needs known, denies pain or complaints. no signs or symptoms/ distress/discomfort noted at this time. Vital Signs within normal limits, enhanced monitoring protocol initiated. Will continue to monitor resident for safety this shift. 10/11/2023 at 12:37 PM, Resident unable to be located while prepping for lunch meal. All staff immediately began facility search for resident. It was noted that resident did sign self out of the facility without alerting staff of LOA, (leave of absence), but did not sign out a time of LOA, only a signature was present. Staff searched for resident off facility premises also and resident was located nearby and noted to be disoriented to self & situation. Resident stated his name was Not (R2) and gave a different name. Resident had complaints of knee pain but stated he did not fall or anything, it just made a pop sound. Ambulance called to transport resident to hospital ER for evaluation & treatment. Resident's State Guardian notified and detailed message left regarding occurrence and status of resident. ER Nurse was given report and face sheet and order summary faxed to ER. DON, (Director of Nurses), & Administrator aware. 10/11/2023 at 6:50 PM, Resident returned to this facility via ambulance. Resident alert & oriented. Resident has a closed fracture of the lateral portion of the right tibial plateau. Immobilizer in place to right leg. Resident provided meal upon return et consumed 100% of meal. Staff provided enhanced supervision for elopement risk. No complaints of pain noted. R2's Other Event, dated 10/11/23 at 12:34 PM, documents, R2 was not in the dining room for meal. All staff began searching for resident. Resident is alert, confused/forgetful and non-compliant with safety guidance. No witnesses found and resident unable to give description. R2's ER/ED Notes, dated 10/11/23, document the following: 10/11/23 - arrived in ED 10/11/23 at 3:10 PM, He has pain, swelling and redness to the right knee. This started sometime since yesterday. It was reported that he may have fallen out of a tree. The patient denies any known injury. Physical Exam: right knee swelling, effusion, and erythema present. Decreased ROM, (range of motion), tenderness present. X-Ray of the right knee: Mildly comminuted minimally displaced right lateral tibial plateau fracture. Moderate suprapatellar joint effusion, which is likely post traumatic. Patient to ED via EMS, (Emergency Medical Services), with complaints of right knee pain. Patient eloped from facility sometime last night. Patient felt a pop in his knee followed by pain. Patient states he sat under a tree to seek shelter from the rain and has been there until this afternoon when the staff from the facility found him. Patient denies any falls. He has no complaints other than knee pain at this time. Patient has a history of schizophrenia. Nursing Home staff states patient has not been compliant with medications lately. He refused taking his medications this morning. Patient is calm and cooperative with staff at this time. Clinical Impression: Closed fracture of the lateral portion of the right tibial plateau. EMS call log from ambulance to Hospital: 10/11/23 at 1:29 PM - elopement from Nursing Home. R2's Medication Administration Record, (MAR), dated 10/2023, documents R2 refused his medication on 10/10/23 at 8:00 PM. It was documented, that R2 was not in the building on 10/11/23 at 7:00 AM for his pain assessment or at 9:00 AM to receive his medications. The Facility Investigation, undated, documents R2 was last seen by R9 on 10/10/23 after the 9:00 PM smoke time. Other residents interviewed did not see R2 after the 7:00 PM smoke time. V23, LPN, (Licensed Practical Nurse), /ADON, V5, CNA, (Certified Nurse Assistant), nor V9 Infection Control Nurse, saw R2 on 10/11/23. On 10/30/23 at 12:50 PM, V1, Administrator, stated that R2 was not made an elopement risk until he did not return from LOA. V1 stated staff noticed R2 was not at lunch on 10/11/23. V1 stated the Nurse was concerned and did not remember R2 being on LOA. V1 stated, that R2 did sign out, but did not sign out a time. V1 stated at 12:30 PM the facility staff started a search. V1 stated, the Police were not notified. V1 stated it was not normal for R2 not to be at lunch. V1 stated that R2 was found sitting under a tree in a front yard. V1 stated R2 did not know his name or how got there, so 911 was called. V1 stated that R2 was unable to stand. V1 stated this was the first time to her knowledge that R2 had eloped. V1 stated after R2 returned to the facility from the Hospital, the facility started elopement drills, the leave of absence policy was reviewed, and resident rights were reviewed. V1 stated this was not typical behavior for R2. V1 stated that R2 likes to sit outside and draw and V1 stated R2 is not an exit seeker. V1 stated R2 was placed on one-on-one supervision and later placed on 15-minutes checks. On 10/30/23 at 12:53 PM, V2, Director of Nurses, (DON), stated lunch time came around and R2 was not in the dining room, which was odd, so they searched the building. V2 stated R2 was found down the street under a tree. V2 stated R2 complained of knee pain and could not stand, so 911 was called from the site, he was taken to the Hospital and diagnosed with a fractured patella. V2 stated R2 had signed himself out but did not put a time down and did not tell anyone. V2 stated according to the nurse, V24, Licensed Practical Nurse, (LPN), R2 took his morning medications and was in the dining room for breakfast. V2 stated R2 is still having periods of confusion. V2 stated R2 was not previously at risk for elopement but has been care planned for elopement and is in the elopement book. On 11/7/23 at 8:40 AM, V1, Administrator, stated staff noticed R2 was not back for lunch around 12:30 PM on 10/11/23. V1 stated staff went looking for R2 and found him down the road under a tree at 12:40 PM. V1 stated R2 was gone 10 minutes. V1 stated R2 was having a Psychotic episode, though his name was R9, and he was talking to raccoons, so they called the ambulance. On 11/7/23 at 9:28 AM, V1, Administrator, stated they did not interview R2 because he was at the hospital. On 11/7/23 at 9:30 AM, V19, CNA, stated she worked night shift on 10/10/23 and did not recall seeing R2 at all during the night. V19 stated they were moving residents around and wasn't sure if he had been moved. On 11/7/23 at 9:40 AM, V18, LPN, stated, that she worked 7:00 PM - 7:00 AM on 10/10/23 and she doesn't recall when or where she saw R2, but she was told by management, who looked at the cameras, and said she was entering the building around 7 PM as R2 was exiting the building. V18 stated she must have seen him though, because she would not have documented that he refused his medications at 8:00 PM if he hadn't seen him and attempted to give them to him. V18 stated she doesn't recall seeing him during the rest of her shift. V18 stated R2 is independent so she did not check on him during the night. On 11/7/23 at 10:00 AM, V1, Administrator, stated they did an emergency resident council meeting, elopement drills, etc. but we didn't see R2's event as an elopement because he signed himself out. V1 stated V24, LPN, had told them that she saw R2 on 10/11/23 at the beginning of her shift. V1 stated they are not sure when R2 exited the building. V1 stated they have cameras, but he was not seen exiting the building on 10/10/23 or 10/11/23. On 11/7/23 at 10:15 AM, V24, LPN, stated she worked 7:00 AM - 7:00 PM on 10/11/23, she was working three halls and she did not see R2. V24 stated she didn't see him for his 9:00 AM medication administration, so she documented he was out of the facility. V24 stated staff, unsure of whom, told her after he was deemed missing, that R2 was not in the dining room for breakfast that morning and that his tray was sent to his room, when staff went to pick up his tray, it had been untouched, so they took it out of his room. V24 stated they normally serve lunch around 11:00 AM -11:30 AM and she was in the dining room and noticed R2 was not there for lunch. V24 stated she could not find him, so she took her personal car and began looking for him. V24 stated R2 was found down the hill from the facility, under a tree, maybe a mile or less from the facility. V24 stated R2 was confused and was calling himself a different name and told her that he sat under the tree because the raccoons told him to. V24 stated he told her he hurt his knee and couldn't stand up. V24 stated V2, DON, was there and she thinks she (V2) called 911. V24 stated after EMS came and she talked to them, she went back to the facility to finish her medication pass. V24 stated she is not sure how long R2 had been gone from the facility. On 11/7/23 at 10:40 AM, R9 stated he can't remember if he did or didn't see R2 on 10/10/23 or 10/11/23. The Elopement policy, dated 6/2015, documents elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Resident at risk of eloping will be closely monitored. All residents will be supervised when exiting the building. The facility took the following actions to remove the Immediacy, with the IJ removed on 11/08/23. A. Identification of Residents Affected or Likely to be Affected: 1. R2 was physically assessed on 10/11/2023 by Facility Director of Nursing, V2 due to complaint of pain in R knee and unable to stand up and stating that he had knee pain. Resident was then transferred to Local Hospital for further evaluation, returning with new orders for R knee immobilizer and to follow up with orthopedics due to R tibial plateau fracture. Resident remains in facility with implementation of enhanced supervision of 1:1 then reassessed and changed to 15-minute checks following care plan meeting to determine no further need of 1:1 completed on 10/30/2023. CNA's will complete the enhanced supervision; 15 mins checks and update in enhanced supervision binder at the nurse's station. As well as routine monitoring of all residents every 2 hours. 2. Completed reassessments for elopement risk and community survival skills on all residents by V14 Social Services Director, V2 Director of Nursing, V1 Facility Administrator on 11/8/2023. All to be ongoing for new residents to be assessed for elopement and community survival skills. Resident's with newly identified exit seeking behaviors will be reassessed as needed. 3. Care plans were updated with interventions to identify elopement risk by V1 Facility Administrator, V2 DON, V14 Social Service Director on 11/8/2023 and to be ongoing to include all new residents and as needed for newly exit seeking behaviors. Residents will be identified by Care Plan; elopement assessment and community survival skills assessment will be updated quarterly and as needed. B. Actions to Prevent Occurrence/Recurrence: 1. The [NAME] President of Regulatory Compliance and Clinical Operations, V18 reviewed and revised elopement policy and procedures, Leave of Absence Policy and Procedures and Enhanced Supervision on 10/11/2023. Staff educated on Leave of Absence Policy on 10/11/2023. All residents that go out on leave of absence as a result of their community survival skills evaluation will be listed in LOA binders at nurses' station and front desk. All staff education on making sure they also sign along with the residents when leaving and returning to facility completed 11/8/2023 By V1 Facility Administrator and V2, DON and V14 Social Service Director., V19 Director of Staffing, V17 HR Director. Residents that may go LOA with community pass is also listed under special instruction in care profile in PCC, EMR. Per facility LOA Policy if resident has not returned within 24 hours the facility with contact the responsible party listed on the EMR. 2. The interdisciplinary team including V1 Facility Administrator, V2 Director of Nursing, V20 Activity Director, V21 Dietary, V9 Infection Preventionist educated all staff on Elopement Policy and Procedures, Leave of Absence Policy and Procedures and Enhanced Supervision to be ongoing for new hires and agency staff on 10/11/2023 and reviewed again on 11/8 by Nurse Consultant with no changes required. 3. The training will also include providing supervision/monitoring to prevent elopements, immediate head count upon recognition of missing resident, resident who are in building at all times and who are on leave of absence and recognizing when a resident exits the facility or has newly identified exit seeking behaviors to be ongoing including all staff, new hires, and agency staff. 4. All nursing staff will be educated on performing whole house head count at the beginning of their shift without going shift to ensure all residents are accounted for by V2 DON, V9 IP Nurse and V19 Director of Staffing on 10/11/23 to be ongoing. The charge nurse will print a census to perform the head count which will be signed off and provided to the Director of Nursing V2. 5. Emergency resident council meeting to be held on 10/11/2023 by V20 Activities Director and V2 Director of Nursing to inform residents of the need to be supervised when leaving the building. 6. All agency staff and new hires will be educated on elopement policy, leave of absence policy and enhanced supervision prior to the beginning of their shift By V2 DON, V19 Director of Staffing and V17 HR Director to be ongoing. 7. V22, Maintenance Director will conduct elopement drills at least (3) times a month at different shifts to ensure compliance to be ongoing. 8. The elopement drill will be evaluated by the Administrator, V1 and any identified concern will be addressed. Additional staff training will be completed on an ongoing basis. 9. An Ad-Hoc QAPI meeting will be held weekly for four (4) weeks by the QAPI team to discuss this removal plan and identify if additional interventions are necessary to be ongoing. Monitoring/auditing elopement policy and procedures, Leave of Absence Policy and Procedures and Enhanced supervision of ongoing education of all staff by V1 Facility Administrator and V2 DON and elopement drills By V22 Maintenance Director and ongoing assessments of new residents and residents with newly identified issues regarding elopement by V14. 10. Social Services Director V14 and V1 Facility Administrator will continue to be ongoing and will be part of the QAPI process. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 11/8/2023

Based on interview and record review, the facility failed to prevent sexual abuse by a male resident for 1 of 3 residents (R12) reviewed for abuse on the sample list of 27. This deficient practice resulted in R27 having inappropriate sexual contact with R12. Findings include: R12's Care Plan, (CP), dated 12/5/2019, documents, ABUSE: (R12) is considered at risk for abuse/neglect due to, mood cognition, behavioral/physical deficits. She is noted to be social with other residents. It continues, address all complaints/concerns promptly with Grievance policy and procedure. Intervene if observing any conflict to avoid potential situations of abuse/neglect. Report any suspicion of abuse to the Administrator. Will complete/update risk, abuse/neglect assessment initially and prn, (as needed). 9/10/2020 The resident has, impaired cognitive function & impaired thought processes r/t, (related to), dementia. It also documents, 3/24/23 ADL, (activity of daily living), (R12) requires assist with daily care needs r/t impaired decision-making skills r/t mental illness and anti-psychotropic medications. (R12) has a diagnosis & history of severe mental illness (SMI)- Schizophrenia and Bipolar. (R12's) problems & symptoms are manifested by: Observable medical/psychiatric/ cognitive conditions that may require on-going assessment, consultation & intervention. Need for on-going psychoactive medication. Psychiatric diagnosis are Schizophrenia and Bipolar disorder. 5/13/22 (R12) was noted to consume a small amount of hand sanitizer without any adverse side effects R12's Minimum Data Set (MDS), dated [DATE] and 8/10/23, documents that R12 is severely cognitively impaired. The Facility-Reported Incident Form, not dated, documents, Name of resident Allegedly Abused or Neglected: (R12), BIMS, (Brief Interview for Mental Status), 2 (Severe Cognitive impact) Alert and Oriented X1. Diagnosis Ataxia following Nontraumatic intracerebral Hemorrhage, Epilepsy unspecified, COPD, ([NAME] Obstructive Pulmonary Disease), Schizoaffective disorder, Schizophrenia. It continues: name of resident/Alleged Perpetrator (R27), BIMS 15 Alert and Oriented x 4. Diagnosis Schizoaffective disorder, bipolar, essential hypertension, hyperlipidemia, hypothyroidism. Allegation type Sexual Abuse. Initial Report: September 17th at 8:55 PM it was reported that R27 was in R12's room and allegedly inappropriately touching R12 chest on top of R12's shirt. The Final Report documents, conclusion of investigation based on findings. R27 did enter the room and lay in bed next to R12. He immediately left once the other residents on the hall asked him to leave. R12 did call him into the room, because she thought he was her husband. No intent of sexual abuse was intended by R27. R27 was placed on 1:1, until his discharge the following day to (sister facility) during investigation of allegation for safety of all residents. An interview of the alleged perpetrator, not dated, documents, that R27 was going in R12's room to lay down with R12, because R12 was calling out to him and smiling. Then a lady saw him go in the room and yelled at R27 to get out, so R27 left the room. On 9/26/23 at 9:00 AM V4, LPN, stated, that she was the Nurse on duty the night of the incident. V4 stated, that (R1) and (R2) came to her and reported that they saw (R27) laying in (R12's) bed with his hands going up the front of her. V4 stated, that she was told that R1 watched R27 going down the hall and go into the room. V4 stated, that they followed him and yelled at him to get out. V4 stated, that she assessed R12. V4 stated, that when asking R12 about the situation R12 stated, that R12 thought R27 was her husband. On 9/26/23 at 1:56 PM R1 stated, that she was at the Nurse's Station and saw R27 go pass her. R1 stated, that she saw R27 go from room to room going in and out of them. R1 stated, that when he got to (R12's) room he did not come out. R1 stated, that she told R2. R1 stated, that she and R2 went down to the room R1 stated, that R2 went in first to the room and opened the door. R1 stated, that R27 was lying in the bed with his hand going up the front of R12's shirt. R1 stated, that she and R2 started, yelling at R27 to get out of the room. R1 stated, that R27 did get up and left the room. R1 stated, that they then told V4. R1's MDS, dated [DATE], documents, that R1 is cognitively intact. On 9/26/23 at 2:15 PM R2 stated, that she was told by R1 that R27 had went into R12's room and had not come back out. R2 stated, at that point she and R1 went to R12's room. R2 stated that the door was closed. R2 stated, that she pushed the door open and R27 was laying on the bed with his hand going up and down R12's shirt. R2 stated, that she started yelling get out of here and R27 jumped up with his hands up, pants unzipped and his penis out. R2 stated, that R27 left the room and she and R1 told V4. R2's MDS, dated [DATE], documents, that R2 is cognitively intact. On 9/26/2023 at 9:29/23 R12 stated, that she does not remember having a man in her bed. R12 stated, that she does not know who R27 is and does not remember him touching her on her shirt her breast. R12 stated, that her husband has passed away. R12 stated, that she would not have invited R27 to lay in her bed. R12 stated, that she does not remember this happening, but would not have asked anyone to get in bed with her and touch her. On 9/27/2023 at 9:30 AM R8 stated, that she was in the room when the male resident got into the bed with R12. R8 stated, that R12 has a loud voice, and she did not hear R12 invite R27 into the room. R8 stated, that she was able to see them in the bed. R8 stated, that she was unsure exactly what was going on, but could see R27 kissing R12's neck and R27's hand moving up and down on R12's chest. R8 stated, that she yelled at them to close the curtain and R27 told her to mind her own business. R8's MDS, dated [DATE], documents, that R8 is moderately impaired cognitively. On 10/2/2023 at 1:20 PM V8, LPN, stated, that R8 is alert and oriented and able to make her needs known and answer questions appropriately. On 9/28/23 at approximately 3:40 PM V1 stated, that she spoke with her Supervisors and was told that, because this was only witnessed by other residents it was not substantiated. When asked what was seen on the camera, V1 stated, that they were not able to see R27 walking on the hall or enter R12's room. V1 stated, that they were not able to see anything. On 10/2/23 1:50pm V5, CNA, stated, that she is the primary CNA on R12's hall. V5 stated, that she has worked with R12 for a long while. V5 stated, that she has not witnessed or heard of R12 inviting a man into her room and bed. The facility's Abuse Policy and Prevention Program 2022, not dated, documents, this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This facility therefore this facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Sexual Abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault including non-consensual or non-competent sexual activity.

Based on interview and record review the Facility failed to ensure residents were free from sexual, physical, and verbal abuse for 2 of 3 residents (R2 and R7) reviewed for abuse in the sample of 12. This failure resulted in R9 assaulting R7 when R7 denied R9 sex. R7 received abrasions to her face and has memories which cause her fear and anxiousness related to this incident. Findings include: 1. R7's June 2023 Physician Order Sheet (POS) documents R7 has diagnoses of schizophrenia, heart failure, major depression, insomnia, need for assistance with personal care and chronic pain. R7's Minimum Data Set (MDS) dated [DATE] document R7 as moderately impaired for cognition. R7's MDS documents R7 uses a wheelchair and is not steady but able to stabilize without staff assistance for moving to seated to standing position, walking, moving on and off toilet. For surface to surface (transfer between bed and chair or wheelchair, and turning around) R7 is not steady, only able to stabilize with staff assistance. R9's June 2023 POS documents R9 has diagnose of schizophrenia, bipolar disorder, and legal blindness. R7's Facility-Reported Incident Form, Initial Report, dated 5/9/23, documented there was an allegation of sexual abuse with R7 being the alleged victim. This form did not document there was an allegation of physical abuse. The Report documented R9 as the alleged perpetrator. There was no description of the incident. The Report documented the incident occurred in R7's room and police were notified. The Report documented residents separated, placing alleged perpetrator on enhanced supervision, providing psychosocial support to alleged victim. R7's Facility-report Incident Form, Follow-up Investigation Report, with date of Incident as 5/9/2023, documents Alleged victim (R7) reports she was reclining in her chair, reading a book when the alleged perpetrator (R9) knocked on her door. R9 alleged perpetrator identified himself when she asked who was there. R7 alleged victim states she allowed alleged perpetrator in, he shut the door. She asked him why he shut the door and he stated he wanted to talk to her, she sat back into her recliner, alleged perpetrator approached her stating he wanted sex, she pushed her call light and started yelling for help, at that time, the alleged perpetrator put his hand over her mouth pressing against her glasses. Staff came in the room and took him out. The Report documented Resident states she was 'shaken up' and doesn't want to see or speak to the resident again. The Report documented Witnesses report hearing resident scream, upon staff member entering room from next door, alleged perpetrator was standing over alleged victim with 'his hand over her face, and he struck her a couple times. The Report documents Upon conclusion of thorough investigation, the facility can not substantiate allegation of sexual abuse. The rapid response of the staff to the call light/resident screaming prevented the alleged perpetrator from carrying out actions related to his stated desire of 'having sex.' R7 alleged victim denies that resident (R9) touched her in any sexual manner. (BIMS/Brief Interview for Mental Status score of 10, good historian) she (R7) denies he (R9) struck her. R9 alleged perpetrator has been discharged from facility, no plan to return to the facility. Based on resident interview, staff interview, record review resident observation no sexual abuse occurred. This Report did not address that R9 struck R7 a couple of times. On 6/13/2023 at 2:02 PM, R7 stated, (R9) lived here and he was blind, and he has a cane. I heard a knock at my door, and it was (R9). He said, 'I need to talk to you,' and then he closed the door. I said 'hi, why did you close the door?' and he said, 'I want to have sex with you,' and I said, 'oh no you are not!' and he said, 'Oh yes I am,' and he came over and put his hand over my mouth to keep me from yelling and I turned my head and started screaming really loud. He began pushing my glasses into my face and nose and he was really hurting me. He is no longer here but I still get so upset just thinking about it scared me so much! He did hurt me, but he did not get what he wanted. I feel sick to my stomach just talking about it, it was awful! R7's Statement dated 5/9/2023 documents, Resident states that she was in chair, reclined back reading her book. Heard knock and asked who it was (R9) was there, he stated, that he needed to talk with her. He came in and shut the door and (R7) asked why he shut the door and (R9) approached stated he wanted sex. She stated that (R9) put his whole palm across his face and pressing as hard as he could against her face and was pressing as hard as he could against her face and glasses, and she began screaming as loud as she could and then staff came running and separated (R9) away from (R7). (R7) states she is okay but shaken up from it. She does not feel safe around (R9). States doesn't want to see or talk to him again. A statement from V11, Licensed Practical Nurse (LPN) dated 5/9/2023 documented, I was sitting at the nurse's station when the CNA (Certified Nursing Assistant) came to report that she heard (R7) screaming and when she walked into the room (R9) had his hand over (R7's) mouth and hitting her in her face. A statement from V9, CNA, dated 5/9/2023 documents, (R9) was standing over (R7) with his hand over her face then he struck her face a couple of times, and I ran in and grabbed him and directed him to his room and told the nurse and supervisor. On 6/14/2023 at 9:12 AM, V9, stated, I remember that day. I was in another room close to (R7's) room laying a patient down when I heard (R7) screaming. That was not like her to scream so I ran into her room, and I saw (R9) standing over her and (R9) was hitting her in the face and she was covering her face with both of her hands. She was crying and upset, and I immediately separated the two and grabbed (R9) and contacted my supervisor on duty and the nurse. (R9) was not wanting to be redirected and leave and we called the police. I eventually got (R9) back to his room. (R7) told me that (R9) had come into her room and shut the door and (R9) told her he wanted to f*** her and she was very upset and crying and told me 'No' he was not. She said he put his hand over her mouth so he could stop her screams and she was shaking. I know she was upset, and angry afterwards. She has calmed down now but she gets nervous with male staff/visitors and is fearful of males even today when they are entering her room and/or with her door being closed. I know she will always remember it. On 6/14/2023 at 3:22 PM, V18, Licensed Practical Nurse (LPN) stated, The CNA (V9) came and got me and told me (R9) had to be pulled off of (R7) because he had went into (R7's) room and he had his hand over her mouth and he was hitting her with his other hand in her face/head area. (R9) had already been removed from (R7's) room and when I went into (R9's) room (R9) was j****** off and had his penis in his hand. When I went to check on (R7) she was hysterical, she was crying and upset. (R7) said (R9) told her he was going to have sex with her, so she started screaming and then he put his hands over her mouth. When the police came and started asking him questions (R9) kept acting like he had not done anything, but he was caught hitting (R7) in the face. A statement from V10, CNA Supervisor stated, Was at nursing station going over paperwork. I heard a loud noise and ran towards the sound upon entering. Nurse has female resident's statement on file. R7's Questions by the Facility dated 5/10/2023 from (R7) documents, Have you ever had any negative experiences with another resident in the facility? R7 replied, No. Do you feel safe? R7 responded, I don't know, I am scared. Are you afraid of any Resident in the Facility? R7 responded Yes, (R9). R7's Psychology Diagnostic assessment dated [DATE]. Case Conceptualization: Met with resident to review the referral for counseling services. Resident appears anxious, has need for order in her environment and with her clothing. Resident voluntarily recalled the incident with the other resident this week and has some continued anxiety related to being in her room alone. R7's Police Report documents, On 05/09/2023 at approximately 6:23 PM, hours, I was dispatched to (Facility) in reference to a report of a PATIENT-ON-PATIENT BATTERY. It should be noted that through prior police experiences, I am aware that (Facility) is a living facility for individuals with mental and/or physical disabilities. I arrived on scene and contacted employee, (V18, Licensed Practical Nurse/LPN), who reported a male patient, (R9), battered a female patient, (R7), after she refused to have sexual intercourse with him. (V18) advised a coworker, (V9), had witnessed the battery. I contacted (V9), who stated she had heard (R7) yelling for help from her (R7's) room. (V9) stated the door to (R7's) room was closed and when she opened it, she observed (R9) holding his hand over (R7's) mouth and hitting her in the face. (V9) was unable to describe the strikes, but stated she separated (R7) and (R9) and placed (R9) back in his own room. It should be noted that (R7) does not move well without assistance and mostly sits in a chair or her bed. It should also be noted that (R9) is blind, bi-polar and utilizes a wheelchair. I contacted (R7). (R7) was actively shaking and crying, stating that she was scared. (R7) stated she was sitting in her room with the door open, watching television. (R7) stated (R9) entered the room and immediately shut the door. (R7) stated she asked (R9) what he wanted; at which time he said something similar to Will you have sex with me? (R7) stated she told (R9) No. (R7) stated (R9) then approached her and attempted to grab her. (R7) stated she began to yell for help at which time (R9) placed his hand over her mouth and hit her. (R7) was unable to describe the strikes. (R7) stated a nurse then entered her room and removed (R9). I observed (R7) to have a small abrasion, approximately the size of a fingernail, in the center of her left cheek. (R7) refused medical treatment, but repeatedly stated she was very scared and did not want (R9) to come back. I utilized a departmental issued camera to photograph (R7), and the photographs were later downloaded and attached to this case. (R7) was advised on how to obtain an order of protection. (R7) stated she was desirous of criminal charges against (R9). I allowed (R7) to sign a departmental agree to prosecute form. The form was later downloaded and attached to this case. Signed by V19, Officer/Sergeant of Local Police. The Resident Right Policy with a revision date 11/2018 documents, You must not be abused, neglected, or exploited by anyone financially, physically, verbally, mentally or sexually. 45947 2. R2's Facility-Reported Incident Form Initial Report, undated document, (V18), LPN (Licensed Practical Nurse) contacted (V1), Administrator, at 8:41 AM on 4/22/2023 that (R2) was in the dining room and requested for more milk for his cereal from Dietary Worker (V21). (V21) asked (R2) to say please, and (R2) got upset. (V21) made a statement to (R2) that was witnessed by (V18). R2's Facility-Reported Incident Form Follow-Up Investigation Report, undated, documents, (V18), LPN, contacted (V1), Administrator, at 8:41 AM on 4/22/2023 that (R2) was in the dining room and requested for more milk for his cereal from (V21). (V21) asked (R2) to say please and (R2) got upset. (V21) was immediately sent home pending the outcome of investigation. MD (Medical Doctor)/POA (Power of Attorney) notified. Police contacted. Staff noted that (V21) stated to (R2) to say please when asking for milk. (R2) cursed at (V21) and (V21) responded in an unprofessional manner towards (R2). The Report documented Staff interviewers conducted and stated that (V21) did react to (R2) in an unprofessional manner. V23's Hand-Written Statement dated 4/22/23 documents, I was sitting at the desk on when I heard yelling from the dining room. I walked in and (R2) and kitchen worker (V21) was yelling at each other. I immediately told (R2) to go to his room. He stayed and (V21) came back out the kitchen and they started yelling and threatening each other. They both said they was gonna beat each other's a**. While these two continued yelling and threatening each other l ushered (R2) out the dining room and another kitchen worker kept (V21) away. After getting back to the hall (R2) told us this all started over him asking for a glass of milk for his cereal. R2's Nurse's Note written by V18, dated 4/22/23 at 11:09 AM, documents, It was reported to this nurse by another resident that this resident asked for a glass of milk and was told to please say please, and this resident got upset and said he didn't have to say pleas [sic] and then he walked off and went to his room, this nurse went to asked this resident what had happened and he stated 'Nothing happened, I asked for another glass of milk to eat my bowl of cereal with and was told I needed to say please, I'm not going to say please when it comes to eating my cereal with and was told I needed to say please, I'm not going to say please when it comes to me eating my food so I got upset and to keep me from going off I got up and left and went back to my room.' On 6/14/23 at 3:18 PM, V18, stated, From what I remember, (R2) wanted extra food and they told him to say please to be nicer. One of them said, Meet me outside, and (R2) said that didn't happen and was told to leave the dining room after he threw his food on the floor. I was not in the room at the time it happened. On 6/15/23 at 1:46 PM, V23, Certified Nursing Assistant (CNA), stated, I was working down the hall when I heard yelling coming from the dining room. When I got down there (R2) was yelling at (V21), and (V21) was yelling back. (R2) was calling (V21) names and was upset about milk. (V21) was threatening to beat his a** because he was being so rude. (R2) was my patient, so I took him out of the dining room. R12's Witness Statement dated 4/22/23 documents, All I know is (R2) wanted some milk, he got up to get it his self and a CNA (Certified Nursing Assistant) told him he couldn't get his own milk. Then (R2) told (V21) he was going to beat his a**. Then (V21) said he was going to beat his a** back. I feel safe around the kitchen workers. On 6/14/23 at 3:54 PM, R12 stated, Both (R2) and (V21) were saying bad words to each other in the dining room. Both were talking about hitting one another and calling each other 'b******'. It was all over a thing of milk.

