Every finding on record at Nexus at Columbia

Based on interview and record review, the facility failed to maintain resident safety during a transfer involving a broken shower chair for 1 of 6 residents (R3) reviewed for resident safety in the sample of 11. This failure resulted in R3 being sent to the emergency room (ER) for x-rays and sutures placed and causing R3 pain and suffering. The findings include:R3's admission Record, dated 8/4/26, documents R3 was admitted to the facility on [DATE] with diagnosis of Acute Transverse Myelitis in demyelinating disease of central nervous system, Osteomyelitis, Type 2 Diabetes Mellitus (DM), Obesity, Chronic Obstructive Pulmonary Disease (COPD), Chronic Pressure Ulcers (PU), Obstructive and Reflux Uropathy, Anemia, Major Depressive disorder, Polyneuropathy, Hypertension (HTN), Atrial-Fibrillation, Congestive Heart Failure (CHF), Peripheral Vascular Disease (PVD), Dorsalgia, and Benign prostatic hyperplasia (BPH).R3's Care Plan, dated 12/9/24, documents R3 is at risk for falls relate to Type 2 DM, pain, COPD, HF, self-care deficit. 9/26/24: Fall from bed; no injuries. Interventions: 9/26/24 Staff and resident to ensure wheelchair is properly placed next to bed prior to transfers, Environmental modification: trapeze to assist with repositioning, Fall risk assessment quarterly and as needed, Monitor for any changes in condition, Monitor resident for tolerance and endurance. Schedule tasks accordingly. It continues R3 requires assist with daily care needs r/t physical and functional deficits self-care deficits. Resident has supra-pubic catheter, incontinent of bowel; use WC with assistance needed with bed mobility, transfers and toileting. Resident is Hoyer lift with transfers. It continues R3 has a self-care deficit in transferring. Interventions: Use adaptive equipment: Standard Walker/ Rolling Walker/ Quad Cane/ Sliding Board/ Gait belt. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact and is dependent on staff for Activities of Daily Living (ADLs). R3 has a urinary catheter and is always incontinent of bowel.On 8/4/26 at 1:12 PM, R3 stated he was getting transferred by a (full body mechanical lift) when his left leg/foot got caught on the bars and bent it. R3 stated the staff thought they broke his foot, but it only cut his foot open. R3 stated he was sent to the ER and had no fracture. R3 stated it hurt pretty bad, especially with getting sutures.R3's Nurses Note, dated 6/17/26 at 11:17 AM, documents, Res (resident) was taking a shower this morning and hit his toe on the shower chair. As a rest of hitting his toe it split open. The rest was sent out to memorial hospital. NP (Nurse Practitioner), family and DON (Director of Nursing) aware.R3's Nurses Note, dated 6/17/26 at 1:10 PM, documents, During shower this am the resident sustained injury to space between digit 4 and 5, injury assessed by NP with (wound company) wound care during wound rounds N.O. (new order) to send to ER for eval and treat.The facility's investigation on R3's incident, dated 6/19/26, documents, Initial: (R3) had a potential injury to foot, Medical Director, Director of Nursing, and responsible party notified. Resident sent to Emergency Department to assess. Investigation initiated. Final to follow. Final: On 6/17/26 (R3) obtained a laceration to his left foot between 4th and 5th digitals while transferring from the shower chair to his bed. The Physician, Director of Nursing, and responsible party were notified. (R3) was transferred to the Emergency Department on 6/17/2026 where he received 9 sutures to his left foot. (R3) returned to facility on 6/17/2026. Requires a (full body mechanical lift) for transfers and dependent on staff for transfers and activities of daily living. (R3) is incontinent of bowels and has a foley catheter. Root cause analysis: (R3) obtained a skin tear from foot being caught on broken shower chair. New interventions implemented to include: *Broken shower chair removed and discarded immediately. *New shower chair ordered and arrived at facility. Incident Description - Nursing Description: During routine shower resident's left foot was caught on broken shower chair and obtained a laceration between his 4th and 5th digits. Resident Description: Caught on something during transfer.V8, Certified Nursing Assistant (CNA's), handwritten note, dated 6/17/26, documents, Got (R3) up for a shower, was putting him back to bed when his legs were on the wrong side of the (full body mechanical lift), was turning him when his feet got stuck on the broken part of the chair and I thought it was just a little scratch cause blood came out, wrapped it and wound care came to look at it.V9, CNA's, handwritten note, dated 6/18/26, documents, Raised pt. (patient) out of shower chair. He was turned the wrong way. Turned him around and his foot got caught on the chair.V10, Licensed Practical Nurse (LPN's) Nurses Note, dated 6/17/26 at 11:23 AM, documents, Res. (resident) was taking a shower this morning and hit his toe on the shower chair. As a rest of hitting his toe it split open. The res. was sent out to memorial hospital. NP (Nurse Practitioner), family and DON (Director of Nursing) aware.V9, LPN's Nurses Note, dated 6/17/26 at 1:12 PM, documents, During shower this am the resident sustained injury to space between digit 4 and 5. Injury assessed by NP with (wound care company) wound care during wound rounds. N.O. (new order) to send to ER for eval and treat.R3's Hospital Record, dated 6/17/26 at 12:45 PM, documents, HPI (History of Present Illness): (R3) is a 65 y.o. (year old) male presenting to the ED (emergency department) c/o (complaining of) laceration to foot. Patient is bed-bound. Facility was transferring him out of the shower when he cut his foot on the shower. Laceration between 4th and 5th toes. He does not know the last time he had a tetanus shot. He has no other acute symptoms. Laceration Repair: Location - top of left foot (between toes), 3 CM (centimeters) long. Number of sutures: 9.On 8/13/26 at 1:30 PM, V2, DON, stated, I would expect all staff assisting a resident to monitor facility equipment for anything broken, not to use the broken equipment, and to dispose of that equipment properly to avoid any resident injury.On 8/13/26 at 1:35 PM, V1, Administrator, stated, I would expect all staff to report or dispose of any piece of furniture or equipment they find is broken and to not use on a resident to maintain resident safety and well-being.The facility's Equipment Lock Out Policy, dated 9/2017, documents, To ensure equipment that is defective or does not work properly is not used. If a piece of medical equipment does not work property follow these guidelines: 1. Place a Do Not Use tag on the piece of equipment. The label may be obtained from the maintenance department or at the clinical units. 2. On the label describe the nature of the problem, current date, and your name so you may be contacted if additional information is requested. 3. Remove the equipment from the work area so it will not be used and place it where it may be picked up by Maintenance. 4. Notify Maintenance staff via online submission. If computer is unavailable, contact maintenance by phone.