Based on interview and record review the Facility failed to develop and implement a safe discharge plan to meet resident's needs including identifying the capability of home caregiver and need for resident equipment for 1 of 5 residents (R13) reviewed for discharge planning in the sample of 17. This failure resulted in R13, who had dementia with aggression, being sent home to V26, R13's wife, who did not have the physical capability to care for R13 and meet his needs. This caused V26 fear and stress. Finding include: R13's Hospital Admission Diagnoses with an encounter date of 2/27/2023 at 7:18 PM, document diagnoses of aggressive behavior, dementia, dementia with agitation, dementia with behavioral disturbances. R13's Hospital Records also document a Computerized Tomography was performed on 2/27/2023 at 4:40 PM and document, history, worsening dementia. R13's Hospital Discharge Records dated 2/27/2023 documents, Per wife patient's dementia is progressively worsening since past couple of months and becoming more aggressive and agitated. Patient went to primary care physician office who recommended to go to the emergency room to have MRI (Medical Imaging Technique) brain and further work up. R13's Face sheet document he was admitted to the facility on [DATE]. The Face Sheet documented R13's home as a city being located 84 miles away from the facility. R13's Care Plan Meeting Quarterly Report dated 3/17/2023 documents, Moderate protein-calorie malnutrition, type 2 diabetes mellitus without complications, and difficulty in walking, not elsewhere classified. Patient and Family Goals: To move to a LTC (Long Term Care) facility closer to family. Alert with confusion. Compliant with care and medications. Skin intact. Needs supervision with cues for ADLs (Activities of daily living). R13's Care Plan addressing Activity of Daily Living document, Resident requires assist with daily care needs related to dementia. Date initiated 3/8/2023. Mechanical lift with 2 staff assists for transfers. Discharge Planning: The resident and guardian express the desire for the resident to continue with long term care placement. Resident and wife express desire for placement in (different town) to be closer to family after his therapy is completed. Date initiated 5/4/2023. R13's Daily Skilled Nursing Note dated 5/8/2023 at 1:24 PM, Resident alert with confusion, he is independent with his ADL's (Activities of Daily Living). Ambulates with a slow steady gait. Anxious about going home. Cooperative with care. He is able to make needs known. Denies pain when asked. R13's June 2023 Physician Order Sheet documents R13 has diagnoses of difficulty in walking. Type 2 diabetes; cognitive communication deficit; problems related to care; unspecified schizoaffective disorder; and unspecified dementia. R13's Transfer/Discharge Report dated 6/22/2023 at 10:10 AM, private home/apartment, with no home health services. Home. R13's Minimum Data Set Discharge assessment dated [DATE] documents R13 has memory problems and has modified independence for decision making of activities of daily living. R13's Progress Notes dated 6/22/2023 at 10:10 AM, Note Text: resident discharged home via facility transportation. Resident was sent home with discharged paperwork and medication, no narcotics sent with resident. Resident verbalized understanding of discharged instructions. R13's Social Service Notes dated 6/22/2023 at 12:51 PM, Resident was discharged home. Called resident's wife to let them know that they are on their way because wife stated she did not have transportation to pick resident up from facility. Resident's wife okay with discharge and stated where to have resident dropped off with belongings. Social Service Director received a call from resident's primary from [NAME] and they asked why resident was discharged . Doctor (facility) ordered discharge since resident was adamant about going home. On 6/27/2023 at 12:44 PM, V3, Assistant Director of Nursing stated, (R13) was discharged home because he wanted to go home, it was his choice. On 6/27/2023 at 2:32 PM, V26, wife of R13 stated, I got a call from (Facility), and they told me (R13) no longer wanted to be in the facility and they could not hold him against his will. The girl on the phone told me we owed them money and the girl on the phone told me she would lose her job if I didn't accept (R13) back in the house. They did not provide me with any assistance or help or any notice. They just dumped him off with two or three days of his medication. I am [AGE] years old, and I have cancer. My doctor (V27, Primary Physician at home for R13) told me he was against (R13) coming home and it was unsafe and said he would call the (Facility). (V27) told me he told them he did not think it was a good idea because I am not able to take care of (R13) and it was not safe. That was back in May, but I don't remember the date. Some days I can barely get out of bed, and I am having issues just taking care of myself. (R13) needs meals and food. It has been such a hardship for me. Plus (R13) is a good Christian man, and before his dementia he would never hurt me, but he is real active at night and he has broken two of my fingers and broke my eardrum. He becomes violent at times and hurts me. I just can't handle him but what am I supposed to do with him as he is my husband, and he does not know what he is doing. I can't take care of him, and they sent him back for me to take care of him. On 6/27/2023 at 3:24 PM V27, Community Primary Care Physician stated, (R13) has advanced dementia and he is verbally and physically abusive with his wife. That is one of the main reasons he went into the nursing home to begin with. He was abusive to his wife before he went into the home. (R13) is about five foot six inches and his wife is only four foot eleven inches. It is not a good situation for either of them because she has some health issues and is not able to take care of (R13). (R13) is a mechanical lift and the wife is not able to take care of him. It is a bad situation all over. I sent a letter to the facility recommending that they keep (R13) but they ignored my recommendations and sent (R13) home anyway. I can provide a copy of the letter to you. Communication letter to facility starting 5/8/2023 at 12:18 PM, documents, Caller states they were discussing discharge plan for patient and states that (V27, Primary Home Physician) had placed an order for (R13) to not return home. Caller states that if there is an order that states that, they are needing a copy faxed over to them. Communication dated 5/10/2023 at 12:41 PM, It is not an order. The patient cannot take care of himself due to dementia and his wife cannot take care of him. It is unsafe for him to return to his home for the same. Communication dated 5/10/2023 at 12:46 PM, Spoke with (V4, Social Service Director), request for the statement to be faxed to them, as they do not have anything in their chart stating that. Communication dated 5/10/2023 at 12:48 PM, Faxed as requested. On 6/28/2023 at 1:32 PM, V4, Social Service Director stated, (R13) had expressed that he wanted to go home. His wife was apprehensive at first, but I told her we could not keep (R13) against his will, and we discharged him home. His primary physician contacted us regarding him discharging but he did not give us an order that we could not discharge him and (V17), our Medical Director gave us the okay. On 6/28/2023 at 1:45 PM, V28, On Call Physician for V17, Medical Director stated, If a resident has a diagnosis of dementia and has some confusion, we normally do not discharge them back to their home. V17 stated with dementia they have a high risk for self- awareness, safety awareness, elopement risk, just overall lots of risks especially in their moments of confusion. It will all depend on if the resident is able to make safe decisions and their awareness at the time. On 6/30/2023 at 9:01 AM, V4, Social Service Director stated, I thought because (R13) wanted to go home and he was somewhat intact then we could send him home. I was aware of his diagnosis of dementia, but I think there was an issue with his wife not wanting to pay the bill, so we sent him home. On 6/30/2023 at 9:05 AM, V29, Business Office Manager stated, I wanted to talk to you about (R13). I think we are getting a tag but see I talked with the wife, and she did not want to pay us, and she owed us money, so we discharged him. I did not know what else to do and she did not want to lose her income, so we discharged him. I did not document anything in his chart and no we did not issue him or start an involuntary discharge. The Discharge Policy dated June 2015 documents, Discharge potential is assessed by Social Services on admission. When the IDT, (interdisciplinary team) in conjunction with the resident/patient and family determine that a resident/patient is ready to be discharged , the physician is contacted for an order. Social Services will meet with the resident/patient and/or family to set up outside services and equipment. A Discharge Instruction Form is initiated by Social Services or Discharge Planner and finished by the IDT. The Facility Contract dated 3/14/2023 documents, Facility reserves the authority to determine and make all arrangements regarding residency, including admission and discharge of the Resident and other Residents and adjustments in rates and accommodations consistent with law and Facility's policies. The right to a minimum of 30-day notice of an involuntary residency termination, except where the resident poses a threat to himself or others, or in other emergency situations, and the right to appeal such termination.

Based on interview and record review the facility failed to provide person-centered behavioral health services for residents with substance use disorders for 3 of 4 residents (R1, R2, and R4) reviewed for behavior services in the sample of 12. This failure resulted in R2 using drugs and alcohol, found unresponsive and emergency services called. Findings include: 1. R2's Face Sheet, undated, provided by the Facility document he was admitted to the facility on [DATE]. R2's Hospital History and Physical, dated 4/11/22, documented R2 has Polysubstance Abuse but stated he had been sober for 3 years. The Hospital record continued to document R2 urine toxicity screen was positive for amphetamines and opioids. R2's June 2023 Physician's Order Sheet (POS) document R2 has diagnoses of bipolar disorder, unspecified psychosis not due to a substance or known physiological condition, current episode manic severe with psychotic features, generalized anxiety and depression, asymptomatic human immunodeficiency virus (HIV infection status), and other psychoactive substance abuse, uncomplicated, and chronic viral hepatitis c. On 6/13/2023 at 10:02 AM, V7, Regional [NAME] President stated, We admitted (R2) for enteritis (inflammation of the small intestine). R2's Minimum Data Set, dated dated dated [DATE] document he is cognitively intact for decision making and needs staff assistance of one staff with bed mobility and walking in the room. R2's Care Plan last reviewed 4/19/23 documents, Smoking: Resident uses tobacco products and is at risk for complications. The Care Plan documented The resident has a history of substance abuse/chemical dependency. R2's care plan did not contain a resident centered SUD (substance abuse disorder), goals and or interventions or how the facility would address R2's substance abuse issues. The Care Plan documented Resident demands to go to ER (emergency room ) due to various reasons in order to receive narcotic pain medications. R2's Behavior Tracking, dated 4/6/23 at 11:40 AM, document, cursing, entering rooms, rummaging, agitated, worse with redirection, better with re-approach. R2 accusing, cursing, screaming, agitated, worse with redirection. Physical aggression, cursing at others, entering rooms, throwing/smearing food, agitated, worse with redirection. 5/31/23: elopement, exit seeking, no intervention documented. R2's Progress Notes dated 5/12/2023 at 11:11 AM, Writer called to dining room by staff to assess resident related to resident head bobbing slurred speech and diaphoresis. Resident upon initial assessment slow to respond to verbal and tactile stimuli. Resident pale and sweating profusely. Writer questioned resident if he ingested any medications or substances related to resident's presentation. Resident states he only took prescribed medications. Staff and writer concerned that resident may have taken something causing his presentation, so writer gave resident Narcan x(times) 2 via nasal inhalation with little effect noted. Resident attempted to drink nasal Narcan and had to be redirected. 911 dispatched by other staff prior to nasal administration. Resident informed of 911 being called and providers on way and resident became verbally abusive towards staff and other residents and wheeled himself to outdoor smoking area with other nursing staff following to maintain resident safety. Writer followed resident outside to smoking area where resident continued to be verbally abusive toward staff. Resident states he will not go to ER (emergency room ). First responders arrived and after assessing resident and resident's refusal to go to emergency room responders attempted to have resident sign AMA (Against Medical Advice) which resident refused to sign. Resident more alert and speaking in full sentences. Vs WNL (Vital Signs within normal limits) and resident remains angry with staff for giving Narcan and calling 911. R2's Progress Notes dated 5/26/2023 at 9:00 AM, documents, Resident took morning medications as ordered as well as PRN (as needed) pain medication per request. Resident informed this nurse that he would be signing out for the day and going to (Superstore) with his roommate and friend. Resident declined to take medications with him. Education provided on the importance of timely medication administration without success. Resident stated he would be fine. Resident signed both LOA (Leave of Absence Book) books and left facility with personal cane. R2's Progress Notes dated 5/26/2023 at 7:14 PM, documented Received call from ADON (Assistant Director of Nursing) who reported that resident was seen at (Nearby Superstore) and was not acting his usual self, he seemed off per report. Resident had not arrived back to facility as of this time. Call placed to non-emergent police and spoke with dispatcher for a welfare check. 5:14 PM call placed to (V24, Physician) with update on resident situation. 5:22 PM this writer received a call from (V25, Officer) with reports that he had seen resident earlier this afternoon because resident had been accused of stealing money from his roommate's friend who he left the building with. The lady involved did not press charges at this time. 5:30 PM. This writer was leaving work and noticed a male laying on the grass at the school. Upon closer inspection it was (R2). He was unresponsive to this nurse. I called his name and nudged his legs multiple times with no reaction. 911 was called. Upon EMS (Emergency Medical Assistant) arrival resident was starting to become alert. He refused to go to hospital for evaluation. He stated he smoked some weed and a couple hits of the hard stuff. Resident returned to the facility per staff car. (V24) notified and no new orders received. R2's Progress Notes dated 5/31/2023 at 12:12 PM, documents, Resident noted to have vomit on floor next to bed. When this writer asked resident if he got sick resident stated, 'No I spilled something.' Resident noted to have empty alcohol container next to bed called 'Death Punch'. This writer discarded container and educated resident against drinking with current medications. Resident denies can being his and states he does not drink. Attempted to notify MD (Medical Doctor) awaiting response. R2's Progress Notes dated 6/1/2023 at 11:05 AM, document, Call placed to (V24, Physician) who is on call for (V27, Medical Director). Update given on meeting with Ombudsman and decision to issue a 30-day involuntary discharge. (V24) is in agreement that resident does not belong in skilled nursing facility. R2's Social Service Note dated 6/1/2023 at 11:01 AM, documents, (R2) was issued an emergency involuntary discharge with the bed hold policy. Resident is currently here in facility. Facility will assist with finding alternative placement if needed. IDPH and Ombudsman was notified. R2's Social Service Note dated 6/1/2023 at 11:05 AM, documents, Held a care plan meeting for resident with ombudsman SSD (Social Service Director), Administrator, and stated to resident that there have been multiple verbal altercations, physical aggression with both staff and other residents, non-compliance with care and regulations and policy procedures of facility. There have also been multiple incidents related to possible drug/illegal substance abuse. Care plan held to review multiple and continuous behaviors, he is no longer safe at this facility, and will require alternate placement. R2's Progress Note, dated 6/5/23, documented R2 requested to go to ER due to shortness of breath. The Note documented that at that time, R2 stated that he was going to the hospital, and he would not be returning to the facility. R2's Progress note, dated 6/5/23 at 9:00 AM documented that local hospital was called and staff at hospital said R2 got into a cab. On 6/9/2023 at 8:05 AM, V3, Assistant Director of Nursing stated, (R2) would go out on pass and when he returned it was suspected that he was high or intoxicated. He was alert and oriented. Staff had to give him Narcan because he was 'out of it', his VS (vital signs) were low, and he was diaphoretic- staff attempted to send him to the hospital but he refused to go. He was served with involuntary discharge papers, but he left AMA (Against Medical Advice). V3 also stated R2 was the only resident who received Narcan in the facility. On 6/14/2023 at 2:32 PM, V8, Ombudsman stated, I am really not sure what to do because I am really concerned that residents with addictions are being admitted to the facility, but the facility is not putting anything in place and are not addressing the addictions. The resident is not getting better, the addictions are not being addressed and then the resident displays things related to the addiction and then they are discharged . I am just scared that we might find someone dead soon if they do not address what is going on with resident's addiction. If they are not going to try and help them then they just stop admitting residents with addictions. On 6/15/2023 at 12:23 PM, V4, Social Service Director stated, Any resident who is alert and orientated can sign out and leave the facility. The resident just has to document how long they are going to be out and when they are planning on going out. (R2) would go out on pass and when he returned it was suspected at times that he was high or intoxicated. He was alert and oriented. (R2) overdosed in the front yard and they had to give him Narcan because he overdosed. I had never seen anyone overdose before. I was not aware (R2) had any history or struggles with drugs. (R2) was here before I was here. I do not have any contracts or any interventions addressing his drug addictions or anything in place to assist him with his drug issues. I do not make contracts or have any contracts for any resident, but we do have behavior tracking in place. We allowed (R2) to come and go because that was his right as a resident. On 6/28/2023 at 4:01 PM, V8 stated, I know the facility does Bingo programs, but I am here almost 5 days a week and I have never seen any Behavior Programs going on in the facility or any facility efforts to help residents with mental disorders, group counseling or anything targeted at resident's mental disorder or drug/alcohol addictions. For these residents they need more than Bingo. R2's Behavior Tracking does not document anything related to substance abuse disorders. 2. R1's Medical Records does not document a history of drug use only smoking. R1's Care Plan does not document any interventions or goals for drug/alcohol abuse. R1's MDS dated [DATE] documents R1 was alert and oriented x (times) 4; he required extensive assist with bed mobility, dressing, and toileting; he required limited assist with transfers and supervision with walking, eating; he was continent of bowel and bladder R1's Social Service Notes dated 5/31/2023 at 12:58 document (R1) was issued an emergency involuntary discharge with the bed hold policy. Resident is currently at (Local Hospital). Facility will assist hospital with finding alternative placement if needed. IDPH and Ombudsman was notified. Family picked up resident's belongings per his request. R1's Nurse's Notes dated 5/26/2023 at 5:56 PM, documents, This nurse called to resident room to help reposition in bed. Resident was unresponsive, resident assessed. Vitals abnormal. Unable to arouse resident with sternum rub. 911 called. Resident sent to hospital for evaluation. On 6/9/2023 at 8:05 AM, V3 stated, (R1) was alert and oriented and was in the facility for heart problems. She stated he was sent to the hospital when he became unresponsive, and staff suspected heart issues, but he tested positive for cocaine when in the hospital. V3 stated he was discharged with an involuntary discharge while he was in the hospital. (R1) was a very nice man but he had started hanging around with (R2) and (R3) who were suspected to return from outings under the influence. R1's Hospital Records dated 5/26/2023 documents, Found unresponsive in nursing home, unknown downtime, history of opioid abuse. On 6/15/2023 at 12:23 PM, V4, Social Service Director stated I was not aware (R1) had any history of drug abuse and he never left the facility. We had to give him an involuntary discharge because he tested positive at the hospital for drugs. R1's Hospital Records dated 5/26/2023 document [AGE] year old nursing home resident with a history of chronic a flutter, bullous pemphigoid, chronic pain fentanyl patch was brought from nursing home with altered mental status patient was found to be unresponsive at 10:30 AM, this morning last known normal was 5:00 AM. There was no trauma, patient was given Narcan at the scene no response. Upon arrival to the ER, he still is unresponsive. R1's Emergence Department to Hospital-admitted d 5/26/2023 at 11:27 AM documents, EMS (Emergency Medical Service) from (Facility). (R1) found unresponsive in room with low blood pressure and SpO2 (Saturation of Peripheral Oxygen). Per EMS (Emergency Medical Service), patient responds to painful stimuli with groans. Narcan given without change in condition. Last known well at approximately 0200 (2:00 AM) when he was given a pain pill per NH (Nursing Home).Cannabinoids, Cocaine, Fentanyl, and Oxycodone were detected in the urine. R1's medical records did not contain a resident centered SUD (substance abuse disorder), goals and or interventions or how the facility would address their substance abuse issues. R1's medical record does not document any drug screens or orders from the physician for a drug screen test. On 6/16/2023 at 12:02 PM, V26, Nurse Practitioner stated, A lot of it depends on if the resident is short term or long-term care. If a resident is alert and orientated x 3 and going out and if staff would suspect the resident to be drinking or taking drugs, I would expect the staff to notify us so we could be made aware. Normally, in case like this we would order a drug screen to determine if that is an issue so we could adjust their medications. I am not sure if we were ever contacted regarding any issues with drugs use at the Facility. 3. R4's POS dated June 2023 document a diagnosis of anxiety disorder, other psychoactive substance abuse, schizoaffective disorder, and bipolar type. R4's POS document he is taking ziprasidone HCL oral capsule 40 milligrams (MG) two times a day for bipolar disorder related to schizoaffective disorder, bipolar type. R4's MDS dated [DATE] document R4 is cognitively intact for decision making. On 6/29/2023 at 4:33 PM, R4 stated, No they do not provided counseling to me. I do not attend any type of group meeting or counseling session here at the facility. I know I can get upset easy and I do have a temper. I have not attended any meetings. Last week they had me sign a paper saying that I would not hit anybody or lose my temper. R4's Care Plan dated 12/27/2022, Resident is at high risk for elopement related history of poly-substance abuse. 2/26/2023 Resident exited facility again without notifying staff or signing out. Smoking: Observed smoking in his bathroom, became aggressive and belligerent with staff. 3/17/2023 Resident let himself out of the building to smoke, became belligerent and threatening staff with violence. Intervention listed was 3/13/-3/14/23 one on one with Social Service as needed. When behavior occurs inform resident that behavior is inappropriate. 3/17/203 Police Department notified and responded. Resident has symptoms such as mood swings, impulsive behavior and attention seeking behavior related to a diagnosis of Schizoaffective and bipolar type Disorder, He has a history of aggressive inappropriate, attention seeking and/or maladaptive behaviors. This history includes cursing, yelling, following direction, destructive behavior and safety concerns with staff and residents. On 2/5/2023 R4 became verbally aggressive due to wanting a wheelchair that belonged to another resident. On 2/5/23 Resident overhead resident speaking on his cell phone saying that he had Norco's for sale and do you want to buy them. Intervention: Staff to monitor resident taking his medication. SS to meet 1:1 as needed. On 3/18/2023 threatening violence and aggression towards staff. The resident expresses maladaptive behavioral symptoms related to being observed and on occasion possibly being under the influence of unknown substances. R4's Progress Notes dated 6/22/2023 at 6:27 PM, documents, Resident brother called this resident and got this resident update. Resident noted to be yelling and cursing on phone at his brother resident was redirected and calmed down easily no further agitation noted. Resident requested that brother does not call him anymore. A Behavior Contract was requested for R4 and on 6/29/2023 at 4:49 PM, V4 stated, I do not have any Behavior Contracts. When R4's Care Plan was shown to V4 she stated she would look into it. On 6/29/2023 at 5:01 PM, V4 provided a Behavior Contract with a name scribbled on it documents, the name was not legible and was not dated. The contract documents, Resident was made known that this behavior is not tolerated. No assaulting any of the staff and residents or raising voices. For the safety of the staff, residents, and himself. He was told to try to talk to any of the supervisors or managers about a certain issue to help with outbursts. Resident has to wait for staff to put in passcode for the door to go outside. If a grievance is not available for him, he agreed to have staff write it out for him. No other contract or details was provided to the surveyor. The contract does not address anything related to drug addiction. The Resident Right Policy with a revision date of 11/18 documents, Your rights to participate in your own care. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do.

Based on observation, interview, and record review, the facility failed to provide care to a dependent resident in a manner and in an environment that promotes and maintains residents' dignity and quality of life for 1 of 1 resident (R6) reviewed for dignity in the sample of 12. This failure resulted in R6 have feelings of being homeless and uncared for. Findings include: R6's Admission Record, undated, documents R6 was admitted to the facility on [DATE]. R6's Electronic Medical Record, documents R6's diagnoses include Morbid Obesity, Acute Kidney failure, Cognitive Communication Deficit, Blind Right Eye, Traumatic Brain Injury, Arthritis, and Major Depressive Disorder. R6's Care Plan, dated 5/3/23, documents, R6 has an ADL (Activity of Daily Living) Self Care Performance Deficit r/t (related to) Generalized Weakness and Morbid Obesity. R6 refuses to wear clothes, only gowns. Interventions: Requires limited to extensive assist of 1-2 staff participation to use toilet, requires limited to extensive assist of 1-2 assist staff participation with transfers, requires staff participation with bathing. Encourage resident to accept showers per shower schedule. R6's Minimum Data Set, MDS, dated [DATE], documents R6 is cognitively intact and requires extensive assistance of one staff member for dressing, toilet use, personal hygiene, and bathing. R6's MDS documents R6 requires limited assistance from one staff member for all other ADLs. R6's MDS documents R6 is always continent of both bowel and bladder. On 5/30/23 at 10:12 AM, R6 was seen sitting on the side of his bed. R6's wheelchair was sitting next to his bed. R6 stated he put his call light on to get someone to help him get a clean hospital gown on his backside so he can get up to a wheelchair. On 5/30/23 at 10:15 AM, R6 stated he put his call light on to get someone to help him get a clean hospital gown on his backside so he can get up to his wheelchair. V20, CNA (Certified Nursing Assistant) Supervisor, entered to assist R6. V20 gave R6 two clean gowns. R6 put one on his front and one was for his back once he got up. Upon R6 standing upright to pivot to his wheelchair, a large amount of loose stool appeared to be on the incontinence pad lying on the bed, and visible on R6's upper coccyx area, and between R6's buttocks. V20 folded up the incontinence pad and put it into a plastic bag. V20 did not provide incontinence care to R6 and allowed R6 to sit in his wheelchair and go to the dining room. On 6/1/23 at 8:32 AM, R6 was observed laying in bed, with his wheelchair sitting next to his bed with an incontinence pad on the seat with dried feces on the pad. On 6/1/23 at 8:35 AM R6 stated I have not been out of bed yet today. That dirty pad was from yesterday when they got me up. I had an accident in bed bowel movement (BM) and V20 helped me get a clean gown on so I could get into my wheelchair. V20 did not clean me up and the dried bowel movement on the pad was from yesterday. On 6/1/23 at 8:55 AM, V1, Administrator, and V2, Director of Nursing/DON, went into R6's room to see and speak to R6. R6 told V1 and V2 that he had an accident (BM) in his bed yesterday and the CNA V20 gave him a gown to wear and V20 never cleaned him up. The wheelchair is still sitting by his bedside from yesterday when he got back into bed, and the pad on the wheelchair still has feces on it. On 6/1/23 at 9:00 AM, V1 stated I will have staff come in and clean him up immediately. V20 needs to be either suspended or fired because this is unacceptable. On 6/1/23 at 9:05 AM, On 6/1/23 at 9:05 AM, V2 stated Yes, I would have expected V20 to clean R6 up at that time. I would expect any staff to take care of a resident like that. On 6/1/23 at 9:07 AM, V1 stated I was a CNA before becoming an administrator. I expect rounds to be completed, and residents checked every two hours at least. On 6/5/23 at 10:14 AM, R6 was seen laying in his bed with his wheelchair sitting next to his bed with a soiled incontinence pad with feces on it. R6 stated he has not gotten out of bed yet today and that dirty pad was from yesterday when he got back into bed. R6 stated the CNA brought him his breakfast this morning and did not do anything with the pad or ask to clean him up. R6 stated that the DON talked to him and stated that he was to let them know when he is soiled. R6 stated they can see my backside better than he could and they should know. On 6/5/23 at 10:21 AM, V24, CNA, was in R6's room and overheard the discussion about his soiled pad in his wheelchair. R6 came over and removed the soiled incontinence pad from his wheelchair. V24 stated I guess I must have seen that and just delivered his breakfast and left. I am new and still trying to figure out all the residents. On 6/5/23 at 10:25 AM, R6 stated When they don't clean me up, like the other day when they didn't clean me up and I went to the dining room like that, it makes me feel like a homeless shelter person not getting taken care of. I'm always asking the staff if they would like for their loved ones to be cared for like this. On 6/5/23 at 12:53 PM, V2 stated I'm having the staff use the white board in R6's room whenever they do care. V2 stated I want the date/time and who done it so I can follow up on it and hold them responsible when I see things like we've seen. The facility's Resident Rights Policy, undated, documents 4. Respect and dignity. The resident has a right to be treated with respect and dignity, including c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. 8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interview, observation and record review, the facility failed to ensure one-on-one (1:1) supervision was intervened to prevent future accidental falls for 1 of 3 residents (R5) reviewed for fall prevention in the sample of 7. This failure resulted in R5 sustaining a fall with facial and laceration to his scalp and a second unwitnessed fall on 4/11/23 to his head as a result of no one on one supervision provided with a second emergency evaluation and treatment. Findings include: R5's, Admission Record, dated, 4/19/23, documented, the following medical diagnosis, unsteadiness on feet, abnormalities of gait, difficulty in walking, cerebral palsy, paranoid schizophrenia. R5's, Nurses Note dated 3/22/23, documents, Resident continues to be on 1:1, resident stayed in his room; on 3/23/23, R5 remains on 1:1 (one on one staff supervision), due to aggressive behaviors. On 4/5/2023, documents, Resident (R5), continues on 1:1, nurse continues to monitor patient through the shift. R5's, Incident Details, documents, CNA (Certified nurse Aide) notified this nurse, on 4/8/23 at 4:08PM, because residents nurse was on break that resident launched himself from his wheelchair to the floor, resident is baseline confused. CNA stated that resident hit his head on the floor. It appeared he has some swelling of about 1/2 inch on his forehead with about a 2 cm (centimeter) cut, bleeding was cleaned and stopped. Resident was found sitting on the floor sideways, both legs slightly flexed, he was located in front of his wheelchair. R5's, Post Fall Huddle, dated 4/8/22, documented, that R5 had a witnessed fall, in his room and the cause documents: Resident launched self to floor and further documents that R5, sustained an injury of bruise, to face, and immediate interventions documented, Res (resident) is on 1:1 with staff to sit closer. R5's, Care Plan, dated 4/8/23, documented an intervention for this fall of, Medication review to be performed by doctor. R5's, Nurse Note, dated 4/9/2023, documents, Resident returned from (local hospital) via (by way of) ambulance 2 attendants. negative head and neck CT (Computerized Tomography) scan. No new orders. Hematoma to forehead remains from fall. vss. (vital signs stable) denies pain will continue to monitor. R5's, Post Fall Huddle, date 4/11/23, documented, that R5 was alone and unattended in his room, with an attempt to walk, R5 sustained an injury of a laceration to his head. R5 was transferred to the emergency room and the Immediate intervention documented, resident is a one-on-one supervision. R5's, Incident Audit Report, dated, 4/11/23, with incident time of 9:45AM, documents, writer was called by clinical supervisor to residents' room at approx. (approximate) 9:50AM to assess resident. Writer entered residents' room and noted resident on floor near his dresser, wheelchair beside him, resident was in the fetal position. Assessed resident and noted a large, raised area to crown of head. Further documentation that R5 complained of head and both knee pain. Physician notified to send R5 out to emergency room for evaluation and treatment. R5's, Emergency Department Triage Notes, dated 4/11/23, documents, PT (Patient) to ED (emergency department) via (by way of) EMS (emergency medical service) from facility for c/o (complaint) a fall. Per EMS, pt. had an unwitnessed fall out of his wheelchair this morning. Pt has bruising to his forehead. R5's, Care Plan, dated 4/11/23, documented an intervention for this fall of, Neurology consult. R5's Enhanced Supervision Monitoring Tool, (15 minute one on one supervision), dated 4/11/23, documented, from 6:30AM through 10:15AM, documented for the following time/location: 6:30AM-Bed-no staff initials 6:45AM-bed-no staff initials 7:00AM-chair-no staff initials 7:15AM-chair-no staff initials 7:30AM-chair-no staff initials 7:45AM-chair-no staff initials 8:00AM-R5 was in bed until 8:45AM-no staff initials 9:00AM-R5 was in chair until 9:15AM-no staff initials 9:30AM-R5 was in bed until 9:45AM-no staff initials 10:00AM-R5 in bedroom. (Fall incident report documents 9:45AM, unwitnessed fall) The following written times and locations does not indicate, written staff initials. And further documents, at 10:15AM, R5, hospital. On 4/19/23 at 12:36PM, V24, CNA, stated, she had worked on 4/11/23 with her shift starting at 7:00AM, when she was informed that R5 had fallen in his room without a 1:1 nursing staff to provide supervision. V24 stated, R5 is to have ongoing 1:1 supervision due to his aggressive behaviors and history of falls, with a current fall he had on 4/8/23. V24 stated, she came into work on 4/11/23 at 7:00AM, was not assigned to R5 this day for 1:1 supervision, however realized R5 was in his room without a nursing staff present for his supervision. V24 then informed V25, a (previous employee in-charge of staffing nurses), that R5 requires one on one supervision and that there was no nursing staff in his room to monitor him. V24 continues to state, that V25, had stated she had a CNA scheduled to come in at 9:00AM, to provide the one-on-one supervision for R5. V24 continued to state, the unknown nursing staff scheduled for 9:00AM had called off and then heard that R5 had fallen in his room and sent out to a local hospital. V24, stated, that one-on-one supervision requires, to be at the resident side and document supervision every 15 minutes. On 4/20/23 at 2:10PM, V15, Registered Nurse, stated, R5 did not have 1:1 supervision, as there was no staff available to perform the 1:1. R5 wanted to lay down, therefore he was taken to his room. V15, stated, R5 did not have anyone present in his room to do 1:1 supervise with him, and she had to administered medication to other residents but would check on him. On 4/19/23 at 2:05PM, V1, Administrator, stated, this incident occurred 2 days after undergoing Administrator status at this facility, unaware of the incident but R5 should have been and remained on one-on-one supervision status. The facility presented, documentation, entitled, Attestation, dated, 4/20/23, signed by V26, Corporate Nurse, documented, R5 experienced a fall on 4/8/23 and 4/11/23. The resident was sent to the local ER (emergency room ) out of an abundance of caution and desire to obtain CT scan to identify any underlying concerns. This should not be deemed a negative outcome. Both visits resulted in the residents return to facility with no new orders required. This resident did and does not have an order for enhanced supervision nor is this a care planned fall intervention. The resident is monitored at the nurse's discretion that is on shift according to his behaviors. The facility presented, documentation, entitled, Attestation, dated 4/20/23, signed by V26. documents, This should not be deemed a negative outcome. Both visits resulted in the residents return to facility with no new orders required. This resident did and does not have an order for enhanced supervision nor is this a care planned fall intervention. The resident is monitored at the nurse's discretion that is on shift according to his behaviors. The facility presented, documentation, entitled, Attestation,, dated 4/19/23, written and signed by V15, documents, I (V15), was (R5) nurse on 4/11/23. Resident was at nursing station in wheelchair, and I was at my med. (medication) cart. Resident requested to go lay down, as I note him to be calm, cooperative and head bobbing, with occasional snoring noted. I asked another staff member to lay him down and between myself and other staff we wanted do 15 min (minute) checks. The facility's policy and procedure, entitled, Residents' Rights and Residents' Safety, Enhanced Supervision Guidelines, revision date of 7/8/2020, documented and entitled, one to one observation, documents, one staff member will be scheduled to provide one to one observation. The scheduled staff member will not have other resident in his/her care assignment. This is an integral part of a therapeutic plan and ensures the safe and sensitive monitoring of the patients' physical and psychological wellbeing. The facility will utilize the Enhance Supervision Monitoring Tool, form to document the enhanced supervision provide to the resident. The staff will document the location and activity or behavior of the resident. When a resident has been assessed by facility staff to have decompensated and requiring more observation, the attending physician will be notified to obtain order for treatment and enhance supervision, as needed.

Based on interview and record review, the facility failed to ensure residents are free from verbal and physical abuse for 6 of 7 residents (R2, R3, R4, R5, R6, R7) reviewed for abuse in the sample of 9. This failure resulted in R5 and R6 being hit with a hot cup of coffee. R5 sustained a hematoma to the head, experienced pain, anger and not wanting to be around R2. Findings include: 1. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is cognitively intact and has verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). R2's Care Plan, dated 1/27/23, Psychotropic Meds documents: (R2) requires the use of psychotropic medication Buspirone, Ramelteon, and Geodon to assist with managing mood and behavior related to DX (diagnosis) of Insomnia, schizoaffective disorder and schizophrenia with targeted symptoms/behaviors of wakefulness, paranoia, verbal outbursts. It also documents 2/22/23 Resident attempted to throw a cup in the dining room during a meal at a specific resident. He hit two other residents instead. It continues Interventions: Geodon increased per psych (psychiatrist). Resident's assigned table in dining room moved away from both residents. 1/4/23 Resident can become accusatory of nurse's taking his medications when they have been DC'd (discontinued) and he was notified. It continues Interventions: Intervene when any inappropriate behavior is observed. Communicate that the resident is responsible for exercising control over impulses and behavior (Social Skills training). Use creative refocusing to alter behavioral patterns if the person suffers from Dementia (e.g., provide drawers, laundry basket for rummaging, provide a tube sock with a knot to focus the resident's attention). It also documents 2/22/23 Resident can get verbally abusive with staff. Hits nurses' carts demanding pain medications. Cusses and becomes accusatory. It also documents 1/25/23 Resident has symptoms such as mood swings, impulsive behavior and attention seeking behavior related to a diagnosis of Schizoaffective, bipolar type Disorder. Monitor for increase of signs and symptoms of increased anxiety and change in mood. R2's Nurses' Notes, dated 2/17/2023 at 6:08 PM, document Note Text: (R2) and another resident exchanged a few words back and forth, the other resident called for (V12, Human Resources) to come over and get the resident because he had came in the dining room starting stuff; this nurse (V13, Licensed Practical Nurse/LPN) and V12 walked over to see what was going on, by the time this nurse and V12 made it over to the residents, (R2) got more upset and tried throwing his coffee cup at the other resident; the coffee cup ended up hitting a different resident in the head and bouncing off of him and hitting another resident in the shoulder; this nurse as well as other staff members redirected the residents. (R2) was instructed to go back to his room so he could calm down. This resident was sent out to the hospital for a psych eval, EMT (Emergency Medical Technician) called, resident going to (local hospital) for further evaluation. (V14) NP (Nurse Practitioner), (V1), Administrator made aware. The facility's Follow-up Investigation Report, not dated, documents Interview with (R2) reveal that him and (R7) were having a disagreement about their shared bathroom and (R2) does not deny swinging his cup in attempt to hit (R7) with it and he missed and accidentally hit (R5). (R2) was apologetic for his actions and was educated about his inappropriate behavior. It also documents Conclusion of the investigation: On 2/17/2023 @approximately 4:50pm, staff reported possible resident to resident physical altercation physical altercation between (R2) a [AGE] year male whose diagnosis includes Schizoaffective Disorder, Bipolar Type and (R5) a [AGE] year male whose diagnosis including Cognitive Communication Deficit. While in dining room preparing for dinner meal, (R7) and (R2) were having an argument about their shared bathroom when (R2) tossed his coffee cup at (R7) missing him and making contact with (R5's) forehead. The cup did bounce off (R5's) head and make contact with (R6's), a fell ow peer, right shoulder however she has no injuries or psychosocial harm. On 2/27/2023 at 11:38 AM, R2 stated that he did throw his cup with hot coffee in it. R2 stated that R7 was poking and poking and poking at him. R2 stated that he became so upset that he threw the cup. R2 stated that he intended to throw the cup. R2 stated that it was deliberate. R2 stated that it didn't hit the person (R7) that was bothering him. R2 stated, It hit the nicest guy (R5) you could ever meet. R2 stated that he is sorry that it hit R5. R2 stated that he just wanted R7 to shut up. R2 stated that he does not eat in the dining room. R2 stated that he does go in the dining room to get coffee. On 2/27/2023 at 11:53 AM, R5 stated that he was sitting in the dining room and R2 threw a cup at his tablemate (R7). R5 stated that the cup missed him (R7) and hit (R5) in his head. R5 stated that he was upset and that it hurt. R5 stated that his head was swollen and bruised. R5 stated that he doesn't like to be hit. R5 stated that he still has some bruising to his head, and it is tender and hurts when touched. R5 stated that he doesn't want anything to do with R2. R5 stated, He (R2) can stay over there, and I can stay over here. R5's MDS, dated [DATE], documents that R5 is cognitively intact. On 2/27/2023 at 3:30 PM, R1 stated that he was sitting in the dining room at the table. R1 stated that it was before supper. R1 stated that R2 was walking into the dining room. R1 stated that R2 and R7 were arguing and yelling at each other. R1 stated that R2 got mad and threw a cup of hot coffee at R7. R1 stated that the cup missed R7 and hit R5 in the head. R1 stated that it was a lot of commotion, and the staff came running asking what happened. R1 stated that the staff started asking what happened to her (R6). R1 stated that when looking R6 had gotten hit as well. R1 stated that R2 threw the cup at R7 but missed him. R1 stated that R2 is aggressive at times yells and screams and gets mad easy. R1 stated that he doesn't want to be around him (R2). R1's MDS, dated [DATE], documents that R1 is cognitively intact. On 2/28/2023 at 9:17 AM, R6 stated that she got hit in the head and arm by a cup. R6 stated that 2 guys were arguing, one threw the cup and it hit her. R6 stated that she doesn't want to be bothered with and doesn't care to be around R2. R2's MDS, dated [DATE], documents that R6 is cognitively intact On 2/28/2023 at 11:44 AM, V10 (Dietary Aide) stated that she was passing drinks in the dining room before supper. V10 stated that R2 came in the dining room and asked her for a cup of coffee. V10 stated that R2 then stated that they wouldn't give him his pain pill. V10 stated that she gave R2 a hot cup of coffee and he started rolling away. V10 stated that R2 continued to yell about not receiving his pain medication. V10 stated that R7 told R2 to be quiet about his pain medication. V10 stated that R2 stopped and turned around and asked R7 what he said. V10 stated that R2 and R7 started yelling at each other, cursing at each other. V10 stated that R2 then threw his cup of coffee at R7. V10 stated that R2 missed R7 and hit two other residents. V10 stated that after he hit the other residents R2 started apologizing. V10 stated that R2 deliberately and intentionally threw the cup of coffee at R7. On 2/28/2023 at 2:28 PM, V1 (Administrator) stated that he is aware of the incident that occurred. V1 stated that (R2) and (R7) were arguing in the dining room. R2 threw his cup of coffee at R7 and missed. V1 stated that the cup of coffee missed its intended target. V1 stated that the cup then hit R5 and R6. V1 stated that R5 sustained an injury. V1 stated that R5 had a hematoma to his head. V1 stated that R2 intended to hit R7. V1 stated that he had a sentinel call with corporate and this incident was discussed. V1 stated that at that time this event was not viewed as abuse and because the injury was not serious the event was not reported. 2. R3's Care Plan, dated 1/9/23, documents that 12/13/22 R3 displays behavioral symptoms related to Dementia and are manifested by agitation and verbal aggression, 1/8/2023 Resident has a history of aggressive and inappropriate behavior, and 1/8/23 Resident involved in an altercation with another resident. R3's MDS, dated [DATE], documents that R3 has some moderate impairment cognitively. R3's Nurses' Notes, dated 1/8/2023 at 11:36, documents Note Text: resident was approached by fell ow resident in dining room and asked to move so fell ow resident could sit at her usual table for lunch. resident smacked fell ow resident, smacked her on the left side of her face. residents re-educated to appropriate behavior towards others. administrator and NP notified. psych notified as well. The facility's Follow-up Investigation Report, not dated, documents Occurrence Resolution: On 1/8/2023 @ 120p 11:00 am staff reported resident to resident physical altercation between (R3) a [AGE] year old male whose diagnosis includes unspecified Dementia, Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbances, and Anxiety and (R4) a [AGE] year old female whose diagnosis includes Unspecified psychosis not due to a substance or known physiological condition. (R3) and (R4) were on their way to the dining room for lunch when the two had a verbal altercation resulting in a physical altercation causing (R3) to make contact with (R4) left face cheek. Staff were able to intervene and separate the residents. R4 obtained a slight red tint to her face. R3 denied the altercation occurred. R4 stated that R3 was in her spot, and she asked him to move. She denies being rude or in R3's face. It also documents that Based on the results of the investigation, facility was not able to substantiate intentional abuse. Chart review reveals (R3's) diagnosis of dementia results in him having poor communication skills to communicate with (R4) to move away from him instead of making contact. On 2/27/2023 at 2:55 PM, R3 stated that he does not remember hitting R4. On 2/27/2023 at 3:00 PM, R4 stated that she went to the dining room. R4 stated that they have an assigned seat in the dining room. R4 stated that she asked R3 to move out of her space. R4 stated that she did get close to R3 but did not touch him. R4 stated that R3 then slapped her in the face. R4 stated, R3 does this a lot and he likes aggravating you. R4 stated that she is frustrated and tired of it. On 2/28/23 at 9:57 AM, V9 (Certified Nursing Assistant/CNA) stated that R3 yells and becomes agitated. V9 stated that the only time she has seen R3 be physical is in the dining room. V9 stated that R3 was sitting at a table and (R4) told him to move out of her space. V9 stated that R3 and R4 were going back and forth. V9 stated that R4 told R3 to move out of her space in the dining room, and R3 told R4 to get away from him. V9 stated that R4 told him to get out of her space and R3 slapped her. V9 stated that R3 meant to hit R4. On 2/28/2023 at 11:49 AM, V11 (CNA) stated that she heard some commotion in the dining room. V11 stated that she was standing in the hallway. V11 stated that R4, in her wheelchair, rolled up to R3, knees to knees, and told R3 to get out of her space. V11 stated that R4 then pushed R3 in his chest and R3 then slapped R4. V11 stated that R3 slapped R4 on purpose, but it was after R4 pushed him. V11 stated that R4 and R3 were loud and yelling and that their actions were deliberate and intentional. The facility Abuse Policy and Prevention Program 2022, not dated, documents This facility affirms the right if our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on interview and record review, the facility failed to provide behavioral health services for mental illness to maintain/improve resident's psychosocial well-being for 1 of 3 residents (R2) reviewed for behavioral health services for mental illness in the sample of 3. This resulted in R2 having ongoing behaviors of impulsive and explosive verbal and physical aggression. This failure resulted in R5 and R6 being hit with a hot cup of coffee, causing a hematoma to R5's head, R5 experiencing pain, anger and not wanting to be around R2. Findings include: R2's Face Sheet documents original admitted [DATE]. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is cognitively intact and has verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). R2's Care Plan, dated 1/27/23, Psychotropic Meds documents: (R2) requires the use of psychotropic medication Buspirone, Ramelteon, and Geodon to assist with managing mood and behavior related to DX (Diagnoses) of Insomnia, schizoaffective disorder and schizophrenia with targeted symptoms/behaviors of wakefulness, paranoia, verbal outbursts. It also documents 2/22/23 Resident attempted to throw a cup in the dining room during a meal at a specific resident. He hit two other residents instead. It continues Interventions: Geodon increased per psych. Resident's assigned table in dining room moved away from both residents. 1/4/23 Resident can become accusatory of nurse's taking his medications when they have been DC'd (discontinued) and he was notified. It continues Interventions: Intervene when any inappropriate behavior is observed. Communicate that the resident is responsible for exercising control over impulses and behavior (Social Skills training). Use creative refocusing to alter behavioral patterns if the person suffers from Dementia (e.g., provide drawers, laundry basket for rummaging, provide a tube sock with a knot to focus the resident's attention). It also documents 2/22/23 Resident can get verbally abusive with staff. Hits nurses' carts demanding pain medications. Cusses and becomes accusatory. It also documents 1/25/23 Resident has symptoms such as mood swings, impulsive behavior and attention seeking behavior related to a diagnosis of Schizoaffective, bipolar type Disorder. Monitor for increase of signs and symptoms of increased anxiety and change in mood. R2's Nurses' Notes, dated 11/30/2022 at 7:50 PM, document: Note Text: patient arrived via ems (emergency medical services). patient is alert and oriented x4 and able to verbalize needs and concerns. patient is diabetic with hx (history) of cellulitis, pancreatitis, and substance abuse. patient arrived with multiple sharp blades that were taken on arrival and placed in narc (narcotic) box. patient seems pleasant, oriented to room and call light system. R2's Nurses' Notes, dated 12/1/2022 at 3:00 AM document: Late Entry: Note Text: Nurse (V15) turned in 9 knives and blades that resident (R2) voluntarily gave him. They are now in the SS (social services) office secured. R2's Care Plan does not document problem or interventions of R2 having multiple sharp blades and knives. R2's Nurses' Notes, dated 12/9/2022 at 1:33PM, document: Note Text: resident has been very aggressive towards staff today. resident has been cussing at staff throughout the morning This resident also accused staff of taking his wallet. this nurse went into resident's room and he stated 'SOMEONE TOOK MY F****** WALLET, FIND MY F****** WALLET.' this nurse asked the resident to please stop cussing at me and then I asked him what color was his wallet and where was the last place he had it. he stated 'My WALLET IS BLACK AND I HAD IT IN THE F****** SHOWER ROOM.' CNA (Certified Nursing Assistant) staff stated they had already looked in the shower room and nothing was left in there, this nurse then looked in the resident's bedside dresser and seen a black wallet in the drawer. I showed him the wallet and asked him was this his black wallet, resident then apologized and stated 'yes it is; somebody must have put it in there when I left out of the room.' resident had not left out the room since he had his shower. nothing was missing out of the resident wallet. R2's Nurses' Notes, dated 12/27/2022 8:02 PM document: eMAR (electronic Medication Administration Record) - Shift Level Administration Note Text: Resident is verbally aggressive with this nurse regarding unfulfilled oxycodone script. Resident states that he has been out of the medication for 9 days. Resident called corporate hotline after this nurse told him that he needed a new script for the medication. Resident started screaming that he was going to get it one way or another or that he would just go back to the emergency room . This nurse notified (V14) NP (Nurse Practitioner) and NP stated that she doesn't write scripts after 8:00PM and she will be in at 8:30 am tomorrow morning to see resident. Administrator made aware of conversation. R2's Nurses' Notes, dated 12/31/2022 at 1:06 PM, document: Note Text: resident was brought the wrong tray for lunch by accident. resident started yelling and screaming and cussing, resident was walking back from the dining room. this resident then told another resident to get the f*** out his way. this nurse went into resident's room and asked resident who delivered the hall tray. he stated some short person gave him one. this nurse tried to explain to resident that he had the wrong tray and that's why his food was not double portioned. this resident then continued to cuss and yell, this nurse told resident that he needed to not yell and to lower his voice, I explained to him that I was not yelling at him so he did not need to yell at me. he responded I'M GONNA SAY WHAT THE F*** I WANT TO SAY, I'M TIRED OF THIS SH** EVERY F****** DAY. this nurse then told this resident he can state what he needs to state but he will do it without yelling. we have other residents on the hall that don't deserve to be in a disruptive environment. resident then stated 'F*** THIS SH**.' this nurse stated once again that he needed to calm his voice down and stop yelling, Resident kept yelling. this nurse then tried to show this resident the name on the meal ticket to confirm to him that he had gotten the wrong tray by mistake. resident then started to yell stating 'SO YOU THINK I CAN F****** READ THAT?' I told him ok, you can sit in here and calm down. I will shut your door until you do. Resident stated 'SHUT THE F****** DOOR.' resident kept cussing and screaming; this nurse walked out of resident room and closed the door. this nurse will go back to talk to resident about the mistake that was made on his food tray once this resident calms down. No new interventions added for aggression noted on 12/27/22 and 12/31/22. R2's Nurses Notes, dated 1/19/2023 at 10:30 AM, documents, Note Text: Today I was notified by a CNA that (R2's) room smelled like cigarette smoke and requested that I come and speak to him. I went to his room which indeed smelled of cigarette smoke. I asked him if he had been smoking and he stated no. I asked him to come to my office and have him to sign the (facility's) Smoking Policy which he agreed to. I read to him the entire policy because he stated that he has a hard time seeing. Later a room sweep was done with the DON/ADON (Director of Nursing/Assistant Director of Nursing) and a cigarette/lighters/empty cigarette boxes/Butane Canister were found. Also, a black case that was found that he refused to open resulting in the (local) police assistance was needed because of (R2's) aggressive behavior. In result, the black box was locked inside the nurse cart on the hall. R2's Nurses' Notes, dated 1/19/2023 at 2:14 PM, documents Social Service Note Text: room was searched by DON, ADON and social services. We found cigarettes, 2 lighters, a butane torch with a canister and a locked box. He was given the option to open it or allow us to remove the box for safety and he became irate. We were unsuccessful at calming him down. The police was notified r/t (related to) aggression towards staff. Lock box removed from the room once police arrived. Resident was taken outside by staff to smoke and an attempt to calm down. Guest was placed on q (every) 15 min (minute) checks x 72 hours. His BIMS (Brief Interview for Mental Status) score is 15. Social services educated and a signed a smoking policy was given in addition to being educated on appropriate smoking areas. He is self responsible. MD (physician) notified. No timely progressive interventions added for aggression noted on 1/19/2023, 2/5/2023, and 2/17/2023. R2's Nurses' Notes, dated 1/26/2023 12:02, document: Note Text: resident with complaint of depression. psych (psychiatrist) made aware. R2's Nurses' Notes, dated 2/5/2023 at 1:38 PM, document: Note Text: resident noted to have w/c (wheelchair) belonging to hospice resident. this nurse returned w/c to rightful owner, while replacing a different w/c to resident. resident became belligerent calling the (local police department). Upon speaking with (local police department) resident continued to talk loudly. (local police department) officer advised resident to lower his voice. resident was told by (local police department) w/c was inspected and did not belong to him. resident became loud with (local police department) officer. (local police department) officer re-directed resident telling him w/c was replaced. resident stated it wasn't his w/c and he would eventually get the other w/c (wheelchair) back. (local police department) officer advised resident not to try it or there could be consequences. resident walked away from (local police department) officer and returned to room. resident sitting in room at this time. R2's Nurses' Notes, dated 2/17/2023 2:45 PM, document: Note Text: resident complaining of back pain. resident was offered over the counter pain meds that he has scheduled. resident refused and stated those medications do not work. this nurse explained to the resident that the other medication had been d/c (discontinued) and I could not give medication that I do not have an order for. Resident started yelling and screaming stating this was bullsh** and he doesn't understand why they would D/C his medication in the first place. this nurse told resident I would contact the doctor to see what we could give him. resident yelled f*** this sh** and punched the treatment cart. resident was redirected to his room, where he went and laid down in his bed to calm down. R2's Nurses' Notes, dated 2/17/2023 at 6:08 PM, document: Note Text: (R2) and another resident exchanged a few words back and forth, the other resident called for (V12) (Human Resources) to come over and get the resident because he had come in the dining room starting stuff. this nurse (V13, Licensed Practical Nurse/LPN) and (V12) walked over to see what was going on. by the time this nurse and (V12) made it over to the residents, (R2) got more upset and tried throwing his coffee cup at the other resident. the coffee cup ended up hitting a different resident in the head and bouncing off of him and hitting another resident in the shoulder. this nurse as well as other staff members redirected the residents. (R2) was instructed to go back to his room so he could calm down. this resident was sent out to the hospital for a psych (psychiatric) eval (evaluation). EMT (Emergency Medical Technician) called; resident going to (local hospital) for further evaluation. (V14) NP, (V1) Administrator made aware. The facility's Follow-up Investigation Report, not dated, documents Interview with (R2) revealed that him and (R7) were having a disagreement about their shared bathroom and (R2) does not deny swinging his cup in attempt to hit (R7) with it and he missed and accidentally hit (R5). (R2) was apologetic for his actions and was educated about his inappropriate behavior. It also documents Conclusion of the investigation: On 2/17/2023 @approximately 4:50pm, staff reported possible resident to resident physical altercation between (R2) a 46yr old male whose diagnosis includes Schizoaffective Disorder, Bipolar Type and (R5) a [AGE] year male whose diagnosis including Cognitive Communication Deficit. While in dining room preparing for dinner meal, (R7) and (R2) were having an argument about their shared bathroom when (R2) tossed his coffee cup at (R7), missing him and making contact with (R5's) forehead. The cup did bounce off (R5) and make contact with (R6's), a fell ow peer, right shoulder, however she has no injuries or psychosocial harm. On 2/27/2023 at 11:38 AM, R2 stated that he did throw his cup with hot coffee in it. R2 stated that R7 was poking and poking and poking at him. R2 stated that he became so upset that he threw the cup. R2 stated that he intended to throw the cup. R2 stated that it was deliberate. R2 stated that it didn't hit the person (R7) that was bothering him. R2 stated, It hit the nicest guy (R5) you could ever meet. R2 stated that he is sorry that it hit R5. R2 stated that he just wanted R7 to shut up. R2 stated that he does not eat in the dining room. R2 stated that he does go in the dining room to get coffee. On 2/27/2023 at 11:53 AM, R5 stated that he was sitting in the dining room and R2 threw a cup at his tablemate (R7). R5 stated that the cup missed him (R7) and hit (R5) in his head. R5 stated that he was upset and that it hurt. R5 stated that his head was swollen and bruised. R5 stated that he doesn't like to be hit. R5 stated that he still has some bruising to his head, and it is tender and hurts when touched. R5 stated that he doesn't want anything to do with R2. R5 stated, He (R2) can stay over there, and I can stay over here. R5's MDS, dated [DATE], documents that R5 is cognitively intact. On 2/27/2023 at 3:30 PM, R1 stated that he was sitting in the dining room at the table. R1 stated that it was before supper. R1 stated that R2 was walking into the dining room. R1 stated that R2 and R7 were arguing and yelling at each other. R1 stated that R1 got mad and threw a cup of hot coffee at R7. R1 stated that the cup missed R7 and hit R5 in the head. R1 stated that it was a lot of commotion, and the staff came running asking what happened. R1 stated that the staff started asking what happened to her (R6). R1 stated that when looking, R6 had gotten hit as well. R1 stated that R2 threw the cup at R7 but missed him. R1 stated that R2 is aggressive at times, yells and screams, and gets mad easy. R1 stated that R1 doesn't want to be around him R1's MDS, dated [DATE], documents that R1 is cognitively intact. On 2/28/2023 at 9:17 AM, R6 stated that she got hit in the head and arm by a cup. R6 stated that two guys were arguing, one threw the cup and it hit her. R6 stated that she doesn't want to be bothered with and doesn't care to be around R2. R6's MDS, dated [DATE], documents that R6 is cognitively intact. On 2/28/2023 at 9:28 AM, V5 (CNA) stated that R2 does have behaviors. V5 stated that he yells and gets upset easily. V5 stated that R2 likes coffee and if there is not coffee on the cart he gets upset. V5 stated that if his coffee is not on the hall cart, she has to go and get it for him. On 2/28/2023 at 9:31 AM, V4 (LPN) stated that R2 has behaviors. V4 stated that R2 is aggressive. V4 stated that R2 yells, screams, and gets in the personal space of the staff and residents. V4 stated that when R2 gets mad, he will leave the facility and grounds without telling anyone. V4 stated that when he is upset, she can at times talk to him and let him go through his meltdown, and then R2 apologies but then the next day it's the same thing. V4 stated that R2 likes coffee. V4 stated that R2 gets his coffee from the kitchen and walks through the facility with it. On 2/28/2023 at 9:38 AM, V6 (CNA) stated that R2 is aggressive. V6 stated that when R2 can't get his way he becomes volatile. V6 stated that R2 yells and threatens the staff. V6 stated that R2 gets in your personal space and threatens to hurt you. V6 stated that R2 does this with staff and other residents in the building. V6 stated that R2 will have this behavior then later apologize. V6 stated that then the next day he does the same thing. V6 stated that the only thing she knows to do is leave him alone or if there is a specific person he is mad at, then they try to keep that person out of his room. V6 stated that R2 does carry his coffee cup with coffee in it around in the facility. On 2/28/2023 at 11:44 AM, V10 (Dietary Aide) stated that she was passing drinks in the dining room before supper. V10 stated that R2 came in the dining room and asked her for a cup of coffee. V10 stated that R2 then stated that they wouldn't give him his pain pill. V10 stated that she gave R2 a cup of coffee and he started rolling away. V10 stated that R2 continued to yell about the not receiving his pain medication. V10 stated that R7 told R2 to be quiet about his pain medication. V10 stated that R2 stopped and turned around and asked R7 what he said. V10 stated that R2 and R7 started yelling at each other, cursing at each other. V10 stated that R2 then threw his cup of coffee at R7. V10 stated that R2 missed R7 and hit two other residents. V10 stated that after he hit the other residents, R2 started apologizing. V10 stated that R2 deliberately and intentionally threw the cup of coffee at R7. On 3/1/2023 at 12:05 PM, V16 (Psychiatrist) stated that he has worked with this facility for years. V16 stated that this facility was primarily skilled but within the last few years has taken more mentally ill patients. V16 stated that bipolar is a mental illness and the patients require psychosocial programs and services, whether or not it is in groups. V16 stated that the facility is to provide this service and this would be his expectation, especially if a patient is having increased uncontrolled behaviors. On 3/1/2021 at 2:00 PM, V1 (Administrator) stated that the facility does not provide any psychosocial programing or services. V1 stated that he is not saying that it is not needed, but at this time the facility does not provide that service. On 3/1/2023 at 3:28 PM, V1 stated that the facility does not have a Mental Health Psychosocial policy. On 3/1/2023 at 3:33 PM, V17 (Social Services Director/SSD) stated that she is new to the facility. V17 stated that she has only worked at the facility 6 days. V17 stated that she is working on reviewing residents but has not had the opportunity to talk with and review R2. V17 stated that she does not know of R2 having a program because she has not gotten to him yet. On 3/1/2023 at 4:02 PM, V18 (previous SSD) stated that R2 was not receiving psychosocial programing or services at the facility. V18 stated that she doesn't remember why but knows that he wasn't.