Based on interview, observation, and record review, the facility failed to perform proper wound care to promote healing and to prevent infection for 1 of 3 residents (R3) reviewed for proper wound care in the sample of 11. This failure caused a delay in R3's wounds healing and/or the worsening of R3's wounds.Findings Include: R3's admission Record, dated 8/4/26, documents R3 was admitted to the facility on [DATE] with diagnosis of Acute Transverse Myelitis in demyelinating disease of central nervous system, Osteomyelitis, Type 2 Diabetes Mellitus (DM), Obesity, Chronic Obstructive Pulmonary Disease (COPD), Chronic Pressure Ulcers (PU), Obstructive and Reflux Uropathy, Anemia, Major Depressive disorder, Polyneuropathy, Hypertension (HTN), Atrial-Fibrillation, Congestive Heart Failure (CHF), Peripheral Vascular Disease (PVD), Dorsalgia, and Benign prostatic hyperplasia (BPH).R3's Care Plan, dated 12/9/24, documents R3 has skin complications r/t (related to) personal care deficit, obesity, edema, anemia, Type 2 DM, incontinent of bowel, self-care deficit and gout. R3 will refuse to get out of bed; allow staff to assist with personal hygiene/care and refuse repositioning in bed or wheelchair; or cushions being places in his wheelchair. R3 is not compliant with dressing changes and refuses to see the wound team for rounds. R3is refusing to wear heels protectors. Diabetic ulcer: Right lateral ankle malleolus, Venous ulcers: Right lower leg, Left medial foot heel, Left calf, Right foot 5th metatarsal. MASD: left medial ankle, Left posterior thigh, Right buttock. Pressure Ulcers: Left, lateral great toe, Right, lateral, anterior knee. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact and is dependent on staff for Activities of Daily Living (ADLs). R3 has a urinary catheter and is always incontinent of bowel.R3's Skin Assessment, dated 7/29/26, documents, No new skin issues noted.R3's Skin Assessment, dated 8/5/26, documents, Resident refused skin check and wound care today.R3's Physician Order, dated 7/29/26, documents, Wound culture of wound to right 5th metatarsal r/t increased drainage, wound worsening.R3's Physician Order, dated 2/2/26, documents, Enhanced Barrier Precautions for Indwelling Medical Device urinary catheter and for open wound on left foot and right leg.On 8/4/26 at 1:12 PM, R3 stated he has a wounds and gets dressing changes daily. R3 stated they do wear gloves during care, but he doesn't remember seeing them wear gowns. On 8/6/26 at 9:32 AM, V5, Wound Nurse, was observed performing wound care to R3 after donning Personal Protective Equipment (PPE). V5 used wound cleanser sprayed onto 4x4's to wipe each wound, would then change gloves with no hand hygiene done, then would apply the Calcium Alginate with Silver to each wound and cover with occlusive dressing. After cleaning R3's right leg wounds, V5 changed her gloves, the blanket fell onto his wounds with V5 pushing the blanket back off with her clean gloves, then applied the Calcium Alginate and dressing to the wound. V5 noticed a small area bleeding on R3's right lateral knee with V5 stating, That is new. I think that happened when I pulled the old dressing off and the skin stuck to it. V5 continued doing wound care and stated she was done. When asked about an open area on R3's right sacrum area, V5 stated, I did not see that one, it must be new. V5 left the room to get more supplies and re-entered with supplies placed on table. V5 donned gloves with no hand hygiene done, then applied a small piece of Calcium Alginate to R3's right sacrum area. When asked if she cleaned the wound yet, V5 stated, No, I forgot. and removed the Calcium Alginate piece and sprayed wound cleanser onto 4x4's and cleaned the wound, measured the wound (1 CM (centimeter) X 1.5 CM) then reapplied the Calcium Alginate to the wound followed by an occlusive dressing. V5 stated, I will have to let the NP (nurse practitioner) know about the new wounds and get an order for the one on his knee, for now, I'm just going to put an occlusive dressing on. During the entire wound care, which finished at approximately 10:30 AM, V5 changed her gloves multiple times, but did not do hand hygiene between glove changes each time. When asked why sometimes she does hand hygiene and sometimes she doesn't, V5 stated, I don't know, I was getting flustered. Also, during wound care to R3's legs, V5 used her clean gloved hands to move the curtain around herself, then would proceed with cleaning the wound and/or putting Calcium Alginate on the wound. V5 was seen picking up a piece of Calcium Alginate with Silver with her bare hands, and upon realizing what she had done, dropped it back on the barrier cloth, then donned gloves and picked it back up and placed it on R3's wound.R3's Wound Management Note, dated 7/29/26, document, Wound #3 Right, Lateral Ankle malleolus is an acute [NAME] Grade 2 Diabetic Ulcer acquired on 12/03/2025 and has received a status of Not Healed. The wound is deteriorating. Wound #4 Right Lower Leg is a Full Thickness Venous Ulcer and has received a status of Not Healed. There is no change noted in the wound progression. Wound #7 Left, Medial Ankle is an acute Full Thickness Moisture Associated Skin Damage and has received a status of Not Healed. There is no change noted in the wound progression. Wound #8 Left, Medial Foot Heel is a Full Thickness Venous Ulcer and has received a status of Not Healed. There is no change noted in the wound progression. Peri-wound skin presents with s/s of infection. Wound #11 Left, Posterior Thigh is a Full Thickness Moisture Associated Skin Damage and has received a status of Not Healed. There is no change noted in the wound progression. Wound #14 Left, Lateral Great Toe is an acute Stage 4 Pressure Injury Pressure Injury and has received a status of Not Healed. The wound is improving. Wound #15 Right Buttock is a Partial Thickness Moisture Associated Skin Damage and has received a status of Not Healed. There is no change noted in the wound progression. Wound #16 Right Foot 5th metatarsal is a Full Thickness Venous Ulcer and has received a status of Not Healed. The wound is deteriorating. Peri-wound skin presents with s/s of infection. Wound #17 Right, Lateral, Anterior Knee is an acute Stage 3 Pressure Injury Pressure Injury acquired on 05/29/2026 and has received a status of Not Healed. The wound is deteriorating. Wound #20 Left Calf is a Full Thickness Venous Ulcer and has received a status of Not Healed. There is no change noted in the wound progression.On 8/13/26 at 1:30 PM, V2, Director of Nursing (DON), stated I would expect all staff to don PPE upon entering and caring for a resident on Enhanced Barrier Precautions and/or any isolation. I would expect all staff to perform hand hygiene before resident care, during glove changes, and after resident care. I would expect all staff to perform glove changes when appropriate and/or when soiled. I would expect the nurses doing wound care to perform glove changes and hand hygiene during wound care and when going from soiled areas to clean areas and to not contaminate wound dressings and/or clean areas.On 8/13/26 at 1:35 PM, V1, Administrator, stated, I would expect all staff to maintain infection control practices by donning appropriate PPE for residents on Enhanced Barrier Precautions and/or isolation, performing hand hygiene and gloves changes when necessary, and reporting or disposing of any piece of furniture or equipment they find is broken and to not use on a resident. All of this is to maintain resident safety and well-being.On 8/13/26 at 2:30 PM, V19, Medical Doctor (MD), stated, Anytime you are not doing hand hygiene, or you are contaminating a wound, it is possible that they could get infected, but at the very least, it would cause a delay in the healing process.On 8/13/26 at 3:02 PM, V20, Physician/Medical Director, stated, If you do poor hand hygiene and/or glove changes during wound care, you may be contaminating the wound which could be delaying the healing of the wound and possibly causing an infection in the wound. That's always true.The facility's Wound Management Program, dated 6/2024, documents, The purpose of our Wound Management Program is: To identify risk factors for potential skin breakdown and wounds, to prevent skin breakdown and wounds as much as possible, to provide treatment that promotes the prevention of wounds and skin breakdown and the healing of existing wounds, when desired or possible, and to improve resident outcomes and quality of life by providing prevention and treatment or management of skin breakdown and wounds. In order to ensure our residents have access to the appropriate assessment and management to prevent, treat, maintain, or oversee palliative wounds, this facility will have an ongoing organized approach to wound care. This facility will employ the following pertinent aspects of wound care to achieve the mission of this wound Management Program: Assessment of the resident including risk factors for wound development including pressure injury. Periodic skin assessment and the assessment of wounds. Appropriate local wound care including management of bioburden, bacterial colonization, and infection. Preventative measures for pressure injury and other wounds as possible or allowed. Support for the healing of pressure injuries and other wounds that are present as possible or allowed. Improving the quality of care and clinical outcomes through the quality improvement process. Wound Cleansing and Dressings: It is the policy of this facility to cleanse all wounds and clear exudates, bacterial contamination, and debris from the wound bed. Optimal wound healing cannot proceed until inflammation-producing substances are removed from the wound bed. Wound cleansing is completed as indicated in the provider's order by the licensed nurse. It is the policy of this facility to perform wound dressing changes as ordered by the provider using clean technique on all chronic or contaminated wounds. A moist wound environment is most favorable for optimal wound healing. Clean Dressing Change Procedure: 1. Prepare a clean, dry area at the bedside. 2. Bring supplies into the resident's room. 5. Perform hand hygiene. 7. [NAME] gloves; in the event that personal contamination is anticipated, PPE such as gown and mask, should be worn. Remove soiled dressing and place in the plastic trash bag. 10. Remove soiled gloves and place in plastic trash bag. 11. Perform hand hygiene. 12. [NAME] clean gloves. Clean or irrigate the area/wound with appropriate cleanser as ordered (Normal Saline, wound cleanser, etc.); pat the peri-wound and wound areas dry with dry gauze. Apply prescribed treatment and/or dressing per physician treatment orders and secure dressing in place as indicated. Remove gloves and discard in plastic trash bag. Perform hand hygiene. Note: In the event more than one wound is present, each wound site is considered a separate treatment.

Based on interview, observation, and record review, the facility failed to maintain infection control practices for 6 of 11 residents (R1, R3, R4, R5, R10, R11) reviewed for infection control practices in the sample of 11. The findings include:1. R4's admission Record, dated 8/4/26, documents R4 was admitted to the facility on [DATE]. R4's Minimum Data Set (MDS), dated [DATE], documents R4 is cognitively intact. On 8/4/26 at 12:58 PM, there was an Enhanced Barrier Precautions (EBP) sign seen on R4's door with a PPE cart outside the door. R4 stated, The staff wear gloves when taking care of me, but no one wears a gown. R4's Physician Order, dated 3/24/26, documents, Enhanced Barrier Precautions for Indwelling Medical Device of Foley Catheter and Open wound. On 8/4/26 at 1:45 PM, V7, Registered Nurse (RN), brought in supplies to change R4's urinary catheter tubing and bag. V7 stated the catheter was just changed on 7/30/26 but the tubing has sediments and looks cloudy, so she is changing it. V7 failed to don appropriate PPE upon entering and while changing catheter tubing and performing catheter care. 2. On 8/13/26 at 9:53, V17, CNA (Certified Nursing Assistant) Supervisor, and V18, CNA, provided incontinent care and catheter care on R4. During care, V18 did appropriate glove changes, but there was no hand hygiene done. When asked, V17 stated, We don't have any little bottles of hand hygiene, all we have is the big ones on the walls. 3. R3's admission Record, dated 8/4/26, documents R3 was admitted to the facility on [DATE]. R3's MDS, dated [DATE], documents R3 is cognitively intact. On 8/4/26 at 1:12 PM, there was an EBP sign on the entry door, and a PPE cart outside the door. R3 stated he has a wound to his foot and gets dressing changes daily. R3 stated they do wear gloves during care, but he doesn't remember them wearing gowns while caring for him. On 8/6/26 at 9:32 AM, V5, Wound Nurse, in with supplies on clean barrier on table to do wound care to R3. V5 used wound cleanser sprayed onto 4x4's to wipe each wound, would then change gloves and apply the Calcium Alginate with Silver to each wound and cover with occlusive dressing. After cleaning R3's right leg wounds, V5 changed her gloves, the blanket fell onto his wounds with V5 pushing the blanket back off with her clean gloves, then applied the Calcium Alginate and dressing to the wound. During the wound care, which finished at approximately 10:30 AM, V5 changed her gloves multiple times, but did not do hand hygiene between glove changes each time. When asked why sometimes she does hand hygiene and sometimes she doesn't, V5 stated I don't know, I was getting flustered. Also, during wound care to R3's legs, V5 used her clean gloved hands to move the curtain around herself, then would proceed with cleaning the wound and/or putting Calcium Alginate on the wound. V5 was seen picking up a piece of Calcium Alginate with Silver with her bare hands, and upon realizing what she had done, dropped it back on the barrier cloth, then donned gloves and picked it back up and placed it on R3's wound. 4. R1's admission Record, dated 8/4/26, documents R1 was admitted to the facility on [DATE]. R1's MDS, dated [DATE], documents R1 is cognitively intact. On 8/4/26 at 12:50 PM, R1 stated the nurses do wound care every day and they always wear gloves, but no one ever wears a gown when caring for him or doing wound care. On 8/13/26 at 10:25 AM, R1 stated, They normally don't wear gowns when they come in or change my dressing, but today they are wearing them. They told me State's here, we have to wear them. So today they are wearing them. 5. R5's admission Record, dated 8/4/26, documents R5 was admitted to the facility on [DATE]. R5's MDS, dated [DATE], documents R5 is cognitively intact. R5's Skin Issues Note, dated 8/5/26 at 4:24 PM, documents, Skin Issues: Skin Issue: #1: Skin issue is resolved. Location: Right gluteus. Additional location information: right medial buttock, reopen previously healed wound Issue type: Pressure ulcer/injury. Progress: Resolved: Wound healed and/or closed. Pressure ulcer staging: Stage 2 Pressure ulcer/injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Exact date: 6/2/26 Staged by: Health care provider. On 8/4/26 at 3:05 PM, there was an EBP sign on R5's door with a PPE cart by the door. V13, CNA, was seen in the room transferring R5 to his wheelchair with no PPE on. R5 stated he has a sore on his right butt, gets a dressing change daily. R5 stated no one wears a gown only gloves when caring for him or changing his dressing. 6. On 8/6/26 at 9:05 AM, V11, Licensed Practical Nurse (LPN), was seen passing meds on 300-Hall. V11 was popping the medications out of the card and into her bare hands, then putting them in a cup. V11 missed the cup once and picked the pill up with her bare hand and put it into the medicine cup. V11 then was seen giving the cup of medications to both R10 and R11. On 8/13/26 at 1:30 PM, V2, Director of Nursing (DON), stated, I would expect all staff to don PPE upon entering and caring for a resident on Enhanced Barrier Precautions and/or any isolation. I would expect all staff to perform hand hygiene before resident care, during glove changes, and after resident care. I would expect all staff to perform glove changes when appropriate and/or when soiled. I would expect the nurses doing wound care to perform glove changes and hand hygiene during wound care and when going from soiled areas to clean areas and to not contaminate wound dressings and/or clean areas. On 8/13/26 at 1:35 PM, V1, Administrator, stated, I would expect all staff to maintain infection control practices by donning appropriate PPE for residents on Enhanced Barrier Precautions and/or isolation, performing hand hygiene and gloves changes when necessary. All of this is to maintain resident safety and well-being. On 8/13/26 at 2:30 PM, V19, Medical Doctor (MD), stated, Anytime you are not doing hand hygiene or are contaminating a wound, it is possible that they could get infected but at the very least, it would cause a delay in the healing process. Staff need to be wearing gowns and gloves when necessary. On 8/13/26 at 3:02 PM, V20, Physician/Medical Director, stated, If you do poor hand hygiene and/or glove changes during wound care, you may be contaminating the wound which could be delaying the healing of the wound and possibly causing an infection in the wound. That's always true. The facility's Enhanced Barrier Precautions (EBP) Policy, dated 10-16-25, documents, Our facility employs the use of Enhanced Barrier Precautions (EBP) to reduce transmission of MDROs to staff hands and clothing that employs targeted gown and glove use during high-contact resident care activities. EBP are indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: open wounds that require a dressing regardless of MRDO status, or an indwelling medical devices regardless of MDRO status, or colonization with a targeted MDRO (multidrug-resistant organism)/XDRO (Extensively Drug-Resistant Organism). Staff utilize gown and gloves for high-contact resident care activities when residents require EBP; high contact activities may include: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care: any skin opening requiring a dressing. The facility's Infection control - Personal Protective Equipment Policy, dated 10/2024, documents, To prevent the spread of infections from resident's known to be infected or colonized with pathogens that can be transmitted by contact, droplet or airborne transmission. PPE is chosen based on the nature of the task to be completed and the type of precautions involved. 2. [NAME] PPE when entering the room as indicated and before contact with the resident in the following order: a. Gown, b. Mask, c. Goggles/Face Shield, d. Gloves. 5. Remove gloves if they become torn, perform hand hygiene and replace gloves to complete the task.7. Perform hand Hygiene. The facility's Hand Hygiene Policy, dated 4/2026, documents, Proper hand hygiene is necessary for the prevention and the transmission of infectious disease. 1. Hand hygiene is done before and after resident contact, before and after any procedure, after using a Kleenex or the rest room, before eating or handling food, when hands are obviously soiled and regardless of glove use. 2. Hand hygiene is to be done before putting on gloves and after removing gloves. The facility's Medication Administration Policy, dated 10/2025, documents, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. 4. Hand Hygiene must be performed after: Touching an oral medication during administration, After touching any inanimate object possibly infected with microorganisms.