Based on observation, interview, and record review, the Facility failed to provide Tube Feedings as ordered by the Physician for 1 of 2 residents (R2) reviewed for Tube Feedings in the sample of 4. This resulted in R2 being hospitalized and requiring intravenous (IV) fluids for Diagnosis of Dehydration. Findings include: R2's Admission Record, dated 2/1/23, documents that R2 was admitted to the facility on [DATE] and discharged from the facility on 1/29/23. R2's Electronic Medical Record documents R2's medical diagnoses include Protein-Calorie Malnutrition, Cerebral infarction, Dysphagia, Cortical Blindness, Disorder of Autonomic Nervous system, Antiphospholipid Syndrome, Hypertension, Psychoactive Substance Dependence, and Major Depressive Disorder. R2's Care Plan, dated 1/26/23, documents Dietary: (R2) is on a therapeutic diet related to disease process: s/p (status post) stroke with dysphagia. NPO (nothing by mouth) diet with Enteral Feedings for full nutrition. Interventions: Monitor monthly weight, Monitor tolerance of TF (Tube Feeding), Monitor weight weekly, NPO diet order, RD (Registered Dietitian) to evaluate appropriateness of TF regimen and adjust PRN (as needed). R2's Interim Baseline Care Plan, dated 1/26/23, documents (R2) is at risk for Dehydration. Interventions: Monitor for signs/symptoms of dehydration (i.e., decreased urine output). It continues (R2) requires tube feeding and stoma site care. Interventions: Administer Tube Feeding per MD (Medical Doctor) order, Elevate HOB (head of bed) while feeding is infusing, check placement and patency of feeding tube prior to administering medications, feedings, and flushes, and monitor stoma site for signs/symptoms of infection. R2's Minimum Data Set (MDS), dated [DATE] (Entry) and 1/29/23 (Discharge) was not completed due to R2's short stay at the facility. On 2/1/23 at 2:50 PM, V9 (R2's Mother) stated My daughter (R2) arrived to that facility on 1/26/23 at 10:30 AM. (R2) has a feeding tube and relies on her feedings to survive. When she got there, they did not have any tube feeding to give to her. They went to their sister facility in (local town) to get a case of the Jevity Tube Feeding. (R2) missed her 12:00 PM feeding that day because they didn't have any to give her. (R2) is supposed to get 300 ML (milliliters) four times a day. I do not believe that she was getting all of her feedings and water boluses as was ordered. On Saturday morning (1/28/23) when I came into the facility, there was a bottle of the tube feeding in (R2's) room and it was dated 1/26/23, which was the date she came in. My daughter started complaining of being thirsty and wanting water, which she never asks for. I was sponging (R2's) mouth with some water and that wasn't even helping her. I knew that something was not right. I looked at the bottle of tube feeding in her room, and it was indeed dated 1/26/23 and it looked like it was still half full. (R2) definitely should have been on a second or third bottle by then. The facility got an entire case of the tube feeding from their other facility, so I know they had some. When I mentioned it to the nurse (V7, RN/Registered Nurse), she told me that it does look like (R2) has not been getting her feedings. The nurse told me that (R2) has not urinated all day and that she would call me if she did, but I never got a phone call. When I went to the facility the next morning (1/29/23), I spoke with (V12, Licensed Practical Nurse/LPN), and he said that he will push fluids on her, and I told him no, and they are to send (R2) to the hospital. When she got to the hospital, they had to put a urinary catheter in (R2) to get some urine. They diagnosed (R2) with Dehydration and told me that (R2) was really dry. We had to do an emergency admit for (R2) to go to another facility, because I was not letting (R2) go back to that place. On 2/1/23 at 3:10 PM, V7 (RN) stated I picked up a shift on Saturday evening (1/28/23) and took care of (R2). She was to get G-Tube (Gastric Tube) feedings at 6:00 AM, 12:00 PM, 6:00 PM, and again at 12:00 AM. I gave her the feeding at 6:00 PM and flushed it like I'm supposed to. I think the date on the bottle was either 1/26/23 or 1/27/23. I remember (R2's) mother (V9) was here and thought that (R2) was dehydrated and was not getting her feedings. I showed her in the computer where she was getting them along with the flushes. I asked her if she wanted me to call the physician and ask for an increase in her water/feedings and she didn't answer me. (V9) pointed out the date on the bottle was 1/26/23 and said that (R2) should not still be on this bottle and she should be on a newer bottle. There was still at least another feeding left in the bottle after I fed her. I could not honestly tell you if she was getting her feedings or not. On 2/1/23 at 3:30 PM, V10 (MDS Coordinator) stated We keep the tube feedings either in the medication room or in Dietary. I believe when (R2) got here, we had to get some from our sister location, and we put that case in the medication room. It looks like there are two bottles missing from the case of six. There is 1500 ML (milliliters) in each bottle. On 2/1/23 at 3:30 PM, a case of Jevity Tube Feeding was setting in the medication room on the floor. The case held six bottles of the tube feeding. There were four unopened bottles left in the case, with two bottles missing from the case. Each bottle had 1500 ML of tube feeding in it. On 2/2/23 at 7:45 AM, V12 (LPN) stated I was the one who sent (R2) to the hospital that day. It was the first time I took care of (R2). I was told in the morning report to make sure (R2) voids because she may be dehydrated. (R2's) mother (V9) came in on 1/29/23, very concerned about (R2) possibly being dehydrated, however, (R2) did void while her mother was here that morning. (R2) already received her tube feeding at 6:00 AM that morning prior to my arrival. I remember there was still some feeding left in the bottle, but I am not exactly sure how much. It looked like at least another feeding or two worth. I don't remember what the date was on the bottle. I know that either (V13, Certified Nursing Assistant/CNA), or the Dietary Department orders the tube feeding. I really think that (R2) should have been on at least her third bottle of feeding by Saturday (1/29/23), and it looked like she was still on her second one. On 2/2/23 at 8:00 AM, V14 (Dietary Manager) stated I used to order the tube feeding, but since the new company took over around July 2022, (V13) orders it now. I do have eight cases of TwoCal HN (high nutrition) which has twenty four eight ounce cartons of feeding per case. I have had this in Dietary since 10/1/22. I heard that someone had to go to (other facility) to get a case for a resident and that they were ordering more. On 2/2/23 at 8:15 AM, V14, stated (V13) ordered seven cases of Jevity on 1/27/23 at 2:26 PM. It looks like we received it already, but I'm not sure where it is. On 2/2/23 at 8:30 AM, V1 (Administrator) stated There are seven boxes of Jevity sitting at the end of the 300-hall. I don't know why they were put there, but there is no tracking or delivery sheet with them. It looks like one box was opened already. On 2/2/23 at 8:30 AM, there were seven cases of Jevity setting on the floor at the end of the 300-hall. Each case had twenty-four eight-ounce cartons of Jevity. One case was opened with three cartons removed. On 2/2/23 at 8:40 AM, V1 (Administrator) stated It looks like the Jevity was delivered on 1/30/23 at 12:53 PM. (R2) was already gone by then. I understand now. It does look like (R2) should have been on at least her third bottle of Jevity by the time she left here. I will check with each of the nurses who documented it as given and try to find out what happened. R2's Physician Order, dated 1/26/23, documents Enteral Feed QID (four times a day), flush feeding tube with 100 ML of water. R2's Physician Order, dated 1/26/23, documents Jevity 1.5 Cal/Fiber Oral Liquid (Nutritional Supplements). Give 300 ML via Peg-Tube four times a day for bolus feedings. R2's Physician Order, dated 1/26/23, documents Check residual. If greater than and/or equal 100 ML hold feeding. If feeding held: Check residual after one hour and if residual still great than or equal to 100 ML notify MD (Medical Doctor). Every Shift. R2's Physician Order, dated 1/26/23, documents Check placement of G-Tube using auscultation before administering food/medications/fluids. R2's January 2023 Medication Administration Record (MAR) documents Residual Checks BID (twice a day) from 1/26/23 PM until 1/29/23 AM. Each residual check was documented as zero. Flush Peg-Tube with 60 ML BID was documented as completed from 1/26/23 PM until 1/28/23 PM. Enteral Feeding QID - Jevity 1.5Cal/Fiber - 300 ML via Peg-Tube QID was documented as given from 1/26/23 at 6:00 PM until 1/29/23 at 6:00 AM for a total of eleven times. R2's MAR documents that there were eleven feedings given to R2. If R2 received 300 ML of feeding each eleven times, there should have been 3300 ML's given. There were only two bottles missing (1500 ML per Bottle) which equals to 3000 MLs. R2's Nurses Note, dated 1/26/23 at 1:13 PM, documents Patient arrived via EMS (Emergency Medical Service) from (Metropolitan Hospital). NKA (No Known Allergies), Full Code, alert to self only, unable to respond to verbal commands. Is blind, has a Peg-Tube in left lower abdomen, flushed with no resistance. Patient has bolus feedings QID 300 ML Jevity 1.5 with flush, flush increased to100 ML before and after feedings by NP (Nurse Practitioner). Was admitted to hospital on 12/23/22 after being unresponsive. Patient is incontinent of bowel and bladder, history of HTN (Hypertension), Stroke, Substance Abuse, and Anxiety. (Documented by V15, LPN) R2's Nurses Note, dated 1/26/23 at 6:46 PM, documents Jevity bolus feedings given. Tube flushed, no resistance or issues noted. (Documented by V15, LPN). R2's Nurses Note, dated 1/29/23 at 00:42 AM, documents Family called up to facility very concerned that resident may be dehydrated. Family stated her bottle of feeding was dated back to 1/26/23 and she should have had another bottle of feeding by this date. Family thinks resident was not getting her feedings at night. This writer reassured the family that she would get her feedings on night shift when they are due and will get her flushes when due. Resident received her feedings and medicine at midnight on tonight. Tolerated well and will continue to monitor. Resident has a new bottle of feeding at bedside. (Documented by V16, LPN). R2's Nurses Note, dated 1/29/23 at 6:26 AM, documents Resident has not voided on night shift. Family notified and aware. Tried to contact doctor, no answer. Will ask day nurse to notify doctor to see what are the next steps to take. (Documented by V16, LPN). R2's Nurses Note, dated 1/29/23 at 10:17 AM, documents Follow-up from last nurse's note: resident did void this morning. Mother is currently at bedside and requested resident to be sent out to (Local Hospital) to be evaluated. Notified NP, agreed to send out resident. Called (Local Hospital) and gave report to the RN, tried calling (Local EMS) and they stated that ETA (estimated time of arrival) is close to two hours, called 911 and they stated that they will send an ambulance as soon as they can. Resident's mother is concerned but calm. EMS just arrived. (Documented by V12, LPN). R2's Nurses Note, dated 1/29/23 at 10:32 AM, documents EMS from (Local) Fire Department just departed facility with resident to (Local Hospital). Resident's mother just left facility as well. (Documented by V12, LPN). R2's Nurses Note, dated 1/29/23 at 7:30 PM, documents Family was present mid-afternoon today to pick up resident's belongings. They stated that resident was admitted to (Local Hospital) but she is directly transferring to (Another Facility) after discharge. (Documented by V12, LPN). R2's Hospital Record, dated 1/29/23, documents that R2 was treated in the Emergency Department for Dehydration, including IV (intravenous) fluids, and then transferred to another living facility. The Facility's Tube Feeding Policy, dated 9/2022, documents Nasogastric, Gastrostomy, and Jejunostomy tubes are used when an alternate method of nutrition is needed. It continues Guideline: 7. All residents who are admitted for long term care: during the conversation on advanced directives, will have wishes for alternate feeding methods discussed and education on the risks and benefits will be provided. It further documents, 9. The tube feeding will be labeled with the date and time hung as well as the initials of the person hanging the feeding. It continues Bolus Feeding: 1. Ensure head of bed is 30-45 degrees. 2. Explain procedure, provide privacy, cleanse hands and done gloves. 3. Check tube placement by aspiration or air insertion. 4. Instill formula and run over appropriate time frame, monitoring resident for signs and symptoms of aspiration. 5. Flush tube with amount of water ordered at end of tube feeding. 6. When feeding complete, disconnect and cover the end of the feeding set. 7. Document feeding and alert the Health Care Provider of any issues or problems.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent sexually inappropriate behavior, between cognitively impaired residents for 3 of 3 residents (R1, R3, and R4) reviewed for supervision in a sample of 8. This failure resulted in psychosocial harm as a reasonable person would react in a such a situation with feelings of fearfulness, humiliation, anxiety and distress. Findings include: On 9/28/2020 at 1:30 PM, R5 stated, (R4) took his privates out in his room. The door was open. I told someone who works here but I am not sure who. It was inappropriate and disgraceful. On 9/28/2020 at 1:45 PM, R2 stated, I have not seen any incidents, but I have heard about (R3) and (R4) being sexually inappropriate together more than once. Maybe 3 or 4 times. I have heard it from other residents. The last episode was about a week ago. I heard (R3) walked up to (R4) and dropped his pants. (R4) started orally pleasuring (R3). (R3) is not 'with it'. (R4) mostly stays in his room but he also wanders into rooms. On 9/28/2020 at 2:00 PM, V4, Housekeeping, stated, I wouldn't go in there (R4's room). (R4) doesn't comprehend really well. I have not seen (R4) or any other residents being inappropriate. On 9/28/2020 at 2:14 PM, V6, Temporary Nurse Aid (TNA) stated, I was here for the first incident between (R3) and (R4). It took place in (R4)'s room. (R4) was orally pleasuring (R3). (R4) has dementia. (R3) is kind of new to the facility. I reported it to the nurse, I am not sure of her name. (V2), (V3) and (V8) were contacted. We separated them and we check on them frequently. On 9/28/2020 at 2:25 PM, V7, TNA, stated, I have heard rumors of residents performing sexual favors to each other when they were bunked together (roommates). I did not witness it, I heard about it from (V6). (R4) was giving (oral sex) and (R3) was receiving (oral sex). Both (R3, R4) have dementia. They are on separate halls now. (R4) is in his own room. We have to keep an eye on (R3). (R3) is quick and we have to re-direct him. On 9/28/2020 at 2:34 PM, V8, Certified Nursing Assistant (CNA) Coordinator, stated, I did hear about the incident, but I was not here. We have a communication log of what is reported. (V2) Director of Nursing (DON) and (V3), Assistant Director of Nursing (ADON) made us aware the following day. (R3) and (R4) had been roommates. Staff came into the room and found them pleasuring each other. Neither one of them are really cognitive to much, other than self. I don't know if the police were notified but I know the families were. On 9/29/2020 at 9:44 AM, R7 stated, (R3) and (R4) 'had ahold of each other' in the cafeteria. Everyone knows about it. One day a couple weeks ago, I was in the hall and (R4) was shaking his thing at me. On 9/29/2020 at 11:45 AM, R6 stated, I heard (R3) and (R4) were having oral sex. (V6) is the one who saw it. It happened outside the kitchen door in the dining room. On 9/29/2020 at 12:28 PM, V12, Licensed Practical Nurse (LPN) stated, (R3) and (R4) are both 15-minute checks due to the accusation of them having sexual relations in public places. They were roommates at the time of the incident. The Facility's Staff Interviews form, undated, documents, Name: (V8) 1. Have you ever had any concerns with (R3) being sexually inappropriate with another resident? If yes, do you think it is related to his diagnosis? V8 answered, Yes and Yes. The Facility's Staff Interviews form, undated, documents, Name: (V14) 1. Have you ever had any concerns with (R3) being sexually inappropriate with another resident? If yes, do you think it is related to his diagnosis? V14 answered, Yes and Yes. The Facility's untitled, undated form documents, When I was walking past room [ROOM NUMBER] I saw (R4) and (R3) in the same bed together. (R4) was performing oral sex. Residents immediately separated. We redirected (R3) to the dining room. Nurse was informed immediately. This form was signed by V6. R3's Face Sheet documents R3 has a [DIAGNOSES REDACTED]. R3's physician's orders [REDACTED]. R3's Care Plan reviewed 9/21/2020 documents The resident has a communication problem related to dementia. R3's Care Plan continues documentation, The resident has impaired cognitive function related to Dementia. R3's Minimum Data Set ((MDS) dated [DATE] documents R3 has a Brief Interview for Mental Status (BIMS) score of 11, which indicates R3 has cognitive impairment. R3's Progress Notes dated 9/11/2020 at 6:46 AM, documents, Resident was noted to have his penis in another resident's mouth. Staff separated residents and moved resident to room [ROOM NUMBER]. ADON notified. Family notified. No injury noted. No distress noted. R3's Progress Note dated 9/13/2020 at 22:20 PM documents, Resident was observed giving resident oral sex in dining room. R3's Progress note continues, Resident immediately separated for safety and placed on 15-minute checks. R3's Progress Notes dated 9/17/2020 and 9/21/2020 documents that the 15-minute checks were continued. On 9/30/2020 an attempt to interview R3 was unsuccessful. R3 did state, (R4) Who? The Facility's Incident Report/ Abuse Notification form documents that on September 10, 2020 staff walked into the dining room and observed (R3) providing oral sex to resident (R4) and that residents were separated immediately. This form continues to document that the administrator was notified, and an investigation was initiated. The Facility's Incident Report/ Abuse Notification form documents, On September 13, 2020, during routine rounds, staff observed (R3) providing oral sex to resident (R4) in room. Residents were separated immediately. This form continues to document that the administrator was notified, and an investigation was initiated. R3's Behavior Tracking for dated September 2020 documents that R3 is tracked for inappropriate sexual behavior with staff and residents. The document reflects that the frequency of this type of behavior was observed 8 times. There is nothing documented for September 10, 2020 or September 13, 2020. R4's MDS dated [DATE] documents R4 has a short-term memory problem. R4's Progress Notes dated 9/11/2020 at 7:03 AM documents, Resident noted to have another resident's penis in his mouth. Resident's separated. No distress noted. No injury noted. ADON aware. Family aware. R4's Progress Notes dated 9/13/2020 at 5:05 PM documents, Administrator and ADON notified immediately of sexual incident between resident and resident. R4's Progress Notes dated 9/13/2020 at 21:42 PM documents, It was reported to this nurse that a resident was observed in the dining room at approximately 5 PM putting his penis in (another) residents' mouth. It continues to state that residents were separated and placed on 15-minute checks for protection of self and others. R4's Care Plan documents that R4 is at risk for abuse/neglect. R4's Care Plan further documents that R4 displays socially inappropriate and maladaptive behaviors related to sexual aggression towards peers. R4's Care Plan documents, On 9/10/2020, resident was noted by staff to have another resident's penis in his mouth. The intervention listed was to separate the residents. R4's Care Plan further documents, On 9/13/2020 resident was noted by staff to be putting his penis in another resident's mouth. The interventions listed for this incident include 15-minute checks initiated, police notified, and R4 was sent to the emergency room for evaluation. R4's POS documents a telephone order was received on 9/13/2020 to Place on 15-minute checks to ensure resident safety. R4's Behavior Tracking for dated September 2020 documents that R4 is tracked for inappropriate sexual behavior with staff and residents. The Behavior Tracking reflects 9 incidents related to this behavior, but none were documented for 9/11/2020 or 9/13/2020. On 9/29/2020 on continuous observation of R4 were made from 9:00 AM until 9:44 AM. At 9:00 AM R4 was in his room and the door was closed. At 9:44 AM, V7 Temporary Nurse Aid (TNA) opened R4's door, looked in, and stated, Just checking on you. On 9/29/2020 continuous observations of R4 were made from 11:00 AM until 11:38 AM. During this observation, R4 remained in his room with the door closed. Multiple staff members, including V3, Assistant Director of Nursing (ADON), and V8, Certified Nursing Assistant (CNA) Coordinator, walked by R4's room without performing visual checks on R4. On 9/30/2020 at 11:27 AM, V9, R3's Power of Attorney (POA) stated that he was aware of the incident and was really surprised. V9 continued to state that R3 would not have been consensual to those activities with a man. V9 was told that the facility would check on the residents every 15 minutes. On 9/30/2020 at 11:50 AM, V6, TNA, stated that R4 is a 15-minute check and that anybody can perform these checks. V6 stated that she does not know where these checks are documented. On 9/30/2020 at 12:30 PM, V11, CNA, stated, I wasn't there for the 1st incident (in R3 and R4's room), but I witnessed the second incident in dining room. (R4) was sitting in chair by kitchen door, (R3) came up to (R4) and pulled his pants down. (R4) started giving him oral. I yelled 'Stop, no!' and (R3) pulled up pants and ran away. (R3) is pretty fast. I am not really sure if (R3) could consent. I know (R4) is in his right mind but he just doesn't like to talk to females. I did one on one with (R3) afterwards. (R3) would try to play with his private areas and I had to tell him that it was not appropriate. I don't know if he knows what he is doing. On 9/30/2020 at 2:00 PM, V2, Regional DON, stated that there was not a specific form that the checks were documented on. V2 and V3 stated that R4 was sent to the hospital and that he did not come back with orders to continue 15-minute checks. At this time, this surveyor located the order in R4's POS, indicating that the order was not discontinued. V2 stated it was a short-term solution and should have just been temporary. On 9/30/2020 at 5:36 PM, V13, Police Officer, stated that he went to the nursing home because a nurse saw two males residents performing oral sex. V13 continued to state that R4 was in the dining room and R3 walked up to him and pulled down his pants. V13 stated that someone from the facility had called the local police station on the Friday before this incident took place and that it was regarding these two residents being sexually inappropriate. V13 continued to state, I know it happened more than once. V13 stated the facility separated their rooms but, They still found each other. V13 stated, I feel like it shouldn't be going on in the facility, especially twice and that is why I called. The (local) Police Department Incident Report dated 9/13/2020, documents that the nurse witnessed R4 place his genitals in R3's mouth and that it has happened on multiple occasions. 2. R1's Face Sheet documents R1 has a [DIAGNOSES REDACTED]. R1's MDS dated [DATE] documents R1 has a BIMS score of 2, indicating R1 is severely cognitively impaired and is sometimes understood. On 9/29/2020 at 12:28 PM, V12 stated, (R1) and (R3) were roommates. (R1) had a [MEDICAL CONDITION] (TBI) and can't communicate well. (R1) screamed to communicate that (R3) was on his bed. (R1) pointed at (R3) and then pointed to his (R1's) bed. On 9/29/2020 at 10:24 AM, R2 (R1's current roommate) stated, A couple weeks ago I heard (R3) touched (R1) inappropriately and after that he (R1) didn't want anyone touching him or changing his diaper. It was like he felt violated. The nurse (unsure of which one) told me (R1) was going to be my roommate because he had to get out of that hall (400 hall). On 9/29/2020 at 11:39 AM, V10, Dietary Cook, stated, I heard (R3) walked into (R1's) room and touched him inappropriately. On 9/30/2020 at 12:30 PM, V11 stated, (R1's) screaming episode happened the same evening as the (R3) and (R4) thing. The verbal altercation took place in the evening time, sometime after 6. The incident with (R3) and (R4) happened around 5 in the dining room. On 9/29/2020 at 2:30 PM, R8 stated, (R3) and (R4) were caught s*****g each other. (R3) is a 'F****T' and that is why I don't want him as my roommate. On 9/30/2020 at 3:09 PM, V14, Social Service Director (SSD) stated, In the morning meeting (R1) was mentioned and it (the screaming incident) was brought up and that's why we moved him. (R1) can kind of talk but we don't know how cognitive he is. He (R1) just told nurse (no idea who) or staff that (R3) had tried to touch him. I don't know how he communicated that. It was in the room (R3) is in now. (R3) has dementia. (R3's) brother told me he is a wanderer. I tried to mention that it wasn't a good idea to put him in with (R1). (R8) did not want to be his (R3's) roommate. The Facility's Incident/Abuse Notification dated 9/13/2020 documents that on 9/13/2020, staff responded to a loud voice in R1's room. R1 yelled out towards R3. It continues to document that R1 was relocated to another area for the night with increased monitoring. This failure resulted in psychosocial harm as a reasonable person would react in a such a situation with feelings of fearfulness, humiliation, anxiety and distress. The Facility's Abuse Prevention Policy dated 11/27/2017 documents, Residents have the right to be free from abuse. The policy continues, The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse. The policy defines sexual abuse as non-consensual sexual contact of any type with a resident. On 10/1/2020 at 9:03 AM the Facility's policy regarding supervision was requested. No policy was provided.

Based on observation, interview, and record review, the facility failed to provide adequate nutrition for 2 of 5 residents (R8, R38) reviewed for gastrostomy tubes ([DEVICE]s) in the sample of 43. This failure resulted in R38 having a significant weight loss of 5.3 % in two weeks, and due to no additional interventions, R38 continued to lose weight, resulting in a significant weight loss of 8.3 % in 3 months. Findings include: 1. On 7/22/20 at 7:55 AM, R38 was lying in his bed, partially covered to the waist with a sheet. He had an emaciated appearance, with the bony prominences of his shoulders, elbows and knees easily evident. He had enteral nutrition formula, [MEDICATION NAME] 1.5, infusing at 55 milliliters (ml) per hour (hr) via his gastrostomy tube ([DEVICE]). The bottle of tube feeding hanging was dated 7/21/20 and was untimed. It had about 200 mls left in the bottle. There was dried tube feeding formula on the tube feeding pump and on the floor below the pump. On 7/22/20 at 11:26 AM, V25, Registered Nurse (RN), pulled R38's sheet back to uncover his [DEVICE] site, which did not have a dressing around it. V25 stated R38 should have a dressing around his [DEVICE] to protect it because he is a scratcher, and will dig at the skin around his [DEVICE] with his fingernails. R38's fingernails on both hands had dark brown debris under them, and they were long and uneven. On 7/23/20 at 8:05 AM, R38 had a different enteral nutrition formula, [MEDICATION NAME] 1.2, infusing at 55 mls/hr infusing per his [DEVICE]. On 7/24/20 at 9:55 AM, V6, Certified Nursing Assistant (CNA), and V26, CNA, used full body mechanical lift to raise R38 completely off his bed, removed his heel protectors so he was only wearing a gown, and weighed R38 with the scale on the mechanical lift, after the scale was zeroed. R38's weight was measured as 85.8 pds. V6 hit the weigh button a second time and got the same weight. R38's Progress Notes, dated 4/27/20 at 10:18 PM, document he was admitted to the facility on that date from an acute care hospital. He is N.P.O. (nothing by mouth) and he has [DEVICE] to his mid abdomen. He had [MEDICATION NAME] 1.2 @ 55 ml/hr infusing continuously with 100 ml water flushes every (q) 6 hrs. R38's Medical [DIAGNOSES REDACTED]. R38's Minimum Data Set (MDS), dated [DATE], documented he is severely cognitively impaired and dependent on staff for all Activities of Daily Living (ADLs), including eating. His MDS documents R38 has a feeding tube and he receives 51 % or greater of total calories per day via his [DEVICE]. R38's EMR (Electronic Medical Record) included the following weights: There was no admission weight until 12 days after he entered the facility. On 5/9/20 his initial weight was 99 pds; two weeks later on 5/23/20 his weight was 93.8 pds (5.3% weight loss); on 6/1/20 his weight was 93.6 pds, on 6/5/20 his weight was 93.8 pds; on 6/11/20 his weight was 96.2 pds; on 7/2/20 his weight was 98.4 pds, and on 7/27/20 his reweight was 90.8 pds (8.3% weight loss in two and a half months). R38's Initial Registered Dietician (RD) Assessment by V35, Registered Dietician, on 5/7/2020 at 9:53 PM, documented R38 is NPO and on continuous tube feeding and is receiving [MEDICATION NAME] 1.2 at 55 ml/hr and 100 ml flushes every 6 hours with no feeding intolerance noted. R38's feeding and flushes are providing a total of 1584 kcal, 73 g (grams) protein and 1465 mL fluids. The RD's assessment reviewed his labs from 4/24/20: Hgb 10.2 L (low), Hct 30.4 L, Na 142, K 3.1 L, magnesium 1.8, protein 6.2, [MEDICATION NAME] 2.7 L, BUN 3 L, Cr 0.5 L, calcium 8.4, phosphorus 3.2. V35 documented R38's height (ht) and weight (wt) taken on 4/18/20 per hospital record: ht 62 inches, Wt 114 pds, BMI 20.9-normal. Calories: 1560-1820 (30-35 kcal/kg); protein: 62 g (1.2 g/kg); fluids: 1560 mL (30 mL/kg). V35 recommended increasing R38's tube feeding to 60 mL/hr x 23 hours and flushing with 120 mL fluid every 6 hours. New orders will provide a total of 1656 kcal, 77 g protein and 1594 mL fluids. RD will monitor for tube feeding. V35's tube feeding/weight note on 5/22/2020 at 1: 23 PM documented: (R38) was just weighed and new weight reported to be 93 pds, reflecting a 6 pd weight loss (6.1%) x 2 weeks. Significant. RD (V35) spoke with the nurse who said that resident is currently getting the [MEDICATION NAME] 1.5 at 55 mL continuous to substitute for the [MEDICATION NAME] 1.2 at this time. RD will recommend continuation of the [MEDICATION NAME] 1.5 at 55 mL since the 1.5 is more calorie concentrated. If resident is on the 1.5 for awhile, weight gain likely to occur. Run at 55 mL x 23 hours daily and flush with 125 mL water every 4 hours. New orders will provide a total of 1898 kcal (45 kcal/kg), 80 g protein (1.9 g/kg) and 1711 mL fluids (40 mL/kg). RD will monitor. V35's RD weight/tube feeding note on 6/25/2020 at 8:26 PM documented, (R38) is on the [MEDICATION NAME] 1.2 at 55 mL continuous. No tube feeding intolerance noted. Weight 6/11 96.2 pds, 6/5 93.8, 6/1 93.6 pds. Resident was reported to have a weight loss on 5/22 when he weighed in at 93 pds. See RD note 5/22. He is up 3.2 pds x 3 weeks-favorable. Current feeding and flush (100 mL flush every 6 hours-see 5/7 RD assessment) is providing 1584 kcal, 73 g and 1465 mL fluids. No labs in PCC (Electronic Medical Record) available to review at this time. Since resident recently had a weight loss, RD will recommend increasing feeding rate to ensure weight gain continues. Will recommend running [MEDICATION NAME] 1.2 at 65 mL x 23 hours daily and flush with 150 mL every 6 hours to provide a total of 1794 kcal, 83 g, and 1806 mL fluids. RD will monitor. On 7/24/20 at 9:15 AM, R38's Physician order [REDACTED]. There were no changes to R38's tube feeding orders since his admission to include changes recommended by V35. On 7/23/20 at 9:00 AM, V2, Director of Nursing (DON), stated she found a dietary recommendation from 6/25/20 for R38 and was going to give it to V36, Nurse Practitioner (NP), to look at. She stated the Registered Dietician emails her recommendations to the DON, who gives them to the MD (medical doctor) or NP. She stated she does not know where any of R38's other recommendations from the RD are, or why they were not followed up on. At 9:25 AM, V2 stated V36 was agreeable with the recommendation from 6/25/20 and R38's tube feeding is now [MEDICATION NAME] 1.2 to infuse at 65 ml/hr for 23 hours a day. On 7/23/20 at 10:25 AM, V36 stated she had not been given any dietary recommendations for R38 until she was given the recommendation from 6/25/20 this morning from V2. V36 stated she did not know what the difference between [MEDICATION NAME] 1.5 and [MEDICATION NAME] 1.2 is because she is not a dietician and that writer would need to call the dietician and ask her. V36 stated she had never disagreed with any dietary recommendations she has reviewed from a Registered Dietician before. On 7/24/20 at 10:15 AM, V2, DON stated that R38's weight of 85.8 pds would be a big weight loss for him and it is the facility's policy to get a reweight, but she did not want to have the same CNAs weigh him .she would have someone else do it later. On 7/28/20 at 8:42 AM during a phone interview, V2 stated R38's reweight was done on 7/27/20 (three days after he was weighed at 85.8 pds) and his reweight was 90.8 pds. She stated the facility does not have a specific weight or weight loss policy. She stated she has requested the MD see R38 on his weekly rounds to address weight loss. 2. R8's Electronic Medical Record documents her [DIAGNOSES REDACTED]. R8's Admission Physician Orders, dated 4/5/20, does not include any order for type of tube feedings, rate or flushes. R8's Progress note, dated 4/7/2020 at 1:51 AM, documents R8's tube feeding is infusing at [MEDICATION NAME] 1.5 @ 60 ml/hr running continuously. On 4/8/2020 at 11:48 AM, R35's INITIAL RD ASSESSMENT documented: NPO (Nothing by mouth). NKFA (No known food allergies [REDACTED]. DX (diagnosis): [MEDICAL CONDITION], transient cerebral attack, [MEDICAL CONDITION] and [MEDICAL CONDITION] affecting left non-dominant side, [MEDICAL CONDITIONS], cerebral infarction, acute [MEDICAL CONDITION], NSTEMI (a type of [MEDICAL CONDITION]), gastrostomy status, hypo-osmolality and [MEDICAL CONDITION], vitamin D deficiency, HTN, [MEDICAL CONDITION], GERD, constipation, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], dysphagia, anorexia, pneumonia, pressure ulcer of sacral region-stage III. Meds: aspirin, MVI/minerals, eliquis, lactobacillus, [MEDICATION NAME], vitamin D3. Labs 4/3/20: Na 150 H, K 3.7, BUN 15, Cr 0.58, glucose 118 H, GFR >90, calcium 7.6 L, Hgb 8.8 L, Hct 31.3 L. Stage III pressure ulcer on sacrum per Initial Skin Alteration Record 4/6/20. Ht 65 in, Wt 130.0#, BMI 21.6-normal. [MEDICAL CONDITION] +1 pitting to RUE (right upper extremity) per nursing note 4/7/20. Calories: 1770-2065 (30-35 kcal/kg); protein: 77 g (1.3 g/kg); fluids: 1770-1947 mL (30-33 mL/hr). Increased protein needs raises fluid needs. Current tube feeding provides a total of 2160 kcal, 92 g protein, 2594 mL. Will recommend running [MEDICATION NAME] 1.5 at 45 mL x 23 hours daily, flush with 180 mL every 4 hours. Give 30 mL liquid protein TID (three times daily). Feeding, liquid protein and flushes will provide a total of 1852 kcal, 111 g protein, and 1866 mL fluid. Will provide a total of 2070 kcal, 88 g protein 2128 mL fluids. Meets 100% kcal, 144% protein and 100% fluid needs. RD will monitor. Review of R8's Physician order [REDACTED].@ 60 ml/hr and no liquid protein was ordered. R8 was hospitalized from [DATE] to 4/28/20. Her readmission orders [REDACTED]. On 5/13/2020 at 6:36 PM, R35 documented : READMISSION RD ASSESSMENT: resident continues on the [MEDICATION NAME] 1.2 at 60 mL/hr continuous. Flush orders not available in PCC for review. Tube feeding currently providing a total of 1728 kcal, 80 g protein and 1162 mL fluids. RD spoke with nursing over the phone today (working offsite d/t COVID-19 restrictions) and there were concerns over residuals since resident has a hx (history) of this. Resident is NPO, NKFA. Family concerned over swollen tongue per nursing note 5/5/20. DX: [MEDICAL CONDITION]. cerebral infarction, [MEDICAL CONDITION] and [MEDICAL CONDITION], NSTEMI, gastrostomy status, hypo-osmolality and [MEDICAL CONDITION], vitamin D deficiency, HLD, GERD, AMS, constipation, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], UTI, dysphagia, anorexia, stage III pressure ulcer of sacral region. Med list taken from discharge orders dated 4/28/20: 1 packet protein supplement, MVI with minerals, eliquis, lactobacillus, [MEDICATION NAME], vitamin D3, [MEDICATION NAME] sulfate, [MEDICATION NAME]. No labs to review at this time. Wt 130.0 pds, Ht 65 inches, BMI 21.6-normal. Stage III pressure ulcer on coccyx per Initial Skin Alteration Record 4/28. No [MEDICAL CONDITION] noted. Calories: 1770-2065 (30-35 kcal/kg); protein: 77 g (1.3 g/kg); fluids: 1770-2065 mL (30-35 kcal/kg). Recommend running [MEDICATION NAME] 1.2 at 45 mL x 23 hours, give 30 mL liquid protein TID, and flush with 250 mL every 4 hours. These orders will provide a total of 1542 kcal, 102 g protein and 2335 mL fluids daily. RD will monitor. Review of R8's Physician order [REDACTED]. On 6/12/2020 at 4:31 PM, V35 documented: the DON contacted this RD earlier to say that the nurse practitioner ordered RD consult regarding her skin breakdown. Current orders for 60 mL/hr [MEDICATION NAME] 1.5 provide a total of 92 g protein-see RD assessment 6/11/20. Will recommend adding 30 mL Prostat once daily for an additional 100 kcal and 15 g protein. Will receive a total of 2260 kcal and 107 g protein daily. Continue MVI with minerals-noted to have an order for [REDACTED]. Review of R8's Physician order [REDACTED]. No Prostat was ordered during that time. On 7/28/20 at 2:50 PM, during a phone interview, V1, Administrator, stated he would expect residents to be weighed soon after they were admitted to the facility to get a baseline weight, but since that is clinical, he does not know the actual time frames during which it should be done. V1 stated residents should be weighed monthly thereafter. On 7/29/20 at 1:30 PM, V35, Registered Dietician, stated she had recommended R8 be given liquid protein 30 milliliters (ml) three times a day when she first assessed her because she was trying to ensure she get the adequate nutrition to maintain her health and to assist with healing her current pressure ulcers and prevent additional skin impairment. V35 stated the nurses had reported to her that they were getting residuals when checking R8's gastrostomy tube, and this could cause decreased calories and nutrition. She stated the liquid protein may not have brought or kept [MEDICATION NAME] level within normal range, but it certainly would have helped, and may have helped wound healing. On 7/29/20 at 2:31 PM via email, V1 stated he is unable to locate any dietary recommendations for R8. The Facility's Policy, Enteral Tube Feeding via Continuous Pump revised January 2020, documents, The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. The Facility's Policy,5.5 Enteral Tube Medication Administration dated December 2017, documents, Procedure: The selection of the enteral formula, equipment, route of administration and rate of flow is determined by the physician based on the nursing assessment of the resident's condition and approval by the physician. The facility dietician and consultant pharmacist may provide consultation for this assessment.