Based on interview and record review the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident for 1 of 1 (R2) resident reviewed for CPR in the sample of 6.This failure resulted in an Immediate Jeopardy that began on [DATE] and resulted in the death of R2, who had an unknown code status and was found breathless and unresponsive and did not receive lifesaving Cardiopulmonary Recusation efforts.On [DATE] at 11:39 AM V1, Administrator, V2, Director of Nursing (DON), and V9, [NAME] President of Clinical Operations, were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on [DATE], but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings Include: R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and had a medical diagnosis of Chronic Obstructive Pulmonary Disease, Cirrhosis of Liver, Hypertension, and Dysphagia. R2's MDS dated [DATE] documents R2 was severely cognitively impaired, and was dependent on staff for showering/bathing, sitting to lying, and toileting hygiene. R2's Medical Records do not document a code status. R2's Nurses Notes dated [DATE] at 4:14 AM documents this nurse went into residents room to help his roommate, while walking in noticed that resident was not breathing but was still warm to the touch. This nurse went to get a second nurse to verify no signs of breathing at 0414. The Facility's Final Investigation Report dated [DATE] documents On February 27, 2026, at approximately 4:00 A.M., a resident was discovered in their room by a licensed nurse. The nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes. Based on the clinical assessment, the nurse determined the resident had expired. At the time of the event, a review of the residents medical record did not identify documentation of a physician order for Do Not Resuscitate (DNR) or other advance directive limiting resuscitative efforts within the record available for review. Cardiopulmonary resuscitation (CPR) was not initiated due to the presence of apparent signs of death, and emergency medical services (911) were not activated. On [DATE] at 10:09 AM V3, Assistant Director of Nursing (ADON), stated a nurse called him and said a resident was having some respiratory distress. V3 stated he asked the nurse about the resident's code status and the nurse said she did not know the resident's code status. V3 stated if a resident's code status or POLST (Physician Orders for Life-Sustaining Treatment) form cannot be found or the facility does not have one, the resident is a full code. V3 stated when in doubt a resident is a full code. On [DATE] at 10:15 AM V2, DON, stated she was informed by V13, Licensed Practical Nurse (LPN), that a resident (R2) had passed. V2 stated when V13 was asked for R2's code status, V13 stated she did not know. V2 stated V13 did not initiate CPR or call 911 as she should have. V2 stated R2 was recently admitted from the hospital and the facility did not have R2's code status. V2 stated she looked through all R2's hospital records and there was no POLST form in the records. V2 stated if a resident's code status is unknown, the resident is a full code On [DATE] at 9:20 AM V24, Nurse Practitioner, stated she was informed by nursing staff that R2 has passed in the middle of the early morning. V24 stated she expects the facility to have a code status for every resident on file. V24 stated if CPR is not initiated on a resident in distress or who is not breathing, the resident will die. On [DATE] at 10:00 AM V25, Medical Director, stated he expects the facility to have a code status on file for every resident in the facility. On [DATE] at 10:36 AM V13, LPN, stated she went to answer R2's roommate's call light and noticed R2 was not breathing. V13 stated she called V11, Registered Nurse, into the room to verify that R2 was not breathing. V13 stated V11 verified that R2 was not breathing and V13 stated she informed V11 they would initiate CPR due to R2 not having a POLST form and V11 stated no. V13 stated she asked V11 again if CPR should be initiated due to not knowing R2's code status and V11 stated no. V13 stated R2 was a new admit and the facility did not have a POLST form stating if R2 was a full code or not. On [DATE] at 12:19 PM V10, Certified Nursing Assistant (CNA), stated about 4:00 AM she saw V13 coming out of R2's room and V13 looked upset. V10 stated V11 and V13 were in R2's room standing by R2's bed and it appeared that R2 was not breathing. V10 stated CPR was not initiated on R2. V10 stated if a resident's code status is not known or cannot be found, CPR is supposed to be initiated. Multiple attempts were made on [DATE] and [DATE] to contact V11, Registered Nurse, without success. The Facility's Advance Directives and DNR (Do Not Resuscitate) Policy Date Reviewed 9/2023 documents When a resident is admitted to the facility, a discuss of advance will take place between the resident and family if the resident is unable to make decisions. This enables staff to readily and clearly ascertain how to treat the resident in advance of an emergency. A Full Code/DNR order will be noted in the resident's medical record. The Facility submitted Abatement Plans and the Abatement Plan #3 was accepted on [DATE]. The Immediate Jeopardy which began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: The facility took the following actions to remove the Immediacy: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the identified deficiency and prevent any additional residents from suffering an adverse outcome. Completion Date: [DATE] R1 no longer resides at the facility Initiated on [DATE] All nursing staff/agency staff were in-serviced by DON/Designee on Cardiopulmonary Resuscitation (CPR) policy, Charting and Documentation, Notification of change and change in condition policy and procedure Completed education on [DATE] to include all current licensed nursing staff and scheduled agency licensed nursing staff. All new licensed nursing staff and licensed nursing agency staff will be educated by DON/Designee prior to their shift. CPR audit for nursing staff/agency staff completed by RNC/DON/Designee. Completed [DATE]. Review of the Charting and Documentation policy by VP of Clinical Operations completed [DATE] Review of the Change in Condition Policy by VP of Clinical Operation completed [DATE] Review of CPR policy by VP of Clinical Operations completed [DATE]. QAPI meeting will be held with the Medical Director on [DATE] attendance included Medical Director, LNHA, DON, ADON, Wound Nurse, Infection Control Preventionist, MDS Coordinators, Social Service Director, Facility Nurse Practioner, Human Resources Director, Activity Director, Maintenance Director and Regional Nurse Consultants. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. The Director of Nursing received copies of CPR cards for licensed nursing staff, completed on [DATE] DON/Designee will request copies of CPR cards for licensed nursing staff and will continue education prior to shift and or start date until next QAPI Review. The DON/designee will review the 24-hour report for any changes in code status or advance directive changes daily until next QAPI Review On [DATE] Code Status Audit was completed to ensure all Resident polst and code status orders were correct and in place. On [DATE] A complete code status audit was completed to ensure care plans reflect correct Code Status as documented on POLST form and Physician order. Upon admission a review of code status/POLST will be completed on all residents. If no signed POLST in place, resident is a Full code until a signed DNR is in place, initiated [DATE]. Ongoing monitoring: DON/SSD/Designee will audit new admissions to ensure code status, advanced directives, signed polst and physicians' orders regarding code status are in place daily x 4 weeks, then 3 times a week for 4 weeks, then monthly for 3 months. SSD/ Designee will audit 5 random residents to ensure code status, advanced directives, signed POLST and Physicians' orders regarding code status are in place. Daily x 4 weeks, then 3 times a week for 4 weeks, then monthly for 3 months. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. On [DATE], the surveyor validated the removal of the abatement through interviews with V5, V8, V19, and V30, review of staff CPR Certification, Code Status Orders and Audits, and verification of Code Status System in place.