Based on record review and interview the facility failed to maintain an environment free of clutter to prevent falls for one of 3 residents (R2) reviewed for falls in the sample of 15. This failure resulted in R2's fall from tripping over roommates belongings, hitting his head on headboard and sustaining a [MEDICAL CONDITION] frontal sinus and orbit. Findings include: R2's Initial Minimum Data Set (MDS), dated [DATE], documents that R2 is cognitively impaired, and requires limited assistance and one person physical assistance for bed mobility, transfers, and locomotion. R2's admission fall risk assessment, dated 9/5/19, documents a score of 16 high risk for falls with any score greater that 10 as high risk for falls. R2's Fall Risk Assessment, dated 9/13/19, documents a score of 19. R2's Transfer/Discharge sheet dated 9/5/19 documents a [DIAGNOSES REDACTED]. R2's Initial Baseline Care Plan, dated 9/5/19, documents R2 is visually impaired, walks independently, and has a history of falls. The Care Plan does not address the need to keep the environment free of clutter and tripping hazards. R2's Incident Report, dated 9/13/19 at 5:15 AM, documents that the nurse entered R2's room to apply pain patch, when she pulled back the covers dried blood was noted to R2's face and on bed linens. The report documents noted laceration to area above right eye, into the brow region, small areas to outer aspect of right eye, lower aspect, 0.3 noted bruising, to right cheek 2 CM X 1.8 CM. R2's incident report documents trip hazard and clutter as predisposing factors. The facility Investigation Conclusion completed by V2, Director of Nursing (DON), documents R2 is legally blind, resident's belongings thrown all over room, dried blood noted to headboard. Concluded that resident tripped over roommate's belongings causing him to hit head on headboard. R2's Nurse's Notes, dated 9/15/19 at 5:50 AM, documents reddish purple discoloration to right eyelid. Steri- strips intact to right eye. R2's Nurses notes, dated 9/16/19 at 2:50 AM, documents R2 continues to have reddish purple discoloration to right eye. This is the only nursing documentation in R2's clinical record in regards to injury. A CT report from when R2 was sent out to the hospital for behavior on 9/18/19 documents a minimally displaced [MEDICAL CONDITION] wall the right fontal sinus, with some extension into the superior aspect of the right orbit roof which appears recent. On 11/14/19 at 1:22 PM, V2, Director of Nursing (DON), stated that R2's room was cluttered because R15 (roommate) was moving out the next day. V2 stated there was stuff everywhere. V2 stated the facility should have had interventions in place for fall prevention, since R2 identified as high risk for falls and a history of falls. The Facility's Fall Management policy and procedure, dated as reviewed 2019, documents, It is the policy to have a Fall Prevention Program to assure the safety of all residents in the facility. It continues, Under Standards: 3. Safety interventions will be implemented for each resident identified at risk using a standard protocol. It further documents, Under Standard Fall/Safety precautions: All Residents, 5. The residents environment will be kept clear of clutter which would affect ambulation and remove hazards.

Based on observation, record review and interview the facility failed to provide supervision and interventions to prevent falls, and assess siderails for accident hazards for 3 of 13 residents (R18, R51, R63) reviewed for falls/accidents in the sample of 34. This failure resulted staff leaving R51 alone on the side of the bed, R51 falling and sustaining a displaced nasal fracture. Findings include: 1. On 12/18/2018 at 9:04 AM, R51 was seated in a wheelchair. R51 refused to answer or respond. A fall mat was on the floor next to the bed. There were no siderails on the bed. The physician's orders [REDACTED]. R51's Minimum Data Set ((MDS) dated [DATE], documents R51 has a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. The MDS documents R51 requires extensive assistance of one staff for transfers, and has unsteady balance with limited range of motion for upper and lower extremities. R51's Fall Risk Evaluation, dated 4/8/18, score is 10, indicating high risk. The facility's Fall Log for 11/2018 documents R51 fell from the bed on 11/04/2018. The facility's investigation of the fall for R51, dated 11/04/2018 at 7:27 AM documents, in part, Resident reported sitting on side of bed this AM getting dressed. The assistant turned to get the resident's bra. The resident fell forward. Resident encountered a nose bleed and a bruise to the bridge of the nose. Assessed resident as she is lying on floor. Resident lifted per bed by nurse and assistant. A cool wet cloth was used to clean the face. Examined mouth to ensure no broken teeth, face and head examined for any cuts, or bruises. Body examined overall for any possible breaks, scratches or bruises. Injury type-Abrasion, Injury location-face, Injury type-bruise. The Investigation Conclusion for R51, dated 11/04/2018, documents, in part, Alert and oriented X 1. Requires assist of 1-2 staff for all ADL's (activities of daily living). Dependant on staff with mobility through building. Plan of Action to Prevent Reoccurrence: Staff education to ensure all items and supplies are collected prior to the start of care. Staff also educated to maintain close proximity to assist with balance. R51's X-ray report, dated 11/04/2018, documents a Mildly displaced nasal fx (fracture), 2 mm (millimeter) of displacement. On 12/19/18 at 9:09 AM, V19, R51's Power of Attorney, stated, She (R51) has a tendency to lean to the side. If she is sitting straight up, she will lean forward. She needs support. You don't just turn or walk away. I was really upset about that. On 12/19/18 at 9:30 AM V18, Certified Nurse's Aide, (CNA) stated, I was used to getting her up every morning and sat her on the side of the bed. I sat her up and sat her on the side of the bed. She pointed at something. Her bra was in the drawer. I turned around and got it from the drawer of the bedside table. Then she fell . She has good and bad days. I guess she was having a bad day. I have walked away before and she was fine. I yelled at the nurse, (V24, Registered Nurse). (R51) was on the floor and was bleeding. When we turned her over she said she was all right. She had no loss of consciousness. Me and the nurse picked her up and put her in bed. She was bleeding pretty good. They said they were going to get an X-ray. On 12/19/18 at 9:44 AM, V20, Physician, stated, Mostly when I see her (R51) she is in a chair or in bed. Look at the Physical Therapy assessment and see what they think as well. By definition, if she's had a stroke her balance is off. Talk to the Aide as well. On 12/19/18 at 9:53 AM, V23 Physical Therapy Aide stated, She needs someone with her for maximum assistance 75% (per cent) of the time, and 25%, she will need CGA (contact guard assistance). She's very weak, unmotivated and requires a lot of encouragement. She previously used a geriatric chair. She can walk with moderate assist of 2. She leans to the right when sitting. R51's Physical Therapy Evaluation, dated 11/03/18 through 1/28/19, documents, in part, Diagnoses-Age-related [MEDICAL CONDITION] without pathological fracture, abnormal posture, muscle weakness, unspecified lack of coordination. Sitting balance, static sitting poor, unable to maintain balance/requires moderate/maximum support. Standing balance=Poor (requires maximum assist and UE (upper extremity) support to maintain stand without balance loss. A Progress Note from V16, Nurse Practitioner (NP) dated 11/06/2018, documents, in part, Chief complaint: Fall. Reported patient fell from bed. Most recent fall resulted in an injury. Patient reports falling once every couple of months. R51's Care Plan, 12/18/2018, documents, in part, (R51) is a high risk for falls related to unaware of safety needs, confusion, wandering, incontinence mobility and unsteadiness on feet, requiring staff assistance to stabilize, She requires extensive assistance for sit to stand and transfers. Has a history of falls, sustaining fractures. (R51) has exhibited poor sitting posture, leaning over to the right and unable to sit safely in her wheelchair. Interventions/Tasks-11/04/2018 staff education to not leave resident unattended during care. 2. The facility's Fall logs documents R18 had two falls on 9/06/2018. The Incident/Accident Report, dated 9/06/2018 at 6:10 PM documents, in part, Staff heard loud crash from adjacent room. Found resident on the floor next to bed lying on right side. Alert with noted confusion from earlier [MEDICAL CONDITION] activity. Resident has active [MEDICAL CONDITION] disorder, benign neoplasm of cerebral meninges, [MEDICAL CONDITION] with [DIAGNOSES REDACTED]. Concluded that resident (R18) had second [MEDICAL CONDITION] from his bed. No injuries noted. Plan of Action to Prevent Reoccurrence: Resident medicated for [MEDICAL CONDITION] activity, bed placed in lowest position with mat on floor next to bed. The Incident/Accident Report, dated 9/6/2018 at 7:00 PM, documents, in part, CNA noted during rounds resident was on the mattress on floor. During staff rounds, CNA staff noted (R18) lying on mat next to bed. Active [MEDICAL CONDITION] activity noted. Conclusion is that resident's [MEDICAL CONDITION] activity caused him to roll off the bed onto mattress on the floor. Plan of Action to Prevent Reoccurrence: 1:1 staff monitoring resident through the night. Resident and family educated that for safety reasons related to [MEDICAL CONDITION] activity, resident for the night is to sleep on the mattress on the floor next to his bed. [MEDICATION NAME] [MEDICATION]) level ordered for next AM. MD (medical doctor) to audit medication on next visit. On 12/14/18 at 10:46 AM, R18 was in bed asleep. There were 2 half, non-padded siderails raised on the bed. The bed was in the raised position. There was no fall mat or mattress on the floor next to the bed. The bed was against the wall. R18's Fall Risk Evaluation, dated 4/5/18, documented a score of 12, (10 or above =high risk). On 12/18/18 at 8:57 AM, R18 was in bed with 2 unpadded half siderails up. The bed was in raised position. There was no fall mat or mattress on the floor next to the bed. R18's Care Plan, dated as revised 11/06/18, documents, in part, (R18) has [MEDICAL CONDITION] disorder related to [DIAGNOSES REDACTED] and takes anti-epileptic medications. His [MEDICAL CONDITION] tend to occur at night and will cause him to fall out of bed. He has one side of the bed pushed up against the wall and a fall mat or mattress on the floor on the other side for safety purposes. (R18) is a high risk for falls related to [MEDICAL CONDITION], requires assistance for transfers history of falls, [MEDICAL CONDITION] disorder and medication use. Interventions-11/06/18-Bed placed in lowest position, floor mat put on floor next to bed. Resident utilizes mini-siderails to left and right side of bed for bed mobility and positioning. On 12/19/2018 at 10:00 AM, V2, Director of Nursing (DON) was asked why R18's siderails were not padded and why there was not a fall mat on his floor. V2 responded, I don't know. 3. The MDS, dated [DATE], documents R63 has a BIMS score of 14-cognitively intact and requires extensive assistance of 2 staff with bed mobility and transfers. On 12/12/18 at 10:47 AM, R63 reported recently fell and hit his head and was sent to the ER (emergency room ). R63 reported he transferred himself and his wheelchair was not locked. Per resident. R63 stated, I know I should wait for help. I won't do that anymore. I use the siderails to help myself. Look how loose that one is. R63 pointed to the siderail on the right side of the bed. The padded half siderail to R63's right side was very loose with a large gap posing an entrapment risk. The left siderail was loose without a gap. The gap between the bottom of the right siderail and the mattress measured 2 1/2 inches. The gap between the middle of the siderail and the mattress measured 3 1/4 inches. The gap between the top of the right siderail and the mattress measured 5 inches. The siderail was unstable and moved back and forth easily. On 12/14/18 at 12:47 PM, V8, CNA used a gait belt and transferred R63 to bed from the wheelchair to bed. R63's Care Plan, dated 11/15/2018 documents he is a high risk for falls related to impaired mobility, [MEDICAL CONDITION] and wounds to bilateral heels and osteo[DIAGNOSES REDACTED] of the left heel. The Care Plan documents R63 requires a 2 person assist for transfers. The Physical Therapy Evaluation and Plan of Treatment, dated 11/3/2018 documents, in part, Diagnoses-Acute hematogenous osteo[DIAGNOSES REDACTED], Generalized muscle weakness, abnormalities of gait and mobility, unspecified lack of coordination. Pt. (patient) presents with decreased bed mobility, decreased transfers and decreased balance. Fall risk. On 12/18/18 at 2:09 PM, V17, Regional Nurse stated, We checked it. The bolt was loose. We fixed it. V17 Reported she can't find the R63's side rail assessment. V17 reported V13, Maintenance Director is responsible for checking the siderails. The facility's policy and procedure, revised 3/2015 and entitled, Fall Management documents, in part, It is the policy of the facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Facility staff are responsible for assuring ongoing precaution are put in place and consistently maintained. Transfer conveyance shall be used to transfer resident in accordance with the care plan.

Based on observation, interview and record review, the Facility failed to ensure residents environment remains free of accident hazards by allowing residents with oxygen in the beauty shop near flammable hair chemicals and hair dryers. This has the potential to affect all of the 109 residents living in the Facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 3/10/15 at 11:35 AM, the Facility remains out of compliance at Severity 2 as the facility continues to educate staff and evaluate and monitor the effectiveness of the Facility Policy and Procedure for Oxygen Administration and Oxygen Safety. Findings include: 1. Facility Policy and Procedure of 3/2004 for Oxygen Administration documents, "Remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles etc.) from the immediate area where the oxygen is to be administered...Instruct the resident, his/her family, visitors and roommate (if any) of the oxygen safety precautions. Provide the resident with a written copy of the Oxygen Safety handout located in Appendex A." Facility Oxygen Safety Policy and Procedure of 2001 documents, "For your safety and the safety of those around you, please observe the following safety precautions during your oxygen therapy!...Do not use flammable materials near oxygen. These include lotions, alcohol, oils, grease, nail polish remover, etc." On 3/10/15 at 11:30 AM, R17 was observed in the beauty shop sitting in her wheel chair with an Oxygen tank and receiving Oxygen per nasal cannula. E4, Beautician, was cutting and blow drying R17's hair. At 11:35 AM, E1 Administrator and E2, Director of Nursing (DON), were informed of R17 being in the beauty shop with Oxygen. E2 ran and removed the Oxygen from R17 with R17's permission and instructed E4 that Oxygen was not allowed in the beauty shop. E4 was blow drying R17's hair at the time. E1, came into the beauty shop and stated R17 was a new resident and it was not facility policy to have oxygen in the beauty shop. On 3/10/15 at 12:20 PM, there were multiple aerosol cans of hair spray, finishing spray, and hair fix spray that labels had documentation, Warning flammable, avoid heat, fire, flame and smoking during use and until hair completely dry. There was an aerosol can of hair shine and texturing spray that documents, Warning: Flammable, do not use by fire, heat or smoking. Keep away from sources of ignition such as; any object that sparks. There was a bright pink sign on the wall of the beauty shop that documents, "No oxygen tanks at any time." E4 stated the sign was there when she started working at the facility. E1 stated E4 had been at the Facility for about 7 months. 2. The Resident Census and Conditions of Residents, CMS 672, dated 3/9/15 documents that the facility has 109 residents living in the Facility. The Immediate Jeopardy began on 3/10/15 at 11:35 AM when R17 was in the beauty shop with oxygen being administered and chemical nearby. E1 and E2 were notified of the Immediate Jeopardy on 3/10/15 at 4 PM. On 3/11/15 the surveyors determined through observation and record review that the facility took the following action to remove the Immediacy: 1. E2, removed R17's oxygen from the beauty shop on 3/10/15 at 11:35 AM and told E4 they could not have oxygen in the beauty shop. 2. E4 was inserviced on 3/10/15 at 12:40 AM by E1 about not having any type of oxygen delivery in the beauty shop. 3. On 3/10/15 staff were educated on Oxygen Administration Policy, specifically not allowing residents receiving oxygen to enter the beauty shop. Completion date 3/11/15. On 3/10/15 Residents and/or family members of residents receiving oxygen were educated on the facility oxygen administration policy with a focus on the safety requirements and prohibition of oxygen use in the beauty shop. Completion Date 3/11/15. 4. On 3/10/15, the Medical Director was notified of immediate jeopardy at 4:50 PM. 5. On 3/11/15 Facility oxygen administration policy was reviewed and revised. 6. E2 or Designee will perform random observations of beauty shop during open hours which is one business day per week for 12 weeks, to assure compliance and understanding of safety requirements. Results of the reviews will be discussed in the Quarterly Quality Assurance Meeting for 3 quarters with educational needs discussed as needed. B. Based on observation, record review and interview, the Facility failed to provide adequate supervision and safe transfers to prevent injuries for 3 of 11 residents (R1, R12, R14) reviewed for falls and fall prevention in the sample of 22 and one resident (R24) in the supplemental sample. Findings include: 1. On 03/08/15 at 11:30 AM during tour of the 100 Hall, R1 was in her bed. R1's wheelchair was on the right side of her bed with a black cushion on top of a non-skid pad (Dycem) that was smashed and folded on one edge. At 1:00 PM, R1 was observed sitting in the wheelchair with her bottom on the cushion at a dining table during the lunch dining service. On 03/11/15 at 2:00 PM, R1 was in her bed and her wheelchair was out in the hall. E16, Activity Director confirmed that R1's wheelchair had a cushion on top of the non-skid pad. The Minimum Data Set (MDS), dated [DATE], documents R1 has severe cognitive impairment with both short and long term memory deficits and requires extensive assistance of at least one staff for bed mobility, transfers, dressing, hygiene and toilet use. It also documents that R1 had only had one fall since last review and R1 did not have any restorative programs or therapy. It also documents R1 was frequently incontinent of both bowel and bladder. The Care Plan, dated 10/23/14, documents R1 had impaired cognition related to Dementia and Alzheimer's Disease, has a self care performance deficit and a high risk for falls due to being unaware of safety needs and confusion. The interventions listed, in part, were to educate on use of call light and be sure call light is within reach, wait for staff for assistance, non-skid pad (Dycem) to wheelchair, keep in view of staff and therapy. The Fall Risk Assessment, dated 10/21/14, documents R1 as a high risk for falls. On 07/14/14 at 8:00 AM, an Incident/Accident Report documented R1 was found lying on the bathroom floor on her back. It documents R1 sustained a 1 centimeter (cm) laceration to the back of the right hand. It documents R1 was alert with confusion. It documents additional steps taken to prevent recurrence as "Resident educated to wait for staff assistance and use call light. A Post Fall Investigation, dated 07/14/14, documents an alarm was not present, i.e. bed/wheelchair alarm. On a Fall Prevention Interventions sheet, wheelchair alarm, call bell within reach and visible, answer call light promptly, remind resident to request assistance and put in a supervised area was added. On 07/18/14 at 11:00 AM, an Incident/Accident Report documented R1 "slid out of wheelchair, sustained abrasion to right knee. Resident holding on to hand rail while propelling self and pulled self out of wheelchair." It documented R1 was alert with confusion. The additional steps to prevent recurrence documented "Dycem to wheelchair." The Fall Prevention Investigation listed, in part as, visually check resident every two hours, or more frequently as determined by care team, chair alarm, answer call light promptly and remind resident to ask for assistance. On 07/26/14 at 6:00 PM, an Incident/Accident Report documents R1 "stood up from wheelchair in dining room." The additional steps to prevent recurrence document "Dycem to wheelchair." The Fall Prevention Investigation listed, in part as, toilet every one to two hours, assistance with all transfers, remind resident to ask for assistance and reorient to call light. On 09/14/14 at 2:15 AM, an Incident/Accident Report document R1 "going to bathroom, came back slipped on floor." It documents R1 sustained an abrasion to the right elbow. It also documents R1 was alert with confusion. The additional steps to prevent recurrence were "every one hour toileting and attempt to wear gripper socks at all times." A Nurse's Note, dated 09/14/14, documents R1 was "Instructed on proper way to use call light and wait for assistance and to keep bedroom door open when in bed. Resident voiced understanding but unable to properly demonstrate use of call light." The Fall Prevention Interventions were listed, in part as, instruct to call for help and call bell within reach, answer call light promptly and visible and put in supervised area. On 09/27/14 at 6:30 AM, an Incident/Accident Report documents R1 "patient wheeled self to the dining room. And was later observed by staff sitting on the floor." It documents R1 was disoriented and had no injury. The additional steps to prevent recurrence were "attempt to keep patient in view of staff when up in wheelchair." The Fall Prevention Interventions were listed, in part as, instruct to call for help and call bell within reach, answer call light promptly and visible and put in supervised area. On 10/15/14 at 5:00 PM, an Incident/Accident Report documents R1 "sitting in wheelchair with feet propped up on bed, slid out of wheelchair onto floor on buttocks." It documents R1 was alert with confusion and sustained a laceration to the left middle finger of the left hand. The additional steps to prevent recurrence were listed as "place at nurses station at meal times to monitor; place Dycem in wheelchair." The Fall Prevention Interventions were listed, in part as, remind the resident to ask for assistance, reorient to call light, answer call light promptly, every 15 minute checks, remind resident to request assistance and keep call light within reach. On 10/21/14 at 4:00 PM, an Incident/Accident Report documents R1 "was being transferred from bed to chair, gait belt buckle caught the arm." It documents R1 sustained a 1 inch skin tear to the left arm. The additional steps taken to prevent recurrence were listed as "attempt to have resident wear long sleeves when up." On 10/25/14 at 12:30 PM, R1's Incident/Accident Report documents "Resident found sitting on bathroom floor on buttocks, alarm sounding, no injury." The additional steps to prevent recurrence listed were "hourly toileting until auto locks can be installed." The Post Fall Investigation, dated 10/25/14, documents "slid out of wheelchair-moved." The Fall Prevention Interventions were listed, in part as, remind the resident to ask for assistance. Reorient to call light, toileting program, keep call light within reach, answer call light promptly, non-slip footwear and wheelchair alarm. On 10/29/14 at 12:00 AM, an Incident/Accident Report documents R1 "trying to go to bathroom." It documents R1 was alert and oriented with confusion at times and no injuries. The additional steps taken to prevent recurrence were listed as "mat to floor by bed, physical therapy to evaluate and gripper socks in bed." The Fall Prevention Interventions were listed, in part as, ask the resident every one to two hours if she needs to use the bathroom, visually check the resident every two hours or more frequently, bed/chair alarm, remind resident to request assistance, keep call light within reach, answer call light promptly and non-slip footwear. On 11/22/14 at 5:30 PM, R1's Incident/Accident Report documented "Resident found on floor by special care exit door." It documents R1 was alert and oriented x 1 and sustained injuries to the back of the head and right elbow. The additional steps taken to prevent recurrence were listed as "attach alarm out of residents reach." The Post Fall Investigation documents R1 had taken off wheelchair alarm then attempted to get up unassisted to go to the bathroom. The Fall Prevention Interventions were listed, in part as, ask the resident every one to two hours if she needs to be toileted, remind resident to ask for assistance, reorient to call light, visually check the resident every two hours or more frequently, bed/chair alarm, keep call light within reach, answer call light promptly and non-slip footwear. On 12/03/14 at 4:40 PM, an Incident/Accident Report documents "sitting in wheelchair in doorway of her room. R1 fell forward out of her wheelchair. She hit her head on floor. She was found laying in the doorway with her head in hallway." It documents R1 was confused and sustained a laceration over the right eye and was sent to the emergency department. The additional steps taken to prevent recurrence were listed as "attempt to keep resident in view of staff when up in wheelchair." The Post Fall Investigation, dated 12/03/14, documents R1 had removed the wheelchair alarm clip from her shirt prior to falling. The Fall Prevention Interventions listed, in part as, ask resident every one to two hours if she needs toileted, remind resident to ask for assistance, reorient to call light, answer call light promptly, visually check resident every two or more frequently, non-slip footwear and wheelchair alarm. On 02/05/15 at 4:00 PM, R1's Incident/Accident Report documents "resident found by (CNA) lying on floor with a bloody nose and lip bit with blood on lip." It documents R1 sustained injuries to her nose, lip, left elbow and right forearm. The additional steps taken to prevent recurrence were listed as, "DON notified, neuro checks initiated and raised edge mattress." The Post Fall Investigation, dated 02/05/15, documents R1 had rolled out of bed and missed the mat on the floor. It documents the side rails were not up and the bed alarm had not sounded at the time of the fall. The Fall Prevention Interventions were listed, in part as, answer call light promptly, remind the resident to ask for assistance, reorient to call light, visually check the resident every one to two hours or more frequently, check battery on all alarms, night light, call bell within reach and visible and low mattress. On 02/27/15 at 8:30 AM, R1's Incident/Accident Report documents, "called to 100 Hall. Noted resident laying on hallway floor in front of wheelchair. Noted laceration forehead 1 cm x 0.2 cm x 0.1 cm. wheelchair alarm sounding." It documents R1 was "alert with periods of confusion, minimal amount serosanguinous drainage. Left knee abrasion 1 cm x 1.2 x 0.1 cm area red with scant serosanguinous drainage. Range of Motion (ROM)done without difficulty. Resident assisted up x two to wheelchair and returned to bed. Resident denies any complaint of pain. Resident stated she fell from wheelchair while propelling wheelchair with feet." The additional steps taken to prevent recurrence were listed as "therapy to evaluate and treat." On 03/02/15 at 1:00 PM, an Incident/Accident Report documents, "called to residents room per CNA, unwitnessed per CNA. Resident slid to floor from wheelchair did not hit head. Resident found sitting on buttocks on floor in from of wheelchair. Wheelchair alarm sounding." It documents, "ROM done without difficulty. Upon assessment noted two small areas to lower back, 0.3 cm x 0.1 cm x 0.1 cm and 0.2 cm x 0.1 cm x 0.1 cm. Red/pink, no drainage, no odor. Resident denies any complaint of pain. Resident assisted up to bed x two staff members, bed alarm intact. Call light within reach." The additional steps taken to prevent recurrence were listed as "therapy to evaluate and treat 02/27/15." The Fall Prevention Interventions listed, in part as, remind resident to ask for assistance, reorient to call light and resident to be more visible to staff when up in wheelchair. The policy and procedure, titled "Fall Management" documents under "Policy: It is the policy of the facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assuasive devices are utilized as necessary." And under, "Standards: #4...Facility staff are responsible for assuring ongoing precautions are put in place and consistently maintained." On 03/13/15 at 12:20 PM, E2 acknowledged that R1's interventions were repetitive and ineffective, and stated that she felt that the facility had tried everything they could think of to prevent R1 from continuing to fall. 2. R12's Minimum Data Set (MDS), dated [DATE] and 1-21-15, documents diagnosis, in part as [DIAGNOSES REDACTED], severe cognitive impairment, total dependence of two plus persons physical assistance with mobility and transfer and upper and lower extremity functional limitation in range of motion. R12's Incident/Accident Reports, dated from 4-28-2014 to 3-9-2015, documented the following incidents: On 4-28-2014 at 10:30 PM, R12 received a 4.0 cm x 2.0 cm and multiple scratches 0.5 cm x 6.0 cm from rubbing his unpadded arm on his wheel chair: On 5-2-1014 at 7:30 AM, R12 received a 0.9 cm x 0.5 cm x 0.1 cm skin tear on his left upper posterior thigh from his adult diaper which unidentified staff were instructed not to use while he was in bed; On 6-18-2014 at 8:15 AM, R12 received a 5 inch long abrasion to the top of his head during care after which unidentified staff where educated to use safety while providing him care; On 1-10-2015 at 1:30 PM, R12 received a 1.0 cm x 1.0 cm skin tear on the outside of his left knee while he was being transferred with a mechanical lifting device: and, On 2-17-2015 at 7:15 AM, R12 incurred a 0.2 cm x 0.1 cm x 1.0 cm skin tear on his left elbow while he was being turned during showering. R12's Care Plan, dated initiated 10-16-1014, documents R12 was at risk for falls related to his lack of safety awareness and that he was at risk for impairment to skin integrity related to fragile skin. R12 requires total assistance with transfers, to provide padding during transfers and to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. 3. R24's MDS, dated [DATE], documents severe cognitive impairment and extensive assistance of two plus persons physical assist with mobility and transfer. R24's Care Plan, revision date 10-22-2014, documents R24 was at risk for falls related to history of falls. R24 has a communication problem related to hearing deficit and to reapproach her at a later time when she becomes frustrated and agitated. During observation of R24's transfer from bed to chair, E9 and E10 CNA's, placed a transfer belt around R24, while she was in bed, and transferred her from bed to chair. R24 was agitated, yelling and grabbing at E9 and E10's clothing and name tags. E9 and E10 did not lay her down and reapproach her. They transferred her from bed to chair supporting her weight with the transfer belt as R24's feet did not touch the floor. The Facility's Repositioning, Lifts and Transfers policy, not dated, documents, in part, "Transfers are a procedure to assist a patient who can bear weight through one leg or both arms move from one surface to another...these include...transfer belts." 4. R14's Physician order [REDACTED]. R14's Brief Interview of Mental Status (BIMS), dated 2/5/15, documents a 0, which indicates that R14 is rarely understood. R14's MDS, dated [DATE], documents that R14 requires extensive assistance and two plus physical assistance for transfers, requires extensive assistance and one person physical assistance with walking. R14's Fall Risk Prevention Assessment, dated 9/15/14, documents that R14 scored 13 ( a score of 10 or above is a high risk for falls). R14's Care Plan, dated 10/17/14, documents that R14 is at a risk for falls related to history of falls, cognitive impairments, visual acuity impairments, decreased safety awareness, impulsiveness with attempt to stand or self transfer without staff assistance. R14's Fall Risk Prevention Assessment, dated 2/8/15, documents that R14 scored 16 (a score of 10 or above is a high risk for falls). R14's Incident/Accident Report, dated 1/24/15, documents that R14 was sitting up at side of bed, and slid to the floor. R14's Incident/Accident Report, dated 2/7/15, documents that R14 was found in room sitting on buttocks in front of wheelchair by bed with alarm sounding. R14's Incident/Accident Report, dated 2/16/15, documents that R14 was attempting to climb out of bed so CNA dressed R14 and sat in wheelchair for monitoring. The Incident/Accident Report documents that R14 stood up from the wheelchair, and that staff were too far away to prevent fall. On 3/13/15 at 11:10 AM E2 was interviewed and stated that interventions based on the investigation of falls is under additional comments on the front of the Incident/Accident Report. E2 stated that interventions in place for a person with falls will be reviewed if they are ineffective. The facility failed to analyze data to identify trends and patterns and perform root cause analysis of R14's falls. The facility failed to review interventions, and make changes based on investigation of R14's falls.

Based on observation, record review and interview, the facility failed to identify and assess pressure sores; failed to turn and reposition residents; failed to monitor for drainage and intact pressure sore dressings; failed to follow physician orders [REDACTED]. This failure resulted in R3, R9 and R18 developing avoidable pressure sores and having a decline in the pressure sore. R18 developed an in house avoidable stage 2 pressure sore that declined to a stage 4 with infection and Osteo[DIAGNOSES REDACTED]. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 1-30-12, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate and monitor the effectiveness of the facility policies and procedures; inservice training on turning and repositioning; pressure sore assessment; pressure sore treatment; and pressure sore prevention. Findings include: 1. R18's Minimum Data Set (MDS) of 11-19-11 documents R18 has severe cognitive impairment and is totally dependent on staff for transfer, bed mobility, dressing, eating, hygiene and bathing. On the afternoon of 1/26/12 a copy of R18's most recent Care Plan of 8-24-10 was obtained. It is documented on the Care Plan, R18 has a potential for skin breakdown related to incontinence with goal to have no skin breakdown. Note of 8-17-11 documents, "Wound Clinic - Unstageable Lt (left) heel - wound graft - Note - Done @ wound clinic." Note of 10-1-11 documents, "Cleanse open area to coccyx with NS (normal saline) Dry Dressing." An undated written note on an added page to the Care Plan documents, "Unable to use call light - Please check on R18 every 1-2 Hrs - and Reposition is being seen by (local) Hospital Wound Care Center for L (left) heel @ wound care needs. 1/3/12 - Cleanse coccyx with NS (normal saline) on wound cleanser - apply collagen daily. 1-25-12 - I am currently on IV antibiotics for coccyx wound...(Catheter due to Stage III on coccyx...)." On 1/30/12 an updated Care Plan of 8-17-11 was obtained. There was a hand written note dated "1-25-12 on low air loss bed now. Turn every 1 hour." This note was not on the Care Plan obtained on 1-26-12. A note written on 1-27-12 documents, "I am to be turned/repositioned every hour. I am to be in bed only up for meals and therapy. I have a new order for Arginade three times daily with meals, for wound healing." Note written on the Care Plan dated 1-29-12 documents, "Cont (continue Vit C and Zinc per MD orders- Heel Protectors. Preventative - Protective Barrier to Lt. Heel q (every) shift - Argenate with Meals " On 1-26-12, R18 was up in a geriatric reclining chair on his back from 8:30AM to 11:30AM. At 11:17AM, E16, Certified Nurse Aide (CNA) stated she got R18 up into the geriatric chair at 8AM. E16 and E19, CNA's, stated R18 had not been out of the reclining geriatric chair at all that morning. At 11:34AM, E16 and E19 stated they had just laid R18 down. R18 was in his bed and on his back. A skin check with E12, LPN, showed R18 had formed feces at his anal area and his pressure sore bandage was in his underwear and not on the pressure sore. There was a dried brownish/tan stain on the back of the underwear at the coccyx level the size of a silver dollar. R18's buttocks were deep creased and red and he had indentation around the waist that showed the imprint pattern of the elastic band on his pants. R18 had an irregular stage 2 pressure sore on his upper right inner buttock and no treatment on his coccyx. E19 got a wash cloth with bar hand soap and wiped the feces at the anal area up into the coccyx. E19 then dried the anal area with a dry wash cloth. After incontinent care was given, E12 changed R18's dressing. E12 cleansed the pressure sore on the coccyx wiping lightly with normal saline and a gauze pad. E12 pulled 2 packages of [MEDICATION NAME] Ag (the prescribed treatment). They were empty. E12 stated he would have to go down stairs to get another package. He put a piece of gauze with tape on R18's coccyx pressure ulcer and left the room. On 1-26-12 at 11:55AM, E12 stated the facility was out of [MEDICATION NAME] so he called Z4, R18's primary physician/facility Medical Director. E12 stated Z4 stated it was OK to use PolyMem silver since they were out of the [MEDICATION NAME]. E12 proceeded to remove the gauze dressing and wiped the coccyx with gauze and normal saline. R18's buttocks were still deep creased. E12 placed a piece of PolyMem directly onto a piece of tape and placed the PolyMem and tape onto R18's coccyx. E12 did not put any gauze or padding on the dressing to absorb the drainage. R18 was then repositioned so a skin check of his heels could be done. R18 had on heel protectors. E16 removed the heel protectors and it was noted R18's left inner heel had a golf ball size unstageable pressure sore. Z7, R18's wife, was present and stated he had the area in the hospital before he was readmitted to the facility. There was no documentation indicating R18 had a pressure ulcer on his left heel. including R18's Admission Nursing assessment dated [DATE], R18's January 2012 Nurses Notes or on the January Treatment Record.. On 1-26-12, at 10 to 15 minute intervals R18 was in his geriatric reclining chair on his back from 12:11AM to 4:00PM without being repositioned and was still up in the geriatric reclining chair when observation was stopped. On 1-27-12, at 10 to 15 minute intervals R18 was up in his geriatric chair on his back from 8:30AM to 10:15AM and then in bed laying on his back until noon. He was up in the geriatric chair for noon meal and then placed in bed on his back. At 3:00PM, E23, Corporate Nurse, was informed of concern that R18 had been on his back all day and has a Stage 4 Pressure Ulcer on his coccyx. On 1-30-12 at 10AM, R18 was in bed. E24, Registered Nurse (RN)/Care Plan Nurse, performed a skin check to see if R18 had a dressing on his coccyx. E24 had a dressing on his coccyx dated 1-30-12. The gauze was visible and had a brownish/tan drainage on the gauze and the tape was rolled up at the edges exposing the gauze. Nurses Note written by E24 on 1-30-12 at 10AM documents R18's dressing to his coccyx was intact and observed by Surveyor. At 2:05PM, a second Surveyor checked the bandage and confirmed it was bunched up and needed to be changed and also confirmed the unstageable pressure sore on his left heel that was the size of a golf ball which now had an area the size and shape of a kidney that was dark brown. At 2:10PM, E23 was informed of concern that R18's dressing needed to be changed. R18's pressure sore on his left heel is documented is in the Nurses Notes of 1-29-12 and documents a stage 1 pressure sore on the left heel 4 x 4 cm, red and soft. R18's WEEKLY PRESSURE ULCER RECORD of 1-29-12 that was provided on 2-1-12, documents date of onset as 1-29-12 left heel 4 x 4 cm unstageable DTI (Deep Tissue Injury) with preventative measures to turn every 2 hours. On 1-27-12 at 11:55AM, E12, and E11 (LPN/Wound Nurse) stated R18 did not get an low air flow bed until he was readmitted to the facility on [DATE]. On 1-27-12 at 9:00AM, Z5, Wound Clinic Nurse, stated Z6, Wound Clinic Physician, had ordered an air flow mattress in November 2011 and the facility refused to provide the mattress. Z6 stated she had talked to a facility Nurse, E5, LPN, and was told R18 didn't need the air loss mattress/bed and that E1, Administrator, refused to get the bed. Z5 stated R18 was first seen in the wound clinic for a pressure sore on his coccyx on 11-29-2011. R18 was first seen with a Stage 2 pressure sore on his coccyx that progressed to a Stage 4. His cushion in his geriatric reclining chair was too small for the chair and pushes him back and has him sitting directly on his coccyx. Z5 stated R18 should be in bed off his coccyx and only up for meals. Z5 was told of observations on 1-26-12 and she stated sitting up for extended time in his geriatric reclining chair is a problem and contributes to the decline in the pressure sore. Z5 stated moving the back or the chair up and down or the legs of the chair up and down does not relieve pressure off R18's coccyx. In a discussion with Z5, regarding the facility running out of [MEDICATION NAME] AG and the E12 calling Z4 for a different order for treatment, Z5 stated E12 should have called the Wound Clinic Physician for an order since R18 was being treated at the Wound Clinic. Z5 stated she believed R18's pressure ulcer on his coccyx declined due to neglect. On 1-27-12, Z5 stated the treatment E12 did on 1-26-12 was a totally inappropriate dressing change. There should be a dressing/gauze to absorb the drainage. On 1-27-12 at 9:10AM, Z6, R18's Wound Clinic Physician, stated she had concerns that R18 was up for extended time in his geriatric reclining chair. Z6 stated she did not consider moving up and down the back of the chair or foot area as repositioning due to pressure is still on the coccyx. Z6 stated on November 29, 2011, R18 had a stage 2 pressure on his coccyx, and it progressed to a stage 3 and then to a stage 4. When Z6 was asked if R18 sitting up for extended time in the geriatric reclining chair would contribute to the decline in his pressure sore, Z6 stated, "Absolutely. It would contribute to the decline." Z6 stated she wanted R18 to have an air flow mattress and the facility refused. Z6 stated she even called Z4 to try to get reinforcement that R18 needed the air flow mattress. Z4 refused stating maybe R18 needs to go to another facility. Z6 stated she was shocked at Z4's response. Z6 couldn't believe it. Z6 stated R18's pressure sore kept getting worse. That's why she called Z4. Z6 stated she considers it neglect. The facility had a direct order for the air flow mattress. Z6 stated she wrote the order and the facility refused to get the mattress. Z6 stated R18's pressure sore and decline was avoidable. Every week the pressure sore kept getting bigger. Z6 stated the facility should have called the Wound Clinic when they ran out of the [MEDICATION NAME] AG and should not have ran out of it in the first place. Z6 stated she did have concerns if the facility was doing the pressure sore treatments as she had ordered. Z6 stated the decline in the pressure sore contributed to R18 developing Osteo[DIAGNOSES REDACTED]. The Facility NON-PRESSURE SKIN CONDITION REPORT of 10-24-11 documents an excoriated open area on R18s coccyx measuring 1cm length x .3 cm in width x .05 cm in depth. It is documented under comments, "Resident with excoriated @ intervals since 10-1. 10-24 noted to have small open area D/T (do to) dampness. The report shows the same size on 10-31-11, and increase in size on 11-4-11 to 1 x .4 x .05cm, with documentation under progress, "deteriorated." On 11-11-11 the area on the coccyx is documented to be 2 x .5 x 1 cm with drainage and "deteriorated." On 11-27-11 the coccyx was documented as measuring 2 x 4 x 1 cm with drainage and slight odor with "improved" checked. Facility WEEKLY PRESSURE ULCER LOG of 12-5-11 documented the coccyx as being a stage 4 pressure sore measuring 1 x .5 x 1 cm with odor and drainage with documentation the Physician and family were notified on 10-24-11. The Pressure Sore Logs show the facility assess the pressure sore to be a stage 4 from 12-5-11 through 1-6-11 with deterioration on 1-6-11 to 1.5 x .8 x 1 cm with no odor or drainage. Report of 1-12-12 does not assess stage of the pressure sore but shows measurements of 1 x .5 x .5 cm with small amount of drainage and odor. The Wound Clinic Report of 11-29-11 shows an order for [REDACTED]. The Facility December 2011 TAR shows the treatment order was not documented to be done every other day as the Doctor had ordered on 11-29-11. There is document that the treatment was done daily until 12-7-11. There is documentation on the TAR that documents a new order 12-6-11 for the treatment to be done every other day even though it was originally ordered on 11-29-11. The Wound Clinic Report of 12-13-11 documents R18's pressure sore as a stage 2 with an order for [REDACTED]. The TAR documents the treatment was done on 12-14-11, 12-15-11, 12-17-11, and then every 3rd day from 12-17-11 through 12-29-11 with no treatment documented as being done from 12-30-11 through 1-5-12. The Wound Clinic Report of 1-3-12 shows a treatment change to the coccyx to cleanse with wound cleanser and cover with collagen daily. On 1-30-12, the facility provided a TAR that is documented as being for the period of December 2011 with treatment order for January 2012 documented on the TAR. The TAR showed treatment change on 1-3-12 to clean coccyx wound with normal saline and apply collagen daily. Documentation shows the treatment was done starting on 1-5-12. There were initials of the treatment being done through 1-22-12 with a "scribble" over the initials on 1-17-12 thru 1-22-12. There was a dash written on 1-23 and 1-24. A bracket was drawn below the initials that were "scribbled" through from 1-17-12 through 1-24-12 and "hosp" written under the bracket. On the afternoon of 1-30-12, E3, Assistant Director of Nursing (ADON), E23, Corporate Nurse and E24, Corporate Marketing Director/Nurse all stated the TAR for January looked like staff had initialed they did the treatments on 1-17-12 through 1-22-12 and someone scribbled through the initials. Wound Clinic Report of 1-17-12 documents an order again for a speciality bed to provide appropriate chair. "This (geriatric) chair is not fit for patient to use." Wound Clinic coccyx pressure ulcer measurement report shows on 11-29-11 the pressure sore on R18's coccyx measured 1.1 x .3 x .6 cm and stayed fairly stable through 12-20-11. Measurement on 12-27-11 showed an increase to 1.5 cm x .4 cm x .7 cm. On 1-17-12 the pressure sore measured 3.6 cm x 2 cm x 1.6 cm. Z6's Wound Clinic Progress Note written on 1-17-12, documents, "SUBJECTIVE: (Obtained from wife). Patient continues to be placed for hours on end seated or semirecumbent in a geriatric chair which probably dates back to the 1970's. A piece of equipment that he is transported in is the same as what is used at the nursing home. It appears to be quite dilapidated in condition. There is no support on the posterior seat or lower back. There is a large gap there. Patient is placed on his (special) cushion which does not nearly fill the seat of the chair and then allowed to fall back in such a way that his buttock does not contact the cushion. Wife also states that he is probably not being turned every two hours as he should be; when he is in the chair he is not turned at all. Patient's wife also states that his oral intake is hit or miss, depending on the aide who may or may not take the time to feed him. He is also not getting his (special) boots applied with any consistency despite the fact that they are supposed to be on his feet 24 hours per day. OBJECTIVE: Patient is afebrile. Temperature 97.3. Blood pressure however is 82/42. Pulse 53. Respirations 20. Patient is not responsive. He does moan in pain however. Examination of the wound shows that it has significantly deteriorated from last week...The wound now is down to tendon directly overlying bone. At 9 o'clock there is a tunnel that measures 2 cm. There is extensive ischemia along the right side of the wound...Our nurse contacted the nurse at (name of facility) and was told that the administrator there refused to order the mattress that we had requested because it was "not cost effective." I believe this is directly related to the worsening of this wound. Assessment: 1. Pressure ulcer of the coccyx stage 4 (patient was a stage 2 when he initially presented)..." R18's Hospital History & Physical of 1-17-12 documents R18 was brought in from the Wound Care Center for [MEDICAL CONDITION]. His Coccygeal ulcer had worsen significantly over the past two weeks. Hospital Consultation Report by 8, Consulting Physician for R18, of 1-20-12 documents, "The patient was initially evaluated in the Wound Care Center back on January 17 due to a pressure ulcer on the intergluteal area. The patient initially presented with a stage 2 ulcer, which has been progressing and became a stage 4 ulceration. When he was evaluated in that Wound Care Center the patient was found hypotensive and referred to the emergency room for evaluation, giving concern [MEDICAL CONDITION]. So tissue cultures were obtained that were reported positive for Proteus mirabilis [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staff Aureus) along with Streptococcus viridans...On examination there is no [MEDICAL CONDITION], but the wound seems having quite amounts of drainage, most likely with bacteria overgrowth but cannot rule out underlying osteo[DIAGNOSES REDACTED]. I suggest to obtain a bone scan to rule out this possibility..." Hospital Bone Scan done on 1-23-12 documents, "IMPRESSION: 1. Focal fairly intense activity in the sacrum on all three phases that is suggestive of Osteo[DIAGNOSES REDACTED]. clinically as an abrasion, blister or shallow crater." 2. A physician order [REDACTED]. Care Plan approaches include, in part: Nursing will complete a pressure ulcer assessment upon admission, quarterly and prn (as needed) and will initiate appropriate interventions. Care plans will be updated accordingly; Skin will be checked daily. A skin check on R8 with E17, LPN/Care Plan Coordinator, on 1-23-12 at 8:15AM showed R8 had a healed pressure sore on his right inner buttock/coccyx area the size of a quarter with a small open bleeding area within the healed pressure sore. A skin check was conducted again on 1-25-12 and the bleeding area on the right inner buttock/coccyx area was now scabbed over. R8 had dried feces on his buttocks that was stuck to the hair on his buttocks. His left outer heel had a stage 2 pressure sore irregular in size and larger than a dime. His right heel had a very small open area. E 31, CNA, was informed of concerns of the scab on R8's buttocks and the 2 open areas on his heels. E31 confirmed the areas and stated he had a bowel movement earlier in the morning and she must not have gotten it all cleaned and stated she would clean him. E17 came into the room to look at R8's heel and buttock and confirmed the areas and left the room. Record review of R8's Nurses Notes from 1-23-12 through 1-28-12 does not mention anything about pressure sores on R8's heels or coccyx area. Note of 1-29-12 at 1210 documents, "Spoke with Z4 - NEW order for air mattress - Barractive Bed - Preventative Protective oint.(ointment) to coccyx EVERY shift and PRN. Nurses Note of 1-30-12 documents R8 was admitted to the hospital for Pneumonia. On the morning of 2-1-12, E23 provided a copy of the facility WEEKLY PRESSURE ULCER LOG for 1-29-12. R8 was not on the list and this was confirmed by E23. E23 stated R8 was also not on their 1/29/12 skin non pressure ulcer list. On 1-2-12 at 10:25AM, E17, stated when the skin check on R8 was performed on1/23/12, he did not have pressure sores, he had abrasions on his feet. E17 stated the areas were not open. Facility undated Policy and Procedure for Pressure Sores documents, "Stage II - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow center. 3. According to the MDS dated [DATE], R3 has cognitive impairment, requires minimal to extensive assist of one staff for all activities of daily living including mobility and transfers. Braden scale dated 9/3/11 identifies R3 to have no risk of pressure ulcers with a score of 19. The care plan dated 11/30/11 documents R3 to have a potential for skin breakdown due to incontinence. Interventions include: skin check daily and report to nurse any red areas that won't go away, assist to turn and reposition at least every two hours, encourage good hydration and nutrition, and "feet are checked weekly by a nurse" due to diabetes. The care plan dated 11/30/11 has a written statement (undated) "lt (left) heel - Apply Santyl per MD (Medical Doctor) orders - heel protectors in bed." added on in the margin. The nurses notes dated 12/11/11 at 3:45pm document "res daughter from kitchen came to this writer stated "when I was getting mom ready to take her out she said ouch when I was putting her sock on her l foot. I noticed she has an area on her L heel." Upon assessment of area I noticed approx (approximately) 3cm circular area hard to touch c dry skin + deep purple in color - will apply protective barrier + slippy sock + float heels when in bed." Interview with R3's daughter, Z1, on 1/23/11 at 10am confirmed that she found the pressure ulcer and informed the staff. Z1 stated her mom had been complaining of her foot hurting the few days prior to 12/11/11 but she didn't look at it until 12/11/11. Lab results dated 1/5/12 show normal Total Protein and [MEDICATION NAME] levels and a Doppler done 11/14/11 showed "signals augmented well" with the findings being negative for [MEDICAL CONDITION]. Weekly Pressure Ulcer QI Logs dated 12/16/11 identify R3's heel ulcer as in house acquired, stage II measuring 2 x 1.5cm, treatment - protective wipe. There is no depth, odor or drainage identified at the time. On 12/21/11, R3's ulcer was assessed by a wound specialist and was determined to be "unstageable", measuring 0.7 x 0.8 - "Woundbed : black center with pink edges." Scant exudate, sero-sanguinous is also identified with no debridement done. an order for [REDACTED]. On the 12/23/11, the facility's weekly skin log shows R3's heel wound has increased to 3 x 2cm with 0.5cm depth with odor and a small amount of drainage. There is no description of the ulcer by the facility. T The facility's weekly log dated 12/30/11 indicates the measurements remained the same. However, measurements by the Wound care specialist dated 1/5/12 show another increase to 0.5cm x 1.3cm, unstageable, yellow woundbed, scant sero-sanguinous exudate. On 1/8/12, the wound specialists measurements are as follows: L (length) 0.8cm Width 1.0 Depth 0.3cm unstageable" with yellow necrosis with minimal pink granulation with the same exudate as before. The wound is identified as "improved." According to R3's daughter, Z1, on 1/23/12, the facility did not implement heel protectors until after the ulcer was found by family. 4. The Admission Sheet identifies R9 as a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] identifies R9 to require extensive assist of one staff for ADL. The MDS indicates he is "always incontinent" of bowel and bladder. According to the care plan dated 11/30/11, R9 has a potential for skin breakdown and history of same. Interventions include "The CNA's will assess my skin daily and with incontinence care and will report any red areas or skin breakdown to the nurse", reposition as least every 2 hours, external catheter for dignity, encourage/help me to drink adequate fluids and have good nutritional habits and put heel protectors on when in bed. The care plan indicates R9 has a history from 1/24/11 for coccyx pressure ulcers, in-house acquired. Weights are stable past year with a little weigh gain past month according to the weight sheets. Labs dated 3/4/11 documents normal Total Protein (7.5) and [MEDICATION NAME] (3.8). According to the Weekly Skin Logs, R9 is not identified as having a pressure ulcer until the week of 1/12/12 and indicates R9 acquired an in-house stage II to coccyx first identified on 1/6/12. Measurements are 1cm x .5cm and .2cm deep with a small amount of drainage. The nurses notes include no entry regarding this pressure ulcer until 1/11/12 even though the log indicates it was first identified on 1/6/12 and then only reflects the treatment order. On 1/11/12 at 10:25am, the nurses notes documents an order was received for Santyl to the Stage II pressure sore on R9's coccyx, cover with wet to dry dressing every day. The TAR shows no treatments done until after this order was received on 1/11/12 but have skin checks documented on the back which indicate on 1/7/12 - R9's skin was intact and on 1/14/12 - No new skin issues is documented. On 1/23/12 at 8:25am, R9 was in bed on his back. He had 2 incontinent pads under him and he smelled of urine. He had heel protectors on bilaterally. R9 had a soaked dressing at the coccyx when he was rolled to his side. 5. R17's Nursing Notes, dated 11-23-11, documented R17 was admitted to the facility on [DATE]. It was also noted "resident noted to have Allevyne on (R) (right) outer aspect of ankle she state her 'family member' ran it over. (R) ankle is larger than (L) (left) and tender to touch." R17's December 2011 Treatment Record documented "12-16-11 Cleanse inner outer (R) ankle wound with NS (noral saline) apply dry dresg (Dressing) qd (every day)" which was changed to "12-20-11 Cleanse two areas on (R) ankle with NS apply skin prep leave OTA (open to air)." Weekly Pressure Ulcer Logs, from 11-11-11 to 11-25-11, did not document any areas of skin break down until the Weekly Pressure Ulcer Log, dated 12-20-11, which documented a right inner ankle unstaged pressure sore measuring 3.2cm x 2.5cm and a right outer ankle unstageable pressure sore measuring 3.7cm x 2.5cm. was identified on 12-16-11. 6. An additional example of not repositioning/turning timely according to the plan of care includes R14 who, according to her MDS dated [DATE], is totally dependent on staff for all activities of daily living and is always incontinent of bowel and bladder. R14's care plan dated 11/23/11 identifies her at risk for skin breakdown due to decreased mobility and incontinence with interventions that include: daily skin checks, turn and reposition at least every 2 hours, and encourage fluid and nutrition, in part. R14 was not repositioned timely. On 1/23/12 E6 and E9 CNA's both stated R14 was up in her wheelchair when they came in at 6:45am that morning as "nights" get her up before they leave. The Immediately Jeopardy began on 10-24-11 when the facility failed to identify and assess R18's new open area on a pressure point, the coccyx, as being a pressure sore and failed to put in interventions in place to promote healing of the pressure sore . This failure resulted in R18 having a decline to a stage 4 pressure sore identified by the facility on 12-5-11. On 1-17-12, R18 was sent to the hospital with infection of the pressure sore and Osteo[DIAGNOSES REDACTED]. E1 was notified of the Immediate Jeopardy on 1-27-12 at 12:15PM. The Facility took the following actions to remove the Immediacy: 1/27/12 - Implemented a Full time wound care nurse 1/27/12 - Total assessment R18 regarding medical needs. 1/27/12 - Reinforced communication with nursing staff regarding present interventions. Staff was inserviced on turning from right to left and turning every 1 hour from right to left side for R18. Other residents were evaluated for the need for the intervention at this time. 1/27/12 - Inservicing in turning and repositioning residents in the facility along with notification to nursing regarding any skin issues 1/27/12 - Reassessed all policies and procedures of the wound care program 1/29/12 - Total body assessment on all residents in the facility started 1/27/12 and completed on 1/29/12, potential residents at risk were reassessed and any interventions and treatments initiated. 1/27/12 - Reassessed resident R18 total body including coccyx and left heel. 1/29/12 - Amended R18's care plan to include continuation of Vitamin C and Zinc and started on [MEDICATION NAME] with meals and house supplement BID. Protective barrier cream was initiated for his left heel. Other potential residents at risk for pressure ulcers were evaluated related to medications and treatments and all orders carried out along with notifying Physician and POA . 1/29/12 - Physician and POAs were notified for the residents presented to us of concern (R18, R2, R14, R16, R17, R9, R3 and any others found from total in house skin assessments) 1/29/12 - Wound care nurse reevaluated R18's pressure ulcers and obtained measurements along with completing the individual pressure ulcer log in addition to all residents in the facility . 1/30/12 - Order for therapy to evaluate for the size and placement of the (special) Cushion in geriatric chair for R18 1/30/12 - R18 received a low bed with a new low air loss mattress, new bariatric geriatric chair along with a (special) cushion. Implemented 15 minute checks from staff to maintain safety. Placed mat on the floor next to residents bed along with placing his bed against the wall with a mat between the bed and the wall

Based on observation, interview and record review, the facility failed to follow their pressure sore interventions for 1 of 7 residents (R9) reviewed for pressure sores in the sample of 13. Findings include: The facility WEEKLY PRESSURE ULCER LOG of 3-9-12 documents R9 has a facility acquired stage 3 pressure sore on his coccyx measuring 1.2 x .4 x .3 cm (centimeters). R9's Care Plan of 1-31-12 documents R9 has an alteration in skin integrity with intervention in part; Pressure reducing low air loss mattress and external catheter. R9 was observed on 3-13-12 at 11:50AM to be in his bed on an air loss mattress. At 12:05AM, E5 and E6, Certified Nurse Aides (CNA's) were observed to go into R9's room and stated they were going to get him up for lunch. R9 was lying on a folded sheet that was quartered, a folded bed blanket that was quartered, a bed pad, a mechanical lift sling and a disposable incontinent pad which were on top of his air loss mattress. R9 did not have an external urinary catheter and his disposable incontinent brief, underpants and sweat pants were saturated with urine. E5 and E6 stated the mechanical lift sling was soiled with urine and needed to be changed. On 3-14-12 at 10:50AM, R9 was observed to be in bed and lying on a disposable bed pad. R9 was observed to have an external urinary catheter. E9, CNA stated R9 has had the catheter for quite some time due to his pressure sore. At 11:00AM, Z1, Outside Wound Consultant Nurse, came into the room to do a treatment, and stated only 1 pad should be used with an air flow mattress.