Based on interview and record review, the Facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 11.Findings include: 1- R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction. R4's Minimum Data Set (MDS) dated [DATE] documented R4 was moderately cognitively impaired and ambulated via wheelchair. R4's Care Plan intervention last reviewed 2/12/26 documents R4 is at risk for abuse and neglect. On 4/29/26 at 8:37 AM, V5, Licensed Practical Nurse (LPN), stated R4 came to her and told her someone hit him and showed him a bruise on his left arm. V5 called V1, Administrator, to inform her of R4's allegation. On 4/28/26 at 3:10 PM, R4 stated he was going down the hall the other day and asked R5 to move when she just punched him in the arm. R4 had a light purple circular area on the back side of his left arm measuring approximately two inches in diameter. He stated this was witnessed by V27, Certified Nursing Assistant (CNA), and another staff he cannot remember. CNA V26's Written Statement documents, To Whom It May Concern I (V26) was present on April 16th 2026. I did not see anyone hit (R4). I seen everyone go there {sic} separate {sic} ways and that was the end of that. On 4/29/26 at 11:52 AM, V26 stated she was interviewed on 4/16/26 about an interaction between R4 and R5 and did not see any physical contact between R4 and R5. V27's Written Statement dated 4/16/26 documents, (R4) was coming down the hall and ran into (R5) wheelchair I didn't see (R5) hit (R4). On 4/29/26 at 12:13 PM, V27 stated she saw R4 run into R5's wheelchair on 4/16/26 but did not see R5 hit R4. R5's Undated Signed Statement documents R4 bumped into her in her wheelchair and she did not hit him. On 4/29/26 at 1:30 PM, V1 stated she was not aware of R4's 4/16/26 abuse allegation, and they were just investigating a bruise on his arm. On 4/29/26 at 1:45 PM, V2, Director of Nursing (DON), stated V5, Licensed Practical Nurse (LPN), notified her that R4 had a bruise on his arm. V2 conducted interviews regarding R4's bruise, but did not get a statement from R4 and probably should have. The Facility's Investigation does not contain statements from R4 or V5. The Investigation does not include initial or final reports with any determination of the cause of R4's bruise or whether the alleged abuse occurred. On 4/29/26 at 2:30 PM, V2 stated she expects the Facility to follow its abuse policy. The Facility's Abuse Policy last reviewed 9/2017 documents the Facility will immediately protect residents involved in identified reports of possible abuse and implement systems to promptly and aggressively investigate all reports and allegations of abuse.

Based on interview and record review, the Facility failed to report an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 11.Findings include: 1-R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction. R4's Minimum Data Set (MDS) dated [DATE] documented R4 was moderately cognitively impaired and ambulated via wheelchair. R4's Care Plan intervention last reviewed 2/12/26 documents R4 is at risk for abuse and neglect. On 4/30/26 at 8:37 AM, V5, Licensed Practical Nurse (LPN), stated R4 came to her and told her someone hit him, then showed her a bruise on his left arm. V5 called V1, Administrator, to tell her about the allegation. On 4/28/26 at 3:10 PM, R4 stated he was going down the hall the other day and asked R5 to move and she just punched him in the arm. He stated this was witnessed by V27, Certified Nursing Assistant (CNA), and another staff he cannot remember. On 4/29/26 at 1:30 PM, V1 stated she was not aware of R4's 4/16/26 abuse allegation. They began investigating a bruise on his arm, and it was determined he bumped into the door frame, so it was not reported. On 4/29/26 at 1:45 PM, V2, Director of Nursing (DON), stated she conducted interviews regarding R4's bruise, but did not report it because the cause was determined to be from R4 running into R5's wheelchair. On 4/29/26 at 2:30 PM, V2 stated she expects the Facility to follow its abuse policy. The Facility's Abuse Policy last reviewed 9/2017 documents the Facility will immediately protect residents involved in identified reports of possible abuse and implement systems to promptly and aggressively investigate all reports and allegations of abuse.

Based on interview and record review, the facility failed to prevent resident-to-resident physical abuse in 1 of 4 residents (R2) reviewed for abuse in the sample of 5. This failure resulted in R2 feeling unsafe in the facility and being hit in the breast. Findings include: 1. R1's Undated Face Sheet documents R1 was admitted to the facility on [DATE], and has the following medical diagnoses: Metabolic Encephalopathy, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Secondary Malignant Neoplasm of Unspecified Site, and Generalized Anxiety Disorder. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. R1's Undated Care Plan documents R1 is at risk for abuse and neglect related to interaction with staff and peers and poly-medication use. R1 has aggressive, inappropriate, attention-seeking, and/or maladaptive behavior. R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE], and has the following medical diagnoses Major Depressive Disorder, Bipolar Disorder, and Anxiety Disorder. R2's MDS, dated [DATE], documents R2 is cognitively intact. R2's Undated Care Plan documents R2 is at risk for abuse and neglect. R2 has history of verbal aggression towards staff, using profanity, and name calling. R2 also displays these behaviors with peers. R1's Nurse's Notes, dated 6/18/2025 at 1:47 PM, documents R1 was asking peers, staff, and visitors for money and was often verbally abusive. R2's Nurse's Notes, dated 6/18/2025 at 7:02 PM, documents R2 was angry at R1 because he opened her door and asked for money to buy soda. R1's Nurse's Notes, dated 6/18/2025 at 7:13 PM, documents R1 went to the room of R2 and asked for money to buy soda, and R2 was angry about it. R1's Nurse's Notes, dated 6/19/2025 at 2:45 PM, documents R1 was demanding money for soda and becoming verbally abusive, yelling, and cussing at peers. R1's Nurse's Notes, dated 6/21/2025 at 12:50 PM, documents R1 was yelling at staff with obscenities. R1's Nurses Notes by V8, Registered Nurse, dated 6/22/2025 at 3:07 PM, documents R1 has been rude and combative with residents and staff, upsetting other residents. Arguments have been taking place, and another resident claimed he hit her in the breast. R2's Nurse's Notes by V8, dated 6/22/2025 at 3:11 PM, documents R2 claimed a resident hit her. The Facility's Initial Report, dated 6/22/2025, documents the following: it was reported that there was an alleged resident to resident altercation in the dining room. R1 exhibits a behavior of asking residents, staff and visitors for money to buy sodas. Recently R1 exhibits verbal behaviors if they refuse to give R1 money. R1has been referred to psychiatry and sent to the hospital for assessment. It was reported that R1 was asking for money and R2 confronted R1. It was reported that R2 was antagonizing R1 and R1 hit R2 In the breast. The nurse assessed R2 with no injuries noted. The two residents were separated for safety. The Facility's Final Report, dated 6/26/2025, documents R1 was sent to the hospital for escalating behaviors and remained in the hospital. The Facility's Final Report, dated 6/26/2025, document R2 was interviewed and stated R1 was hurting V6, Activity Aide, by grabbing her arm, causing multiple bruises on V6's upper arm. R2 also stated R1 punched R2 in the breast. The Facility's Final Report, dated 6/26/2025, documents V6, CNA, was interviewed and confirmed the incident and R1's behavior. V6 stated she witnessed a part of the altercation because V6 left to get a CNA to help her with R1. V6 stated R2 was antagonizing R1 but did not see any physical contact. The Facility's Final Report, dated 6/26/2025, documents V7, CNA, was a witness to this incident, but did not contain documentation that V7 was interviewed during the Facility's investigation. The Facility's Final Report, dated 6/26/2025, documents camera was reviewed. R1 and R2 were sitting in the dining room to participate in a music activity, and R2 was talking to R1. R2 grabbed R1's chair arm, aggressively pushing and pulling it back and forth several times. At that time, R1 swatted at R2 to get her away, hitting R2's right breast. R1 hand was open. R2 hit R1 with two open hands and kicked R1 as R1 was leaving the room. The investigation concluded an altercation did take place. On 7/8/2025 at 11:41 AM, V8 stated R2 reported to her R1 pushed her and hit her on the breast in the dining room. On 7/8/2025 at 9:05 AM, R2 stated R1 had been cussing, yelling, and asking for money for days. R2 stated there was music playing in the dining room and R1 came up behind her and was being loud. R2 stated she turned around and asked R1 to be quiet and R1 stated F*** You, B****. R2 stated R1 would not stop. V6, Activity Aide, asked R1 to be quiet, and R1 cussed at V6 too. V6 told R1 that he had to leave, but R1 was irate. V6 went to find a Certified Nursing Assistant (CNA) to help her, and it took some time for her to find help. V6 came back and told R1 to leave, and R1 grabbed the back of V6's arm. R2 stated she grabbed R1's chair, just trying to jar it to stop R1, then R1 hit her on her right breast. V7, CNA, came to help V6, and V6 and V7 had to strong arm R1 to go to his room. R2 stated she does not feel safe in this facility. On 7/8/2025 at 9:44 AM, V6 stated there was music playing in the dining room and R1 was screaming F you because no one would give him a dollar. V6 told R1 to stop, but R1 would not. She tried to escort R1 out of the room, but he would not leave. V6 stated she went to get a CNA to help her and when she went back into the room, R2 had wheeled closer to R1. V6 stated she did not see anything happen, but R2 told her R1 had hit her in the breast. V6 stated R1 was still yelling and cussing at everyone when the music had stopped. On 7/8/2025 at 11:58 AM, V7 stated R1 was yelling and cursing at V6 in the dining room. V7 stated V6 came to ask for CNA help and when V7 walked into the dining room a minute later, R1 was swinging at V6. R2 was rolling up in her wheelchair to help V6, then R1 hit R2 because R1 was already swinging. V7 stated R1 hit R2 in the chest area. On 7/8/2025 at 12:50 PM, V1, Administrator, stated she watched the video footage where R1 was pushing R2 away and R2 was pushing R1's chair. V1 stated R1 did make contact with R2. The Facility's Abuse Policy and Prevention Program, dated 10/2022, documents, This facility affirms the right of our resident to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits neglect, exploitation, misappropriation of property, and mistreatment of residents. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observation, interview, and record review, the Facility failed to ensure residents wear treated in a dignified manner by providing timely toileting assistance and respecting the resident's right to a home-like environment for 2 of 6 residents (R1 and R4) reviewed for resident's rights in the sample of 6. This failure caused R1 to feel like V4 was mean to R1, resulting in R1 crying, and R4 feeling a little depressed. Findings include: 1. R1's Face Sheet, dated 4/23/2025, documents R1 has diagnoses including, but not limited to, Morbid Obesity, Need for Assistance with Personal Care, Weakness, Reduce Mobility, Depressive Disorder, and Anxiety Disorder. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and is dependent of toileting hygiene. The Facility's CNA (Certified Nursing Assistant) Staffing Assignment, dated 4/20/2025, documents V4 and V11 were assigned to R1's hall. It further documents V9 and V10 were assigned to 200 hall. On 4/22/2025 at 7:30 PM, V16, R1's sister, stated, My sister (R1) is heavy set and in a wheelchair. She is unable to stand without the help of the CNAs (Certified Nursing Assistants) to use the bathroom. She has been in and out of the hospital and is very weak. Now they have to use the (mechanical lift) to use the bathroom. I think they think using the lift is too much work. (R1) is terrified to stand up because she's weak. They tell her, 'you're going to have to stand up and not use the hoyer lift'. (V4, CNA) told (R1) you're gonna have to wait (to use the bathroom) because I have to serve lunch soon. For the past 6 months, I've heard (V4) talk harshly to (R1), telling her she has to wait to use the bathroom. She gets frequent UTIs (Urinary Tract Infections). If she has to wait 15-20 minutes to use the bathroom, she's about ready to pee her pants. (V4) said to her (R1), 'How old are you?' and (R1) replies, 'I'm 58' and (V4) tells her, '[AGE] year olds don't cry'. There's a resident two doors down, whose family is there everyday. The family member was waiting for her mom to lay down. (V4) points to her watch and said, I have only have 20 minutes left of my shift, I'll take you, but I have to lay (another resident) down, then I'll do you (take her to the bathroom). Another CNA told (V4), 'You can do (R1) first' and (V4) replied, 'This is a 24 hour facility, the next shift can do her.' The other residents family member looked at me like, 'I'm sorry'. (R1) ended up wetting herself because they don't want to take the time with her since she's a (mechanical lift). (V4) talks down to (R1). I took my sister outside to vape, and another CNA came out and said, 'I'm sorry you had to go through that. Nobody has the right to say shut up and quit crying.' (V10, CNA) has complained to (V1) many times about (V4) being rude and bullying the residents. I talked to (V1) about (V4) not wanting to take care of (R1), and (V1) said she had a lot of complaints about (V4) this weekend. I told (V1) I wanted (R1) off that hall because (V4) is rude, crude, harsh, and has no heart for these people. I told (V1) I am scared for my sister on the weekends. I cringe when I walk in and see her and my sister is always upset. She has been moved. Her (R1's) whole demeaner changed. The problem started when (R1) came back from the hospital and is now a (mechanical lift). I've never had a problem with any other staff besides (V4). She never has to wait 30 minutes to use the bathroom or they (other CNAs) will explain that they have to change someone else and then will help (R1). Now that she's extra work (due to the mechanical lift), they don't want to help her. I just love my sister and want her taken care of. V16 stated R1 resided on 100 hall on 4/20/2025, but had been moved to another hall. On 4/23/2025 at 11:25 AM, R1 stated, She (V4) was mean to me. She went off on me. I told her I had to go to the bathroom at a quarter to two. She said she's not going to, and that the next shift would have to. She had plenty of time. (V1) took care of it. That's why I moved to 400 hall. I cried to my sister about it. On 4/23/2025 at 11:45 AM, V9, CNA stated, It was 20 minutes before lunch on a Sunday. I was in the dining room. The CNA (not sure of her name) was almost yelling saying (R1) would have to wait until after lunch to go to the bathroom. Kind of caused a scene. There were other residents sitting around. I would have handled it differently. I felt like she should have quit yelling, but I'm not going to tell an older lady what to do. I mind my own business because I am new. On 4/23/2025 at 1:21 PM, V11, CNA, stated, This past weekend there was an issue. It was about taking (R1) to the bathroom. (R1) was heading to the dining room and started going back towards her room. I asked her where she was going. She said she had to use the bathroom. I said, 'Alright, let me go get (V4)' because (R1) is a hoyer. I told (V4) and (V4) said, 'She's going to have to wait, we have to get the trays passed'. I said, 'Why don't we just take her, if she has to go, she has to go. Let's just do it. I don't want someone telling me I have to hold my pee or poop.' (R1) stopped my sister, (V10) and we (V10 and V11) took her and got it done. I am sure she wet herself, but that's not unusual for her. (V4) then said (R1) had to stay in bed. I said 'no, let's get her back up. It takes a whole 5 seconds.' We got her up and went on about the day. (V4) was just adamant about those trays, but which is more important? Is it wrong to make (R1) wait? I personally wouldn't make her wait. On 4/23/2025 at 12:04 PM, V3, Director of Nursing (DON) stated, I was on call over the weekend. The only thing I know is (V2) said (R1's) sister was upset with her being on that hall because (R1) was having difficulty transferring, and felt the CNAs weren't taking care of her. It is my expectation that if someone has to use the bathroom, you take them. On 4/24/2025 at 8:00 AM, V16 stated, I hate to use the word abuse, because that's a strong word. I just feel like they don't want to spend the time since she's (R1) a (mechanical lift). I feel like it's more of a dignity issue because she talks down to her. Abuse is too harsh. (R1) gets nervous to ask to go to the bathroom. (V4) should prioritize her tasks. Someone in a wheelchair who needs to use the bathroom should come before laying someone down. (V4) talks to (R1) like she's a kid. 2. R4's Face Sheet, dated 4/24/2025, documents R4 has diagnosis of, but not limited to, Depression and Anxiety. R4's MDS, dated [DATE], documents R4 is cognitively intact. On 4/23/2025 at 1 PM, R4 was noticeably nervous, reluctant to answer questions, but stated, I don't want to get anyone in trouble. (V4) hollers a little. She says I'm taking up too much space. When asked to clarify, R4 pointed at some of her personal belongings in her room, including an Easter basket. R4 then stated, I guess she's not meaning to be mean, but it makes me feel a little depressed. On 4/23/2025 at 11:32 PM, V10, CNA stated, I don't really know what went on. I just know (R1) and her sister (V16) were outside and (R1) told me all about it. She said she had to go to the bathroom and (V4) told her she had to wait. They were going on and on about how rude and mean (V4) is. She's just a big a** bully. It's (V4's) way or the highway, and it shouldn't be that way. We should treat them (residents) with respect. (R4) has had issues with (V4). (R4) has a staring problem. She's here for a reason. (V4) told her, 'Go on and mind your own business.' On 4/24/2025 at 10:32 AM, V3 stated it is absolutely the residents' rights to have personal belongings in their room and be provided timely bathroom assistance. V3 stated the incident between R1 and V4 should not have taken place in public in front of other residents due to dignity. 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 extend possible in accordance with the resident's own needs and preferences. Responsibility: All staff. Policy: It is the facility's policy to identify and provide reasonable accommodation for resident needs and preferences except when it would endanger the health or safety of the resident or other residents. Residents have the right to retain and use personal possessions to promote a homelike environment and to support each resident in maintaining their independence. The facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extend possible.