Based on observation, record review and interview, the facility neglected to accurately assess a pressure sore; neglected to follow physician orders [REDACTED]. This failure resulted in R3, R9 and R18 developing avoidable pressure sores and having a decline in the pressure sore. R18 developed an in house avoidable stage 2 pressure sore that declined to a stage 4 with infection and Osteo[DIAGNOSES REDACTED]. Findings include: The facility Policy And Procedure titled PREVENTION OF PRESSURE ULCERS that is undated documents, in part: "Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decreased of circulation (blood flow) to that area, which destroys the tissues. The most common site of a pressure ulcer is where the bone is near the surface of the body including the ...backbone...For a person in bed: change position at least every two hours; use a special mattress that contains foam, air, gel, or water, as indicated...Persons confined to chairs should be repositioned at least every two hours. Persons confined to chairs who are unable to shift their own weight may need repositioning more frequently...Infection Control Protocol and Safety...Maintain clean technique and isolation precautions as indicated... The facility documented on their NON-PRESSURE SKIN CONDITION REPORT of 10-24-11 through 11-27-11 that R18 had an excoriated open area on his coccyx. It is documented under comments, "Resident with excoriated @ intervals since 10-1." The facility 's documentation on the report shows a decline from 10-24-11 to 11-27-11. The facility failed to assess and identify the ares on the bony prominence as a pressure sore until 12-5-11 at which time the "excoriated open area" was now a stage 4. Facility WEEKLY PRESSURE ULCER LOG of 12-5-11 documented the coccyx as being a stage 4 pressure sore measuring 1 x .5 x 1 cm with odor and drainage with documentation the Physician and family were notified on 10-24-11. The Pressure Sore Logs show the facility assess the pressure sore to be a stage 4 from 12-5-11 through 1-6-12 with deterioration on 1-6-12 to 1.5 x .8 x 1 cm with no odor or drainage. Report of 1-12-12 does not assess stage of the pressure sore but shows measurements of 1 x .5 x .5 cm with small amount of drainage and odor. Record review shows R18 was first seen in the wound clinic for the pressure sore on his coccyx on 11-29-11. The Wound Clinic Report of 11-29-11 shows an order for [REDACTED]. There is documentation on the TAR that states new order 12-6-11 for the treatment to be done every other day even though it was originally ordered on 11-29-11. The Wound Clinic Report of 12-13-11 documents an order for [REDACTED]. The Treatment Record documents the treatment was done on 12-14-11, 12-15-11, 12-17-11, and then every 3rd day from 12-17-11 through 12-29-11, not every second day as ordered by the Physician, and with no treatment documented as being done from 12-30-11 through 1-5-12. The Wound Clinic Report of 1-3-12 shows a treatment change to the coccyx to cleanse with wound cleanser and cover with collagen daily. On 1-30-12, the facility provided a TAR that is documented as being for the period of December 2011 with treatment order for January 2012 documented on the TAR. The TAR showed treatment change on 1-3-12 to clean coccyx wound with normal saline and apply collagen daily. Documentation shows the treatment was done starting on 1-5-12. There were initials of the treatment being done through 1-22-12 with scribble over the initials on 1-17-12 thru 1-22-12. There was a dash written on 1-23 and 1-24. A bracket was drawn below the initials that were scribble through from 1-17-12 through 1-24-12 and "hosp" written under the bracket. On the afternoon of 1-30-12, E3, Assistant Director of Nursing, E23, Corporate Nurse and E24, Corporate Marketing Director/Nurse all confirmed the TAR for January looked like staff had initialed they did the treatments on 1-17-12 through 1-22-12 and someone scribbled through the initials. Wound Clinic Report of 1-17-12 documents an order again for a speciality bed "Roho Bed" and to provide appropriate chair. "This geriatric chair is not fit for patient to use." Z6's Wound Clinic Progress Note written on 1-17-12, documents, "SUBJECTIVE: (Obtained from wife). Patient continues to be placed for hours on end seated or semirecumbent in a geri chair which probably dates back to the 1970s. A piece of equipment that he is transported in is the same as what is used at the nursing home. It appears to be quite dilapidated in condition. There is no support on the posterior seat or lower back. There is a large gap there. Patient is placed on his (special) cushion which does not nearly fill the seat of the chair and then allowed to fall back in such a way that his buttock does not contact the cushion. Wife also states that he is probably not being turned every two hours as he should be; when he is in the chair he is not turned at all. Patient's wife also states that his oral intake is hit or miss, depending on the aide who may or may not take the time to feed him. He is also not getting his (special) boots applied with any consistency despite the fact that they are supposed to be on his feet 24 hours per day. OBJECTIVE: Patient is afebrile. Temperature 97.3. Blood pressure however is 82/42. Pulse 53. Respirations 20. Patient is not responsive. He does moan in pain however. Examination of the wound shows that it has significantly deteriorated from last week...The wound now is down to tendon directly overlying bone. At 9 o'clock there is a tunnel that measures 2 cm. There is extensive ischemia along the right side of the wound...Our nurse contacted the nurse at (name of facility) and was told that the administrator there refused to order the mattress that we had requested because it was "not cost effective." I believe this is directly related to the worsening of this wound. Assessment: 1. Pressure ulcer of the coccyx stage 4 (patient was a stage 2 when he initially presented)..." R18's Hospital History & Physical of 1-17-12 documents R18 was brought in from the Wound Care Center for [MEDICAL CONDITION]. His Coccygeal ulcer had worsen significantly over the past two weeks. Hospital Consultation Report by Z8, Consulting Physician for R18, of 1-20-12 documents, "The patient was initially evaluated in the Wound Care Center back on January 17 due to a pressure ulcer on the intergluteal area. The patient initially presented with a stage 2 ulcer, which has been progressing and became a stage 4 ulceration. When he was evaluated in that Wound Care Center the patient was found hypotensive and referred to the emergency room for evaluation, giving concern [MEDICAL CONDITION]. So tissue cultures were obtained that were reported positive for Proteus mirabilis [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staff Aureus) along with Streptococcus viridans...On examination there is no [MEDICAL CONDITION], but the wound seems having quite amounts of drainage, most likely with bacteria overgrowth but cannot rule out underlying osteo[DIAGNOSES REDACTED]. I suggest to obtain a bone scan to rule out this possibility..." Hospital Bone Scan done on 1-23-12 documents, "IMPRESSION: 1. Focal fairly intense activity in the sacrum on all three phases that is suggestive of Osteo[DIAGNOSES REDACTED]. Nurses Notes document R18 was readmitted to the facility on [DATE]. R18's most current Minimum Data Set (MDS) of 11-19-11 documents R18 has severe cognitive impairment and is totally dependent on staff for transfer, bed mobility, dressing, eating, hygiene and bathing. R18's most recent Care Plan of 8-24-10 documents R18 has a potential for skin breakdown related to incontinence with goal to have no skin breakdown. Note of 1-25-12 documents, "I am currently on IV antibiotics for coccyx wound...(Catheter due to Stage III on coccyx...)." Note is documented on 1-25-12 "on low air loss bed now. Turn every 1 hour." A note written on 1-27-12 documents, "I am to be turned/repositioned every hour. I am to be in bed only up for meals and therapy. I have a new order for Arginade three times daily with meals, for wound healing." On 1-26-12, R18 was up in a geriatric reclining chair on his back from 8:30AM to 11:30AM. At 11:17AM, E16, Certified Nurse Aide (CNA) stated she got R18 up into the geriatric chair at 8AM. E16 and E19, CNA's, stated R18 had not been out of the reclining geriatric chair at all that morning. At 11:34AM, E16 and E19 stated they had just laid R18 down. R18 was in his bed and on his back. A skin check with E12, Licensed Practical Nurse (LPN) showed R18 had formed feces at his anal area and his pressure sore bandage was in his underwear and not on the pressure sore. There was a dried brownish/tan stain on the back of the underwear at the coccyx level the size of a silver dollar. R18's buttocks were deep creased and red and he had indentation around the waist that showed the plaid print of the elastic band on his pants. R18 had an irregular stage 2 pressure sore on his upper right inner buttock and no treatment on his coccyx. E19 got a wash cloth with bar hand soap and wiped the feces at the anal area up into the coccyx. E19 then dried the anal area with a dry wash cloth. After incontinent care was given, E12, brought in the treatment cart into R18's room to do a dressing change. E12 cleansed the pressure sore on the coccyx wiping lightly with normal saline and a gauze pad. E12 pulled out 2 empty packages of [MEDICATION NAME] Ag. E12 stated he would have to go down stairs to get another package. He put a piece of gauze with tape onto the coccyx pressure ulcer and left the room. On 1-26-12 at 11:55AM, E12 stated they were out of [MEDICATION NAME] so he called Z4, R18's primary physician/facility Medical Director. E12 stated Z4 stated it was OK to use PolyMem silver since they were out of the [MEDICATION NAME]. E12 proceeded to remove the gauze dressing and wiped the coccyx with gauze and normal saline. R18's buttocks were still deep creased. E12 was observed to use scissors that had been sitting directly on the top of the treatment cart to cut the PolyMem. He then placed a piece of PolyMem directly onto a piece of tape and placed the PolyMem and tape onto R18's coccyx. E12 did not put any gauze or padding in dressing to absorb the drainage. R18 was then repositioned so a skin check of his heels could be done. R18 had on heel protectors. E16 removed the heel protectors and it was noted R18's left inner heel had a golf ball size unstageable pressure sore. Z7, R18's wife, was present and stated he had it in the hospital before he was readmitted to the facility. There is nothing in R18's Admission Nursing Assessment of 1-24-12, in R18's Nurses Notes or on the Treatment Record that identifies the unstageable pressure sore on R18's left inner heel. On 1-26-12, R18 was again observed at 10 to 15 minute intervals to be up in his geriatric reclining chair on his back from 12:11AM to 4:00PM without being repositioned and was still up in the geriatric reclining chair when observation was stopped. On 1-27-12, R18 was observed at 10 to 15 minute intervals to be up in his geriatric chair on his back from 8:30AM to 10:15AM and then in bed laying on his back until noon. He was up in the geriatric chair for noon meal and then placed in bed on his back. At 3:00PM, E23, Corporate Nurse, was informed of concern that R18 had been on his back all day and has a Stage 4 Pressure Ulcer on his coccyx. E23 stated she would have staff reposition R18 immediately. On 1-30-12 at 10AM, R18 was in bed. E24, Registered Nurse/Care Plan Nurse, was asked to do a skin check to see if he had a dressing on his coccyx. E24 was observed to have a dressing on his coccyx dated 1-30-12. The gauze was visible and had a brownish/tan drainage on the gauze and the tape was rolled up at the edges exposing the gauze. Nurses Note written by E24 on 1-30-12 at 10AM documents R18's dressing to his coccyx was intact and observed by Surveyor. At 2:05PM, another Surveyor checked the bandage and confirmed it was bunched up and needed to be changed and also confirmed the unstageable pressure sore on his left heel that was the size of a golf ball which now had an area the size and shape of a kidney that was dark brown. At 2:10PM, E23 was informed of concern that R18's dressing needed to be changed. The first time R18's pressure sore on his left heel is documented is in the Nurses Notes of 1-29-12 that documents a stage 1 pressure sore on the left heel 4 x 4 cm, red and soft. R18's WEEKLY PRESSURE ULCER RECORD of 1-29-12 that was provided on 2-1-12, documents date of onset as 1-29-12 left heel 4 x 4 cm unstageable DTI (Deep Tissue Injury) with preventative measures to turn q 2 hours, among others On 1-27-12 at 9:00AM, Z5, Wound Clinic Nurse, stated Z6 had ordered an air flow mattress in November 2011 and the facility refused to provide the mattress and didn't get it. Z6 stated she had talked to a facility Nurse, E5, Licensed Practical Nurse (LPN) and was told R18 didn't need the air loss mattress/bed and that E1, Administrator, refused to get the bed. Z5 stated R18 was first seen in the wound clinic for a pressure sore on his coccyx on 11-29-2011. He was first seen with a Stage 2 pressure sore on his coccyx that progressed to a Stage 4. His cushion in his geriatric reclining chair was too small for the chair and pushes him back and has him sitting directly on his coccyx. Z5 stated R18 should be in bed off his coccyx and only up for meals. Z5 was told of the above observations on 1-26-12 and stated sitting up for extended time in his geriatric reclining chair is a problem and contributes to the decline in the pressure sore. Z5 stated moving the back or the chair up and down or the legs of the chair up and down does not relieve pressure off R18's coccyx. Z5 was told of the facility running out of [MEDICATION NAME] AG and the E12 calling Z4 for a different order for treatment. Z5 stated E12 should have called the Wound Clinic Physician for an order since R18 was being treated at the Wound Clinic. Z5 stated she believed R18's pressure ulcer on his coccyx declined due to neglect. On 1-27-12, Z5 stated the treatment E12 did on 1-26-12 was a totally inappropriate dressing change. There should be a dressing/gauze to absorb the drainage. On 1-27-12 at 9:10AM, Z6, R18's Wound Clinic Physician, stated she had concerns that R18 was up for extended time in his geriatric reclining chair. Z6 stated she did not consider moving up and down the back of the chair or foot area as repositioning due to pressure is still on the coccyx. Z6 stated on November 29, 2011, R18 had a stage 2 pressure on his coccyx, it progressed to a stage 3 and then to a stage 4. When Z6 was asked if R18 sitting up for extended time in the geriatric reclining chair would contribute to the decline in his pressure sore, Z6 stated, "Absolutely. It would contribute to the decline." Z6 stated she wanted him to have an air flow mattress and the facility refused. Z6 stated she even called Z4 to try to get reinforcement that R18 needed the air flow mattress. Z4 refused stating maybe R18 needs to go to another facility. Z6 stated she was shocked at Z4's response. Z6 couldn't believe it. Z6 stated R18's pressure sore kept getting worse. That's why she called Z4. Z6 stated she considers it neglect. The facility had a direct order for the air flow mattress. Z6 stated she wrote the order and they refused to get it. Z6 stated R18's pressure sore and decline was avoidable. Every week the pressure sore kept getting bigger. Z6 stated the facility should have called the Wound Clinic when they ran out of the [MEDICATION NAME] AG and should not have ran out of it in the first place. Z6 stated she did have concerns if the facility was doing the pressure sore treatments as she had ordered. Z6 stated the decline in the pressure sore contributed to R18 developing Osteo[DIAGNOSES REDACTED]. On 1-27-12 at 11:55AM, E12, and E11 (LPN/Wound Nurse) stated R18 did not get an low air flow bed until he was readmitted to the facility on [DATE].

Based on observation, record review and interview, the facility failed to ensure residents are provided complete incontinent and catheter care for 2 of 3 residents reviewed for Urinary Tract Infection [MEDICAL CONDITION] and catheters, in the sample of 22. The facility failed to give appropriate and timely catheter care and failed to have a system in place for catheter replacement for 1 of 1 resident (R18) review for catheter care on the sample of 22. This failure resulted in R18 being hospitalized with an Indwelling Urinary Catheter Infection. Findings include: 1. R18's Minimum Data Set (MDS) of 11-8-11 documents R18 is severely cognitively impaired and being dependent on staff for hygiene and toilet use. R18's most current Care Plan of 8-24-10 documents R18 is total care for all personal care. Care Plan has a written note dated 12-1-11 stating R18 now has an indwelling urinary catheter...change catheter - bag - tubing per MD orders and prn (as needed). Catheter care every shifts and prn - 18 FR - 10 cc Balloon. R18 has a Physician order [REDACTED].#18 French 10 cc indwelling urinary catheter. There is no order as to irrigation of the catheter or changing the catheter tubing and bag. R18's Hospital history and physical examination [REDACTED]. R18 has had an Indwelling Urinary Catheter at the nursing home. This one has been present definitely more that 30 days as per patient's wife (Z7). Under Assessment and Plan: "1. Foley Catheter infection in a patient from a nursing home with advanced dementia. Foley catheter placed in order to prevent worsening of decubitus ulcers from which the patient has been suffering. status [REDACTED]. Will start the patient of IV [MEDICATION NAME] and discontinue IV [MEDICATION NAME] for now for broad-spectrum coverage including Pseudomonas given the patient staying in a nursing home. Informed the patient's wife, and will give written instructions for the nursing facility to change the Foley at least once in 30 days." R18's Discharge Summary of 1-24-12 documents as admitting diagnoses, in part, Indwelling Foley infection and Discharge Diagnoses, in part, Indwelling Foley infection, resolved with antibiotics. Record review of R18's December 2011 and January 2012 Treatment Administration Record (TAR) on 1-26-11 showed there is no documentation concerning the care of R18's indwelling urinary catheter. On 1-26-12 at 2:25PM, E12, Licensed Practical Nurse (LPN), E17, LPN/Care Plan Coordinator and E12, Registered Nurse (RN)/Care Plan Coordinator stated that catheter care is not documented on the TAR it is documented in the Nurses Notes. Record review of R18's Nurse Notes November 30 2011 at 11:30AM confirms the order for the Indwelling Urinary Catheter. Note of 12-1-11 at 10:20AM documents a 18 FR 5 cc urinary catheter was inserted using sterile technique. Note of 12-12-11 states noted R18 pulling at catheter at times. Note on 12-13-11 states R18 returned from Wound Clinic and his wife states he needs to be seen by the doctor tomorrow related to blood in his urine. Note shows Z4, R18's Physician was called later on 12-13-11 due to urine in tubing and bag being burgundy in color with small clots noted. An order was obtained for stat PT and INR and CBC. Nurses Note of 1-15-11 documents R18 found with urine over clothes. Catheter appeared pulled out half way. Upon inspection noted 4 cc in bubble. Catheter replaced 20 Fr/10cc using sterile technique. This is the 1st documentation in the Nurses Notes that R18's indwelling urinary catheter was changed. R18 was observed on 1-26-12 at 11:30AM to be in bed with an indwelling urinary catheter. E19, Certified Nurse Aide (CNA) was observed to clean a small amount of formed feces from the anal area using bar soap, no rinse and then dry R18's anal area. There was visible feces on the catheter tubing that was 1 inch from the tip of the penis. R18 did not get any catheter care. There was a puddle of liquid on the floor where R18 had been sitting in his reclining geriatric chair. E12 came into the room and stated there was urine on the floor. The gray cloth bag on the side of R18's reclining geriatric chair was soaked with urine from the bottom of the bag up to 4 inches. After care, E16 and E19, CNA's were observed to transfer R18 back into his reclining geriatric chair and placed his catheter bag into the soiled gray cover at the side of his chair. Facility Policy and Procedure of August 2001 for "Catheter Care, Urinary" does not address how often the bag and tubing should be replaced or where it would be documented. 2. R8's Hospital Consultation report of 11-1-2011 R8 was brought to the hospital for gastric distention..."He was noted to have a rather severe urinary tract infection on his urinalysis." R8's MDS of 12-28-11 identifies R8 as being occasionally incontinent of bowel and frequently incontinent of urine and requiring extensive assistance with toileting and hygiene. R8's most recent Care Plan dated 11-3-09 documents R8 is continent of bowel and has a handwritten note undated that documents R8 can be incontinent of bladder. There is nothing on the Care Plan identifying R8 as having a history of UTI or the need for incontinent care. R8 was observed on 1-25-12 at 10:56AM to be transferred from his wheel chair to bed by E31, CNA. R8 had balls of dried feces on buttock hairs and dried feces smears on his buttocks. E31 confirmed and stated R8 had a bowel movement earlier in the morning and stated she must not have cleaned it all.

Based on observation, interview and record review, the facility failed to give complete incontinent care for 1 of 2 residents (R8) reviewed for incontinent care and a history of Urinary Tract Infection [MEDICAL CONDITION] in the sample of 13. The facility failed to ensure urinary catheter was appropriately placed during transfer for 1 of 4 residents (R18) reviewed for urinary catheter care and a history of UTI in the sample of 13. Findings include: 1. R18's Minimum Data Set (MDS) of 2-20-12 documents R18 has a history of UTI, and is totally dependent on staff for transfer. R18's Care Plan of 3-8-12 documents R18 is at risk for complications related to catheter use. Intervention, in part, is to maintain position of drainage bag, and keep below waist to ensure proper drainage. R18 was observed on 3-13-12 at 1:07PM, to be transferred by mechanical sling lift from his geriatric chair to bed. E7, Certified Nurse Aide (CNA) was observed to lift the catheter bag one foot above R18's lap and then place the catheter bag on R18's lap during transfer. Urine in the tubing was red tinged and was observed to flow back towards the bladder. 2. R8's Hospital Consultation report of 11-1-2011 documents R8 came to the hospital for a severe UTI. R8 was observed on 3-13-12 at 2:25PM to be transferred from his wheel chair to bed by E5 and E6, CNA's. R8 had been incontinent of loose stool and urine. E6 put R8's soiled sweat pants in a plastic bag. E6 was observed to clean feces from R8's buttocks and anal area. E6 did not clean R8's penis, scrotum or abdomen that had been soiled with urine. E5, CNA, and E3, Licensed Practical Nurse (LPN) were present during the care, and were asked if R8 had been incontinent of urine. All stated "No". E3 was asked to pull R8's sweat pants from the bag and the crotch of the sweat pants were wet. E3, E5, E6 all confirmed the crotch of his sweat pants were wet.

Based on record review, observation and interview, the facility failed to develop and implement effective interventions for repeated skin tears and an effective fall prevention program for 6 of 10 residents ( R1, R6, R9, R14, R17 and R20) reviewed for injuries in a sample 22. This failure resulted in R6 fracturing her right hip after numerous falls. Findings include: 1. R6's Incident/Accident Reports, dated 7-10-11 to 12-2-11, documented R6 fell five times prior to her 12-2-11 fall during which she incurred a right hip fracture. R6's Incident/Accident Report, dated 7-10-11, documented she was found on the floor and incontinent of stool. Fall intervention was to have physical therapy screen. On 8-16-11, R6 was found on the floor in the dining room. On 8-31-11, R6 fell to the floor during self ambulation. R6 hit head head incurring a small hematoma and complained of left knee tenderness. Fall intervention was to take her cane away and try a guad cane. O9-11-11, R6 tripped over a wheel chair in an activity area. On 10-6-11, R6 fell when walking in the 200 hallway. Fall intervention was to use appropriate foot wear. On 12-2-11, R6 was found lying with her back on the floor. R6's incurred a right hip fracture. R6's Minimum Data Set (MDS), dated [DATE] to 10-3-12, documented declines and variances for cognition and ambulation which R6's Incident/Accident Reports fall prevention measurements did not address to prevent further falls. R6's MDS, dated [DATE], documented moderately impaired cognition and supervision with setup help only with walking in room and locomotion on unit. R6's MDS, dated [DATE], documented moderately impaired cognition and extensive assistance with one persons physical assistance with motion off unit. R6's MDS, dated [DATE], documented severe cognition impairment and supervision of set up with mobility, transfer, walking in corridor and locomotion off unit. R6's MDS, dated [DATE], documented severe cognitive impairment and limited assistance of one person physical assistance with mobility and supervision with transfer, walk in corridor and locomotion off unit. 2. The Admission Sheet identifies R69 as a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] identifies R9 to require extensive assist of one staff for ADL including transfers and mobility. According to the care plan dated 11/30/11, R9 has a potential for falls due to decreased mobility, altered thought process and left hemiparalysis. An Incident/Accident Report dated 12/4/11 indicates staff were "called into room by CNA state resident was struck in head by mechanical lift device attempting to put resident in w/c (wheelchair) - trying to move lift - went forward striking resident in L (left) eyebrow area." According to the report, this caused a 2cm x .5cm laceration of the eyebrow area on left side. There were no recommendations/interventions implemented as a result of this incident even though R9 sustained a laceration which had to be steristripped. The report section that asks how the resident sustained [REDACTED]." The staff failed to ensure that R9's transfer was safety done by ensuring the lift did not move/roll. The nurses notes dated 12/4/11 at 4pm reflects the same incident but adds that R9 also sustained a skin tear of the left elbow also which measured 2cm x .5cm which was closed with 2 steri strips. There is no indication the facility implemented anything to prevent this from occurring again. 3. The MDS dated [DATE] identifies R14 to have severe cognitive impairment and be dependent on staff for all activities of daily living including transfers. The care plan dated 11/23/11 documents that she is "non-ambulatory" and is transferred via a mechanical lift with a full body sling. Under skin, the care plan has identified that she is prone to skin tears easily. There are no interventions written to address a prevention plan for the skin tears. According to INCIDENT/ACCIDENT REPORTs; on 11/12/11 at 9pm, the report documents that R14 "obtained a skin tear on her L (left) thigh aprox (approximately) 5cm long. CNA stated she doesn't know how it happened." The report states R14 was in her bed. There is no further investigation as to the causative factor. On 11/20/11 at 1220pm, another Incident/accident report states a skin tear was found on R14's upper arm "possibly caught in gerichair." The tear was 3.5cm x 1/75cm on left upper arm. No further investigation was completed to determine the causative factor and no new interventions or revision added to the care plan to prevent further skin tears. On 11/23/11 at 6:30pm, R14 sustained a skin tear to the left upper arm. This one measured 4cm x 1cm and two other measuring 2cm x 1.5cm and 2cm x 1cm. The report states it was noted when R14's sheets were being changed and the CNA went to put a night gown on. Under RECOMMENDATIONS/INTERVENTIONS, it states "staff education on safety when transfers." There is, however, no new interventions and/or revisions done to the care plan in an effort to prevent further skin tears. On 1/26/12 at 2:58pm, R14's skin was observed and scabbed skin tears were still evident on her upper left arm. R14 had on a short sleeve house dress and her arms were not covered. She had multiple scars over both arms from skin tears. E21, CNA, stated R14 gets skin tears very easily and they are probably done with transfers. E22, Licensed Practical Nurse stated they had not tried protective covering on R14's arms like special arm coverings. but stated they could and see how that went. E22 stated she thought the skin tears were from the lift sheet. 4. R1's MDS, dated [DATE], documented severe cognitive impairment, feeding tube for nutritional approach and total assistance with mobility and transfer. It was also noted R1 was not steady and only able to stabilize with human assistance from surface to surface transfer. During observation of R1's transfer, on 1-23-12 at 12:00p.m., E15, CNA, and E16 CNA placed a transfer belt around R1's waist and stood her up from her reclining chair. R1 repetitively yawned, did not appear fully awake and did not bear weight as E15 and E16 dragged R1 backwards from her reclining chair to her bed. R1's Care Plan, not dated, documented R1 was at risk for falls and "transfers: I use a mechanical lift." 5. R20's MDS dated [DATE], documents that R20 was cognitively impaired and was a total assist of 1-2 staff with all transfers, bed mobility, dressing, eating, hygiene and was always incontinent of bowel and bladder. The facility care plan last updated 08/10/11, documents that R20 is at risk for skin breakdown with potential for bruises and skin tears related to decreased elasticity of skin turgor. On 03/06/11, an incident/accident report documents that the Certified Nursing Assistant (CNA) was holding R20 on his side while changing him resulting in R20 sustaining a skin tear measuring 5cm x 6cm in the center of a purple bruise measuring 10cm x 7cm on R20's left posterior shoulder. Interventions documented that staff was educated on turning and repositioning. On 03/13/11, an incident/accident report documents that R20 had a 4.5cm x 3.5cm purple hematoma to inside right wrist. On 03/14/11 at 11:50 am, an interview note documents that R20 stated that he received the hematoma while "she was trying to get me out of the wheelchair and grabbed me by my wrist and pulled the skin too tight." On 03/14/11, an inservice documents that the CNA's were inserviced on R20's fragile skin precautions. On 03/14/11, an incident/accident report documents that R20 fell out of his wheelchair, unwitnessed, and sustained a 3cm gaping laceration to left eyebrow, a 1.2 cm skin tear to the right thumb and a 0.5cm skin tear to the left posterior forearm. Intervention was to place R20 in a high back wheelchair. On 03/23/11, an incident/accident report documents that R20 had sustained a skin tear located under left arm in the center of a bruise. No measurements were documented. Documentation indicates that staff were unaware of how it happened. Another skin tear was noted on the second finger of the right hand. Documentation indicates that staff believe this might have occurred while trying to take R20's shirt off. No new interventions were put into place. On 09/24/11, a nurses note documents that R20 sustained a skin tear while two CNA's were turning and repositioning R20 and he bumped his arm on the side rail between the left second finger and thumb. There was no incident report presented during the survey. On 11/04/11, a nurses note documents that R20 sustained a skin tear on his left hand from a CNA pulling his shirt off measuring 4cm. There was no incident presented during survey. On 11/23/11, an incident/accident report documents that R20 was being transferred via mechanical lift and sustained a skin tear to the right upper posterior back measuring 2cm x 1cm x 0.5cm. Interventions were to check the mechanical lift for areas of concern. No new interventions were added to the care plan at this time. On 11/28/11, an incident/accident report documents that R20 sustained a 13cm x 15cm purple bruise with a small skin tear measuring 1cm x 0.5cm to the right forearm. The report documents that the incident was not witnessed and was speculated to be caused from R20's arm getting caught in the side rails. The intervention was to talk with Hospice about padding the side rails. There was no documentation in the care plan of adding padded side rails. On 12/07/11, an incident/accident report documents that a CNA had removed an existing Band-Aid on the right forearm, had caused a new skin tear a couple of inches away from the old skin tear measuring 1.5cm x 0.5cm. There were no new interventions documented on the investigation report or the care plan. On 12/12/11, an incident/accident report documents that a CNA was turning R20 and noted a skin tear to left upper arm measuring 2.1cm x 0.8cm x 0.5cm and left elbow measuring .05cm x 0.5cm. The report documents that there were no witnesses to the skin tears. There were no new interventions documented on the report or the care plan. During an interview conducted on 01/27/12 at 9:40 am with E12, Licensed Practical Nurse, (LPN), he stated that he recalled taking care of R20, but only had him for about a month. He recalled R20 having multiple skin tears and bruises that happened when R20 was being transferred, and that some of the skin tears were unwitnessed. He did not recall R20 having any special arm sleeves, but stated R20 could have, he just couldn't remember. During an interview conducted on 01/27/12 at 9:47 am with E11, LPN, she stated that she remembered working with R20 and stated "his skin was paper thin and he would get skin tears, bruises and pressure sores easily when doing care or if he was grabbed to tightly on the arm." When asked what fragile skin precautions included, she responded, "staff is to use soft touch during care, the use of special mattresses, pillows to prop during turning and repositioning and special arm coverings." She recalled that R20 would have soiled arm sleeves often due to skin tears and the sleeves would be removed and had to laundered. 6. R17's MDS, dated [DATE], documented extensive assistance of two plus persons physical assistance with transfer and one person physical assistance with mobility. It was also noted total dependence of one person physical assistance with toileting and limited assistance of one person physical assistance with eating. R17's Incident/Accident Report, dated 11-24-11 at 1:50pm, documented R17 was found lying on the floor with a hematoma to her right forehead. It was also noted her alarm was sounding. R17's Incident/Accident Report and her Nursing Notes, dated 11-24-11 from 1:50p.m. to 1-25-11, did not document increased supervision and/or fall prevention monitoring after her fall. R17's Incident/Accident Report, dated 11-24-11 dated 2:30a.m., documented R17 was found lying on the floor with an additional large hematoma to her right forehead and swollen upper lip. R17 was sent to a local hospital for evaluation. R17's Incident/Accident Report did not document if her alarm was sounding or if the alarm was in place. R17's Incident/Accident Report, dated 12-22-11, documented R17 leaned forward during toileting and hit her right forehead on floor received another hematoma with an open area in the center. R17's Incident/Accident Report did not document if staff were in-serviced in providing toileting supervision. It was also noted R17's chart did not document addtitoinal assessments for her toileting needs. R17's Care Plan, not dated, did not document R17's specific falls or interventions related to those falls. Additional, R17's Incident/Accident Report, dated 1-21-12, documented R17 spilt hot coffee in her lap during dining. R17's 11-24-11 Incident/Accident Reports and her Nursing Notes, dated 11-24-11, did not document increased supervision for her dining. 7. R18 was observed on 1-27-12 to have an air flow mattress and 1/4 side rails. On the morning of 1-3-12, E1, Administrator, was asked for manufactures recommendations for the use of the low air loss mattress. On the morning of 2-1-12 at 9:30AM, R18 was observed to be in another bed that was low to the ground and had a mat by the side of the bed. E1 and E23, Corporate Nurse, were asked if R18 had fallen and they said he had slid out of the bed to his knees and they had changed R18 to another air loss mattress. The manufactures information on the first air flow mattress shows full side rails on the bed. During interview with Z9, a representative from the 1st air flow mattress, on 2-1-12 at 9:55AM, Z9 stated they recommend full side rails be used with the bed due to safety issues. They keep the resident from falling out of the bed.