Based on interview and record review, the facility failed to provide showers for 4 of 4 (R1, R11, R12, R15) residents reviewed for Activities of Daily living in a sample of 15. Findings include: The facility's Resident Council Minutes, dated 12/5/2025, documents 400 hall not getting showers. On 2/18/2025 at 2:50 PM Requested January's shower documentation. As of 2/19/2025 at 4:21 PM the facility had not provided any shower documentation for January. 1. The facility's 400 Hall Shower Sheet documents R1's scheduled showers are on Wednesday and Saturday, day shift. R1's Shower/Bathe task documents R1 received a shower on 1/25, 2/13 and 2/17/2025. On 2/1, 2/5, 2/8, and 2/15 documents not applicable. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. On 2/10/2025 at 12:20 PM, R1 stated the shower room on 500 hall doesn't have heat and doesn't have hot water. R1 stated because of his size, he is not able to take a shower, because the 400 hall doesn't have a large enough equipment for him to take the shower. 2. The facility's 400 Hall Shower Sheet documents R11's scheduled showers were Monday and Thursday, day shift. R11's Shower/Bathe task documents R11 received a shower on 2/13, 2/17 and a bath on 2/10. It documents on 1/23, 1/27, 1/30, 2/3, 2/6, and 2/10, documents not applicable. R11's MDS, dated [DATE], documents R11 is moderately cognitively impaired and requires partial/moderate assist with showers/bath. 3. The facility's 500 Hall Shower Sheet documents R15's scheduled showers were Wednesday and Saturday, day shift. R15's Shower/Bathe task documents R15 received a shower on 2/17 and refused on 2/19/2025. It documents on 2/1, 2/5, 2/8, 2/12, and 2/15 not applicable. R15's MDS, dated [DATE], documents R15 requires Partial/moderate assist with shower/bathe. 4. The facility's 500 Hall Shower Sheet documents R12's scheduled showers were Monday and Thursday, day shift. R12's Shower/Bathe task does not document R10 received a shower from 1/20/25 to 2/17/2025. It documents on 1/20, 1/23, 1/27, 1/30, 2/3, 2/6, 2/10, 2/13, and 2/17 not applicable. R12's MDS, dated [DATE], documents R12 requires partial/moderate assistance with shower/bathe. On 2/18/2025 at 2:30 PM, V14, Regional Nurse, stated the staff document completed showers in the computer. V14 stated the bath and skin report sheet is a QA tool and are not required to use the tool. On 2/18/2025 at 2:55 PM, V15, Certified Nurse's Assistant (CNA), stated they received their shower assignment at the beginning of the shift. V15 stated when the shower is completed, it is documented in the computer. V15 stated all completed showers are to be documented in the computer. V15 stated if its not documented, then it didn't occur. On 2/18/2025 at 2:57 PM, V17, CNA, stated the residents have scheduled shower days, and she gives her resident showers and documents on the shower sheet because she doesn't have charting ability. V17 stated she can't document in the computer. On 2/18/2025 at 3:00 PM, V16, CNA, stated she gives the showers per the schedule and when completed documents in the computer. On 2/20/2025 at 1:30 PM, V2 stated she was not aware of the shower room on 500 being boken. V2 stated the water was cold, and the other shower room was offered for showers. V2 stated she expects staff to utilize the other shower rooms for showers as scheduled and document it in the chart. V2 stated the showers are to be given as scheduled and as needed. V2 stated when the showers are completed or refused, the staff are to document it in the medical record. V2 stated if a resident refuses, she expects the staff to get a nurse or another staff to try as well so the resident can get a shower. V2 stated at times the residents will refuse all attempts, but that's ok, because the staff tried. The facility's Activities of Daily Living policy, dated 9/2024, documents, It is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Policy Explanation and Compliance Guidelines: 1. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 2. Partial baths may be given between regular shower schedules as per facility policy.

Based on observation, interview, and record review, the facility failed to serve food at a palatable temperature for 4 of 4 residents (R13, R14, R15, R1) in a sample of 15. Findings Include: The (facility) Grievance/Concern reporting form, dated 2/6/2025, documents Resident council concerns relates to dietary. The resident Council met on 2/6/25. Most concerns were dietary, or food related. 4. The wire racks with room trays does not keep the food warm. The food is cold when the resident receives it. Investigation: met with regional dietary manager bases and lids to keep food warm. On 2/18/2025 at 12:40 PM, hall trays were prepared. Each tray had a lid, but no base. The plate was placed directly on the tray that was placed on a wire cart. The hall cart left the kitchen at 12:45 PM and sat at the nurse's station. First tray removed 12:48 PM and completed at 12:53 PM. Temperature tested on sample plate from the metal hall cart. The pasta and ground beef mix temped at 126 degrees and the green beans temped at 120 degrees. 1. R13's MDS, dated [DATE], documents R13 is cognitively intact. On 2/10/2025 at 9:57 AM, R13 stated the food is cold when received. R13 stated the food is slightly warm at best. 2. R14's MDS, dated [DATE], documents R14 is cognitively intact. On 2/10/2025 at 10:00 AM, R14 stated the food is always cold, but you have to eat it. 3. R15's MDS, dated [DATE], documents R15 is cognitively intact. On 2/10/2025 at 10:15 AM, R15 stated, The food is cold when its delivered, and the staff don't warm it for you. By the time they answer the light, they are picking the tray up. 4. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. On 2/10/2025 at 12:20 PM, R1 stated he was the president of resident council. R1 stated he has had multiple concerns voiced to him, and in resident council, of the food being cold. R1 stated the food on 400 and 500 come in an insulated cart, but the other halls have a wire cart, and the food is exposed. R1 stated this is an ongoing issue and have been discussed repeatedly, with no resolution. On 2/20/2025 at 1:33 PM, V23, Dietary Regional Manager, stated the food is held at temp on the steam table. V23 stated they are aware of the concerns regarding cold food. V23 stated they are in the process of purchasing insulated covers for the bottom of the plates. V23 stated they are not in yet, but are being ordered. V23 stated currently, they use a plate warmer and an insulated top. V23 stated when the trays go out on the wire carts they don't have any coverage, and depending how long it takes for the staff to serve, the tray will cause the temperature to drop. The facility's Food: Preparation, dated 2/2023, documents, 13. All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (or as stated regulations requires) for hot holding, and less than 41 degrees Fahrenheit for cold food holding.