Based on observation, interview and record review, the facility failed to ensure a safe mechanical lift transfer for 1 of 3 residents (R9) reviewed for mechanical lift transfer in the sample of 13. Findings include: R9's Minimum Data Set (MDS) of 2-22-12 documents R9 as being totally dependent on staff for transfer. R9's Care Plan of 2-17-12 documents R9 requires two assist with transfer using a mechanical lift. R9 was observed on 3-13-12 at 12:40PM to be transferred with a mechanical sling lift from his bed to a reclining geriatric chair by E5 and E6, Certified Nurse Aides (CNA's). E5 was observed to press the mechanical lift button to lift R9 from his bed. The lift would stop during the transfer and not work until E5 would jiggle the cord on the hand held control. The lift would start and abruptly stop during the entire transfer. E5 stated the lift had a short. E5 was asked how long there had been problems with the lift. E5 stated she had been working on the hall for 1 week and the lift was like this when she first started on that hall. E6 stated she had been working the hall for about 1 month, and the lift had problems then. On 3-14-12 at 10:50AM, E9, CNA, stated she almost always works that hall and stated she has had to jiggle the mechanical sling lift cord to get it to work.

Based on interviews, observations and record review, the facility failed to provide adequate assistance and monitoring of meals for 1 (R14) of 12 residents reviewed for weight loss in a sample of 22. This failure resulted in R14 losing 11.86% of her weight within 4 months (8/11-1/12/12). Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R14 to have severe cognitive impairment and be dependent on staff for all activities of daily living including eating. The physician's orders [REDACTED]." The care plan dated 11/23/11 documents R14 "needs to be fed" and her appetite is good. The care plan also documents R14 has no teeth and on 11/18/11, R14 was placed on [MEDICATION NAME] for "wt (weight) loss." On 1/23/12 at 1:09pm, R14 received her tray in the assisted feeding dining room. She was fed by a volunteer. She received meat, spinach, potatoes and applesauce along with a small glass of water and a small glass of milk thickened. She took very small bites and ate <25% with no fluid intake. No substitutes were offered and/or tried before taking R14 from the dining room. No intakes were observed to be recorded at the time that the food plates were discarded. The intake records recorded on 1/23/12 for the noon meal that day documented R14 took 240cc of fluids and at 100% of her meal. . On 1/25/12 at 1:22pm, R14 received her pureed diet which was mashed potatoes, meat, vegetables and apricots along with a shake type drink and water. E6 was feeding R14 along with 3 other totally dependent residents at a 1/2 moon table. E6 repeatedly gave R14 small bites of potatoes but no meat, vegetables or apricots. At 1:50pm, R14 was still being given small bites of potatoes only. At 2pm, E6 stated she didn't know why R14 wasn't eating anything and discarded the entire plate of food along with the full glass of milk and water which she failed to offer/encourage at all. The intake recorded for that day was 25% of food and 0 fluid intake. This was recorded in error as observations showed R14 only ate approximately 25% of her potatoes only and not of the whole meal. According to monthly weight records, R14 weighted #118 in August 2011 and on 1/12/12 weighed 104 pounds. Other than the [MEDICATION NAME] being added to the care plan, the facility failed to develop a plan of care directly toward increasing R14's intake amount. The Registered Dietician's (RD) assessment dated [DATE] indicates R14's "meal intake varies" and she has no pertinent labs. There is no indication the RD attempted any supplements if meals were not consumed or that additional interventions were added to the care plan in an effort to increase her meal intake and daily caloric amounts. There is no indication R14 gets a snack between meals as ordered when appropriate. On 1/30/12 at 12noon, the Dietary manager E20 stated R14 gets only milk and no supplements. She confirmed that the intakes recorded may not be accurate and that no intake for supplements and/or shakes were recorded at this time if residents do have them ordered.

Based on record review and interview, the facility failed to conduct assessments and interventions; and care planning related to a change in condition, pain management, coordination of care with [MEDICAL TREATMENT] services for one (R1), of four residents receiving [MEDICAL TREATMENT] services, and for one (R1) of two residents who had a significant change of condition and were hospitalized with a urinary tract infection, of 9 residents on sample. This failure resulted in R1 being hospitalized with the [DIAGNOSES REDACTED]. Findings include: The Physician's History and Physical, dated 3/31/11, documents R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Nurses Note, dated 3/31/11, documents R1 returned from Z1, physician's office, with an adjustment in pain medications, including a new physician's orders [REDACTED]. Z1's History and Physical, dated 3/31/11, reads, "pain-left lumbar area and at site of shingles-recently started on [MEDICATION NAME] 25 mcg/hour-drowsy. Has tried [MEDICATION NAME] ([MEDICATION NAME]) without any relief." The Nurses Note, dated 4/01/11, at 8:00 AM, documents R1's color is pale, she is refusing breakfast, drank only 240 cc (cubic centimeter) of water, is drowsy and requests to remain in bed. No documentation was noted R1's vital signs were taken at this time. R1 left for [MEDICAL TREATMENT] at 11:00 AM. The Nurses Note, dated 4/01/11 at 12:10 PM, documents R1 is becoming more dependant on staff for ADL's (activities of daily living), has decreased appetite and oral intake, open areas to the buttocks, and continuous pain. R1's family was notified, and Z1 was called with a message left to return the call. No documentation is found to determine if Z1 returned the call to the facility acknowledging R1's change in condition. The Nurses Note, dated 4/01/11, at 1:30 PM, documents the [MEDICAL TREATMENT] provider called the facility to report R1 was hypotensive, BP (blood pressure) of 70 systolic, 40 diastolic, and they considered sending R1 to the hospital. The facility faxed the [MEDICAL TREATMENT] provider a list of R1's current medications. R1 returned to the facility at 4:10 PM, very pale and more confused. No documentation is found as to what happened during [MEDICAL TREATMENT], or why R1 was not sent to the hospital. The physician was not notified. At 5:00 PM, R1 remains hypotensive with BP of 90/50, but the physician is not notified. In an interview E2, Director of Nursing, (DON), on 4/07/11, at 12:55 PM, reported she was unaware why the [MEDICAL TREATMENT] provider wanted to send R1 to the hospital, but R1 was not sent to the hospital that day. No [MEDICAL TREATMENT] record for 4/01/11 was available at the facility until it was requested by the surveyor 4/07/11. The Nurses Note, dated 4/02/11, at 11:25 AM, documents R1's appetite remains poor. The Nurses Note, dated 4/02/11, at 4:40 PM, documents R1's skin color is pale, with an oxygen saturation level of 90 per cent,with oxygen delivered via nasal cannula at two liters, has a poor appetite, and a temperature of 100.1 degrees Fahrenheit (F). E3, Licensed Practical Nurse (LPN), documents an antipyretic was administered with encouragement. No documentation is noted Z1 was notified of R1's fever or decline in condition. No documentation is noted for R1's nutritional intake or fluid intake The Nurses Note, dated 4/03/11, at 6:00 AM, documents the following; R1's skin was moist with a temperature of 102.2 degrees F, a blood pressure of 80 systolic and diastolic of 40, pulse of 120 beats per minute, verbally unresponsive, lower extremity [MEDICAL CONDITION] and cyanosis, with an ashen/gray skin color. At that time, Z1 was notified of R1's change in condition, and an order was received to send R1 to the hospital via an ambulance for evaluation and treatment. In an interview on 4/06/11, at 10:40 AM, E3, LPN reported she did not call Z1 related to R1's fever and decreased intake. E3 stated, "We don't have to call him (Z1) unless a temperature is 101.0 degrees F or above. I didn't recheck her (R1's) temperature." On 4/07/11, at 9:00 AM, E4, LPN stated when asked about R1's condition the late evening shift of 4/02/11 and night shift of 4/03/11, "(R1) was tired with a poor appetite. When I did evening med (medication) pass at 8:30 PM, I took her temperature. It was 100.1. She wasn't drinking well . I gave her [MEDICATION NAME] per her request. When we turned her , she really moaned. I gave her mouth care and her oral mucosa was really dry." E4 reported R1 was only taking sips of water. E4 reported around 5:30 AM of 4/03/11, R1 was not responding verbally. When asked if she was in pain, E4 reported R1 nodded 'yes'. E4 reported she took R1's temperature and "it was 102 something". E4 reported R1"was constantly in pain from shingles." E4 reported both of R1's lower and upper extremities were [MEDICAL CONDITION], and she had excoriated and redness to both buttocks. E4 reported she had no concern R1 was dehydrated, because she had a history of [REDACTED]. E4 reported she did not document the amount of R1's fluid intake during her shift. In an interview on 4/06/11, at 1:25 PM, Z1, physician reported R1 was stable when he examined her on 3/31/10, with no signs of infection. Z1 reported R1 was "groggy" in the office, and he made a change in her pain medication. When asked if he was aware R1 began to have an elevated temperature on 4/02/11, Z1 stated, "They (facility) should have called me. I would have told them to monitor her more closely. A UTI (urinary tract infection) could develop very rapidly due to her kidney failure. She (R1) has a history of UTI's." Z1 reported he has no standing physician's orders [REDACTED]. R1's Pain Assessment, dated 3/22/11, documents R1 has left hip pain related to a recent [MEDICAL CONDITION] and shingles to the left lower abdomen. The Pain Assessment documents R1 is able to verbalize pain. Z1, Physician had ordered on [DATE], [MEDICATION NAME] 5 mg/[MEDICATION NAME] 325 mg (milligrams) two tablets every six hours, for R1's pain management. On 3/30/11, Z1 added [MEDICATION NAME] 25 mcg (micrograms) [MEDICATION NAME] every 72 hours. On 4/7/11, R1's Medication Administration Records for 3/2011 and 4/2011 was reviewed. R1's physician's orders [REDACTED]. During an interview on 4/7/11, at 12:53 PM, E2, DON reported the order of [MEDICATION NAME] 12 mcg and [MEDICATION NAME] 50 mg was never filled by their pharmacy provider. The PRN MAR's fail to assess the intensity of R1's pain when medication is given. R1's Instant Care Plan was reviewed. One problem listed is pain to the left hip, shingles-uncontrolled pain, scheduled pain medication and PRN (as needed), with an intervention for R1 as "assess for pain, intensity, administer meds (medication) as ordered". The Care Plan documents R1 has a Quentin catheter ([MEDICAL TREATMENT]) to her right chest, [MEDICAL CONDITION] to all four extremities, and is toe touch weight bearing with a wheeled walker. No interventions are marked to monitor R1's weight. Attached to R1's Care Plan is Procedures for the Care of [MEDICAL TREATMENT] Resident. Several of the interventions for care and warnings signs for the access site are marked out, including daily monitoring for the thrill for any changes or blood clots. The procedure reads, "The most common adverse reaction to monitor for following [MEDICAL TREATMENT] is [MEDICAL CONDITION]". On 4/11/11, at 3:00 PM, E2 reported the procedures for the care of a [MEDICAL TREATMENT] resident came from the [MEDICAL TREATMENT] provider, not the facility. E2 reported she did not know why some of the interventions had been crossed out. On 4/11/11, at 4: 35 PM, E1, Administrator stated, "We have no facility policy for monitoring [MEDICAL TREATMENT] residents. No procedures." The Outpatient [MEDICAL TREATMENT] Services Agreement, signed by E1, Administrator, dated 3/23/2007, reads, in part, "The parties will mutually develop a written protocol governing specific responsibilities, policies and procedures to be used in rendering [MEDICAL TREATMENT] services to residents at the [MEDICAL TREATMENT] unit, including but not limited to, the development and implementation of a resident's care plan relative to the provision of [MEDICAL TREATMENT] services. The Nursing Facility will provide for the interchange of information useful or necessary for the care of the resident...The Company agrees to provide [MEDICAL TREATMENT] services and to provide to the Nursing Facility information on all aspects of the management of the residents care related to the provision of [MEDICAL TREATMENT] services, including directions on management of medical and non-medical emergencies, including, but not limited to, bleeding/hemorrhage, infection/bacteria, and care of [MEDICAL TREATMENT] and disinfection of [MEDICAL TREATMENT]." On 4/11/11, the evening shift LPN's (E3, E8, E10, E12) and Certified Nurses Aides, (CNA), (E9, E11) were interviewed related to care of residents on [MEDICAL TREATMENT]. At 3:00 PM, E3 reported she checks for bruit every shift, but does not document the information. E3 reported intake and output records are only kept on residents who have a fluid restriction and stated, "not necessarily [MEDICAL TREATMENT] residents." At 3:05 PM, E8 confirmed he does not check [MEDICAL TREATMENT] or document the information on residents every shift he works. E8 reported the [MEDICAL TREATMENT] provider does not send the facility any information related to the residents on [MEDICAL TREATMENT]. At 3:40 PM, E10 stated, "We are supposed to check [MEDICAL TREATMENT] resident's BP (blood pressure) before and after [MEDICAL TREATMENT], and write it in the Nurses Notes, but I don't always do it. The shunt site should be checked at a minimum daily." E10 reported each [MEDICAL TREATMENT] resident has a notebook that is taken with them to [MEDICAL TREATMENT] that includes only information from the day shift before they leave. At 3:55 PM, E12 agreed with E10, and reported, "[MEDICAL TREATMENT] calls us if there is a problem." E12 reported the intake a resident receives while at [MEDICAL TREATMENT] is not reported in the daily Intake and Output record. A review of the Intake and Output Record for 4/2011 for R2, R8, and R9 were noted to be incomplete. E2 reported there was no intake and output records documented for R1 during her stay at the facility to determine adequate nutrition or hydration. The Dietary Assessment, dated 3/18/11, documents R1's fluid needs to be 2250 cc (cubic centimeter) daily with no fluid restriction. The hospital's History and Physical, dated /03/11, documents R1 was admitted with the [DIAGNOSES REDACTED].

Based on record review and interview, the facility neglected to assess, monitor, and implement interventions for a decline in condition for one, (R1) of four residents on [MEDICAL TREATMENT] in a sample of 5. This neglect resulted in R1 experiencing signs and symptoms of an infection and increased dependence on staff for all activities of daily living, and [MEDICAL CONDITION] to the lower extremities. As a result of this neglect, R1 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. Findings include: The Physician's History and Physical, dated 3/31/11, documents R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Nurses Note, dated 3/31/11, 10:30 AM, documents R1 was alert and oriented to all spheres, with vital signs within normal limits. The Nurses Note dated 3/31/11 at 4:35 PM, documents R1 returned from Z1, physician's office, with an adjustment in pain medications, was drowsy, and had left arm [MEDICAL CONDITION] with complaint of pain. The Nurses Note, dated 4/01/11, at 8:00 AM, documents R1's color is pale, she is refusing breakfast, drank only 240 cc (cubic centimeter) of water, is drowsy and requests to remain in bed. No documentation was noted R1's vital signs were taken at this time. R1 left for dialysais at 11:00 AM. The Nurses Note, dated 4/01/11 at 12:10 PM, documents R1 is becoming more dependant on staff for ADL's (activities of daily living), has decreased appetite and oral intake, open areas to the buttocks, and continuous pain. R1's family was notified, and Z1 was called with a message left to return the call. No documentation is found to determine if Z1 returned the call to the facility acknowledging R1's change in condition. The Nurses Note, dated 4/01/11, at 1:30 PM, documents the [MEDICAL TREATMENT] provider called the facility to report R1 was hypotensive, BP (blood pressure) of 70 systolic, 40 diastolic, and they considered sending R1 to the hospital. The facility faxed the [MEDICAL TREATMENT] provider a list of R1's current medications. R1 returned to the facility at 4:10 PM, very pale and more confused. No documentation is found as to what happened during [MEDICAL TREATMENT], or why R1 was not sent to the hospital. The physician was not notified. At 5:00 PM, R1 remains hypotensive with BP of 90/50, but the physician is not notified. In an interview E2, Director of Nursing, (DON), on 4/07/11, at 12:55 PM, reported she was unaware why the [MEDICAL TREATMENT] provider wanted to send R1 to the hospital, but R1 was not sent to the hospital that day. E2 reported there was no intake and output records documented for R1 during her stay at the facility to determine adequate hydration. The Nurses Note, dated 4/02/11, at 11:25 AM, documents R1's appetite remains poor. The Nurses Note, dated 4/02/11, at 4:40 PM, documents R1's skin color is pale, with an oxygen saturation level of 90 per cent,with oxygen delivered via nasal cannula at two liters, has a poor appetite, and a temperature of 100.1 degrees Fahrenheit (F). E3, Licensed Practical Nurse (LPN), documents the antipyretic, Tylenol ([MEDICATION NAME]), 10 grains was administered with encouragement. No documentation is noted Z1 was notified of R1's fever or decline in condition. At 10:00 PM, R1 is documented as "very sleepy" and appetite remains poor. A review of R1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Nurses Note, dated 4/03/11, at 12:00 AM, documents R1 is only taking sips of water with lots of cueing. At 6:00 AM, the Nurses Note documents the following; R1's skin was moist with a temperature of 102.2 degrees F, a blood pressure of 80 systolic and diastolic of 40, pulse of 120 beats per minute, verbally unresponsive, lower extremity [MEDICAL CONDITION] and cyanosis, with an ashen/gray skin color. At that time, Z1 was notified of R1's change in condition, and order was received to send R1 to the hospital via an ambulance for evaluation and treatment. In an interview on 4/06/11, at 10:40 AM, E3, LPN reported she did not call Z1 related to R1's fever and decreased intake. E3 stated, "We don't have to call him (Z1) unless a temperature is 101.0 degrees F or above. I didn't recheck her (R1's) temperature." On 4/07/11, at 9:00 AM, E4, LPN stated when asked about R1's condition the late evening shift of 4/02/11 and night shift of 4/03/11, "(R1) was tired with a poor appetite. When I did evening med (medication) pass at 8:30 PM, I took her temperature. It was 100.1. She wasn't drinking well . I gave her [MEDICATION NAME] per her request. When we turned her , she really moaned. I gave her mouth care and her oral mucosa was really dry." E4 reported R1 was only taking sips of water. E4 reported around 5:30 AM of 4/03/11, R1 was not responding verbally. When asked if she was in pain, E4 reported R1 nodded 'yes'. E4 reported she took R1's temperature and "it was 102 something". E4 reported R1"was constantly in pain from shingles." E4 reported both of R1's lower and upper extremities were [MEDICAL CONDITION], and she had excoriated and redness to both buttocks. E4 reported she had no concern R1 was dehydrated, because she had a history of [REDACTED]. In an interview on 4/06/11, at 1:25 PM, Z1, physician reported R1 was stable when he examined her on 3/31/10, with no signs of infection. Z1 reported R1 was "groggy" in the office, and he made a change in her pain medication. When asked if he was aware R1 began to have an elevated temperature on 4/02/11, Z1 stated, "They (facility) should have called me. I would have told them to monitor her more closely. A UTI (urinary tract infection) could develop very rapidly due to her kidney failure. She (R1) has a history of UTI's." The History and Physical, dated 4/03/11, from R1's admitting physician at the hospital lists admitting [DIAGNOSES REDACTED]. The Emergency Services Patient Care Notes, dated 4/03/11, document R1 arrived at 7:02 AM displaying, in part, the following symptoms; lethargic, hypotensive with elevated pulse, pale, with skin hot to the touch, mucous membranes very dry, mouth containing crushed pills on the roof of her mouth, and skin dry and scaly with 2+ [MEDICAL CONDITION] to bilateral lower extremities. At 7:20 AM, an indwelling urinary catheter was inserted for R1 and "thick, purulent, with foul odor, brownish/yellow in color" urine was obtained.

Based on interviews, observations and record review, the facility failed to ensure that 4 (R3, R10, R12 and R17) of 13 sampled residents were provided services necessary for timely blood glucose monitoring (R10), monitor and treat a rash (R3), assess and monitor for aspiration and loose stools (R12) and assess/monitor injuries/scabbed areas on lower extremeties (R17). Findings include: 1. R12's May 2011, Physician order [REDACTED]. R12's Treatment Record for May 1 thru May 24, 2011, shows skin checks are documented as being done by Nurses initialing each day . R12 was observed on 5-24-11 at 12:05PM to have multiple scabs on his left shin and 1 on his left upper foot. R12 had a larger reddened area on his left mid shin that E4, Care Plan Coordinator, stated was an old area that had the treatment discontinued. R12 had a small BB size superficial abrasion on his right shin. Review of R12's most current Care Plan states R12 has potential for skin breakdown with note documented on 5-6-11 that R12 has an abrasion to left shin and note of 5-10-11 stating area is healed. R12's Treatment Record shows treatment on the lower left leg staring on 5-5-11 and discontinued on 5-12-11. There is nothing on R12's Care Plan or Treatment Record concerning the multiple scabs on his left lower extremity. On 5-25-11, at 9:55AM, E4 stated R12 picks at his skin causing the scabs and stated she had revised his Care Plan. E8, Licensed Practical Nurse (LPN) was present and confirmed R12 picks at his skin causing the scabs. The Care Plan note documented on 5-24-11 state R11 has a habit of picking at his skin and scabs with interventions to redirect R12; let nurse know if there is a need to initiate a treatment (bleeding, etc); give R12 something to hold ie: stuffed animal, pillow, etc. 2. R17's Physician order [REDACTED]. R17's Nurses Notes from 5-9-11 to 5-20-11 show documentation 12 times that R17 is non-compliant with his fluid restriction/nectar thickened liquids and is drinking water from his bathroom sink and the water fountain. Speech Therapist note of 5-18-11 shows less signs and symptoms of aspiration with cold water for 8 of 8 trials. Note states R17 has decreasing signs and symptoms of aspiration with thin liquid trial with speech therapy. There is nothing in the speech therapist concerning R17 drinking water from the water fountain and his bathroom. R17's most current Care Plan documents R17 has a swallowing problem and a pureed diet with nectar thickened liquids and 1500 cc fluid restriction. Undated written note documents R17 is non- complaint with his fluid restriction and thickened liquid. There is nothing on the Care Plan addressing interventions to use when R17 is non-compliant. On 5-25-11 at 10:00AM, E4, was informed of the concern. E4 later provided a revision to the Care Plan dated 5-25-11 documenting R17 is non-compliant with his fluid restriction and thickened liquids. Care Plan interventions are: remind R17 of the consequences every time he attempts to be non compliant; check with nurse to see if he may have more fluids at this time; offer to reward me with and an extra cigarette if I remain compliant for the day; Intake and Output every shift; attempt to redirect when non-compliant. Nurses Notes of 5-20-11 at 1030 state R17 is restless, color pale, with oxygen saturation of 87-93%, crackles noted. R17 noted earlier in shift drinking from water fountain. Call place to Physician's office. Note at 1021 states Physician Assistant returned call and was informed of the above. Temperature 101.2 Note shows an ambulance was called. Note at 6PM states R17 was admitted to the hospital with [REDACTED]. Hospital History & Physical of 5-20-11 documents R17 has a history of [MEDICAL CONDITIONS] and recurrent aspiration pneumonia. H&P documents fever of unknown origin...Will do a CT scan of the abdomen as R17 as he had been complaining of abdominal pain, to rule out any [MEDICAL CONDITION] also check the stool for [DIAGNOSES REDACTED]icile. On 5-25-11, E4 stated R17 was admitted to the hospital, but they ruled out aspiration. Hospital Progress Note of 5-21-11 shows R17 had profuse diarrhea and had to have a Flexiseal inserted. Assessment and plan: Nonspecific [MEDICAL CONDITION], could be due to antibiotics and will check for [MEDICAL CONDITION]; [MEDICAL CONDITION], could be due [MEDICAL CONDITION]; Mild Mental [MEDICAL CONDITION]; [MEDICAL CONDITION]; Chronic [MEDICAL CONDITION]; Recent aspiration pneumonia which has been improving. Chest X ray of 5-20-11 shows improved left upper lobe [MEDICAL CONDITION] infiltrate with no new infiltrates noted from last X-ray. Facility Bowel and Bladder records for May 2011 show there is no documentation for bowel movement until 5-5-15. On 5-15-11 it is documented R17 had a loose stool on 1 shift. The other 2 shifts are blank. On 5-16-11 one shift documents 0 bowel movement. The other two shift are left blank. One 5-19-11 one shift documents no bowel movement and one shift documents continent. On 5-20-11 it is documented no bowel movement and then H for hospital. E6 stated on 5-25-11 at 1:50PM, R17 had very loose stools about a week ago and he was soiled all the way up his back. E6 stated another CNA gave him a shower to clean him up. There is nothing in the nurses notes of R17 having loose stools. 3. R10's Physician Order, dated 11-26-10, documented "Finger stick glucose monitoring AC & HS (before meals and at nights)" scheduled for 7:00a.m., 11:00a.m., 5:00p.m. and 8:00p.m. It was also noted "Insulin [MEDICATION NAME] R U-100 10ml inject sub-q (subcutaneous) per sliding scale (glucose monitoring)" During observation of R10's glucose monitoring, on 5-24-11 at 11:30p.m., E12, Licensed Practical Nurse (LPN), administered R10's finger stick glucose monitoring at 12:50a.m. and then administered 2 units of [MEDICATION NAME] R for a glucose reading of 156, as per the sliding scale. R10 repeated stated, at that time, "I'm hungry...I'm really hungry." R10 was not provided food until 1:30p.m., on 5-24-11, when R10 was served his noon meal. During refutation, on 5-25-11 at 9:50a.m., E2 stated, the dietician would make a list of diabetics who would be served their meals first to facilities timing of glucose monitoring. E2 also stated staff were inservice. 4. R3's Minimum Data Set (MDS), dated [DATE], R3 was a confused resident who was assessed for total to extensive assistance of one person physical assistance with transfer, mobility and toileting. R3's Care Plan, provided as current care plan, documented R3's had a potential for skin breakdown related to decreased mobility and incontinence. It was also noted his skin would be checked daily and report to the nurse ant reddened areas. During observation of R 3' s' transfer and skin check, on 5-24-11 at 12:10p.m., E13, Certified Nursing Assistant (CNA) and E14, Certified Nursing Assistant (CNA), transferred R3 from reclining chair to bed with a mechanical lifting device. R3's left and right buttock, coccyx and lower back region observed slightly creased with scattered areas of general redness and 1 to 2cm round darker areas with whitened centers. During observation of R3's transfer and skin check, on 5-25-11 at 10:47a.m., E16, Certified Nursing Assistant (CNA) and E15, Certified Nursing Assistant (CNA), transferred R3 from reclining chair to bed wit a mechanical lifting device. R3's left and right buttock, coccyx, lower back region and his right upper back to shoulder observed slightly creased with scattered areas of general reddened and 1 to 2 cm darker areas with whitened centers. It was also noted these areas were increased in size from the 5-14-11 observation. During review of R3's Nursing Notes and interview with E5, Wound Nurse, on 5-25-11 at 11:45a.m., E5 stated R3's Nursing Notes, dated 5-24-11 and 5-25-11, did not document the observed areas of skin breakdown of 5-24-11 and/or 5-25-11. E5 also stated his skin was excoriated, checked daily and a cream was applied. R3's Treatment Record, dated April, 2011 and May, 2011, and his Nursing Notes, dated 4-6-11 to 5-25-11, did not documented R3's skin was checked daily or a cream was applied. E5, stated, on 5-25-11 at 11:45a.m., that R3's Treatment Record and Nursing Notes did not document R3's skin was checked daily or a cream was applied. E5 provided a Physician's Progress Note, dated 9-1-10, that documented "lays on right side. [MEDICAL CONDITION] reach (?) rt (right) lower truck areas and rt upper thigh...Rx (treatment) with Aristrocore cream. E5 also stated she would inform the visiting physician's assistance for a treatment. R3 was ordered, on 5-25-11 at 3:00p.m., "Aristrocore Cream BID (twice a day) x (times) 1 week." The facility's Policy For Use of Body Outline Sheet For Resident Skin Assessment", dated 5-01, documented goal "to assure that observation of entire body surface is completed on a regular basis to determine any areas of concern regarding skin, and that any abnormal areas are noted by professional staff with timely follow-up.."