Based on interview and record review, the facility failed to notify the Power of Attorney of medication changes for 1 of 3 (R5) residents reviewed for notification in a sample of 15. Findings include: R5's Care Plan, dated 10/21/2023, documents PSYCHOTROPIC MEDS: (R5) requires the use of psychotropic medication, Risperidone to assist with managing mood and behavior related to DX (diagnosis) Huntington Disease; anxiety and metabolic encephalopathy. ANXIETY MEDS: (R5) requires the use of anxiety medication, Clonazepam and Ativan to assist with managing anxiety related to DX Huntington Disease; anxiety and metabolic encephalopathy. DEPRESSION MEDS: (R5) requires the use of depression medication, Fluoxetine and Mirtazapine to assist with managing depression related to DX Huntington Disease; anxiety and metabolic encephalopathy. R5's Admission Record, not dated, lists Huntington's Disease as diagnosis. R5's Physician Order Sheet (POS), dated 11/09/24 Fluoxetine HCl Oral Tablet 20 MG (Fluoxetine HCl) Give 1 tablet by mouth one time a day for depression. 1/15/2025 Seroquel Oral Tablet 100 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day related to HUNTINGTON'S DISEASE (G10) 12/29/2024 at 11:50 AM buspirone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet by mouth three times a day related to GENERALIZED ANXIETY DISORDER (F41.1) R5's Medication Administration Record, dated January and February, documents R5 received these medications. R5's Progress Note, dated 2/5/2025 at 2:30 PM, Nurses Notes: Note Text: This nurse spoke with (V6) POA (Power of Attorney) and update given on risperidone and Seroquel and she is okay with the new orders. R5's Progress Note, dated 2/5/2025 at 3:52 PM, documents Nurses Notes: Note Text: This nurse called POA and consent received on new medication orders. No futher concerns noted at this time. On 2/10/2025 at 11:42 AM V6, R5 POA, stated she was notified last weekend of R5's new orders. V6 stated R5 was receiving medications prior to admission to facility. V6 stated she was not informed of risk versus benefits of the medication until this last week. V6 stated she did not know R5 was on the buspar, and this was the first time she had heard of it. On 2/10/2025 at 1:12 PM V18, Psychiatric Nurse, stated she was made aware by the family they were not aware that their loved one was on psych medication and had not given consent for the medication. On 2/20/2025 at 1:30 PM V2, Director of Nursing, stated she expects the nurses to notify the Power of Attorney of new orders. V2 stated the Nurse Practitioner puts their own orders in the system. V2 stated she is not sure if they notify families, but doubts it. V2 stated she expects the resident and/or family to be notified of new orders. The facility's Psychotropic program, dated 10/2024, documents, Guideline: 9. If a new order for psychotropic medication is obtained, the resident, resident's representative, or POA must be informed of the risks and benefits of the medication. The facility must obtain informed consent. If the family or resident's representative is not able to sign the consent at the time of the order, a verbal consent will be obtained by the nurse and documented on a psychotropic consent form until written consent can be obtained. This form will be part of the medical record.

Based on interview and record review, the facility failed to obtain consent for psychotropic medication for 1 of 3 (R5) residents reviewed for unneccessary medication in a sample of 15. Findings include: R5's Care Plan, dated 10/21/2023, documents PSYCHOTROPIC MEDS: (R5) requires the use of psychotropic medication, Risperidone to assist with managing mood and behavior related to DX (diagnosis) Huntington Disease; anxiety and metabolic encephalopathy. ANXIETY MEDS: (R5) requires the use of anxiety medication, Clonazepam and Ativan to assist with managing anxiety related to DX Huntington Disease; anxiety and metabolic encephalopathy. DEPRESSION MEDS: (R5) requires the use of depression medication, Fluoxetine and Mirtazapine to assist with managing depression related to DX Huntington Disease; anxiety and metabolic encephalopathy. R5's Admission Record, not dated, lists Huntington's Disease as diagnosis. R5's Physician Order Sheet (POS), dated 11/09/24, documents Fluoxetine HCl Oral Tablet 20 MG (Fluoxetine HCl) Give 1 tablet by mouth one time a day for depression. 1/15/2025 Seroquel Oral Tablet 100 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day related to HUNTINGTON'S DISEASE (G10) 12/29/2024 at 11:50 AM buspirone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet by mouth three times a day related to GENERALIZED ANXIETY DISORDER (F41.1) R5's Medication Administration Record, dated January and February, documents R5 received these medications. R5's Progress Note, dated 2/5/2025 at 2:30 PM, Nurses Notes: Note Text: This nurse spoke with (V6) POA (Power of Attorney) and update given on risperidone and Seroquel and she is okay with the new orders. R5's Progress Note, dated 2/5/2025 at 3:52 PM, documents Nurses Notes: Note Text: This nurse called POA and consent received on new medication orders. No futher concerns noted at this time. On 2/10/2025 at 11:42 AM, V6 stated she was notified last weekend of R5's new orders. V6 stated R5 was receiving medications prior to admission to facility. V6 stated she was not informed of risk versus benefits of the medication until this last week. V6 stated she did not know R5 was on the buspar, and this was the first time she had heard of it. On 2/10/2025 at 1:12 PM, V18, Psychiatric Nurse, stated she was made aware by the facmily they were not aware that their loved one was on psych medication and had not given consent for the medication. On 2/20/2025 at 1:30 PM, V2, Director of Nursing, stated she expects the staff to get consent for psychotropic medication before administration. V2 stated she has been at the facility for a short time. V2 stated there has been a problem with getting and finding the consents. V2 stated they are aware of the problem, and are working on fixing it. The facility's Psychotropic program, dated 10/2024, documents, Guideline: 9. If a new order for psychotropic medication is obtained, the resident, resident's representative, or POA must be informed of the risks and benefits of the medication. The facility must obtain informed consent. If the family or resident's representative is not able to sign the consent at the time of the order, a verbal consent will be obtained by the nurse and documented on a psychotropic consent form until written consent can be obtained. This form will be part of the medical record. 10. once consent is obtained, the order will be entered into the medical record and the diagnosis will be added to the diagnosis list.

Based on interview and record review, the facility failed to prevent resident verbal and physical abuse for 1 of 8 residents (R2) reviewed of abuse in a sample of 8. This failure resulted in an Immediate Jeopardy on 12/19/24, when V6, R2's brother, who was known to have a history of abusing R2, was allowed to have unsupervised visits with R2 and verbally abused her. Subsequently, on 12/29/24, V6 verbally and physically abused R2. Using a reasonable person concept, this would have caused psychosocial harm resulting in feelings of being unsafe, sadness, fear, and humiliation. The Immediate Jeopardy began on 12/19/24, when the facility failed to prevent V6 from verbally abusing R2 and implement interventions to prevent future abuse. On 12/29/24, V6 again verbally and physically abused R2. On 1/7/25, at 11:00 AM, V2, Assistant Administrator, and V3, Director of Nursing (DON), were notified of the Immediate Jeopardy. The surveyors confirmed by interview and record review, the Immediate Jeopardy was removed on 1/9/25, but remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's Face Sheet, undated, documents she has diagnoses of metabolic encephalopathy, severe protein-calories malnutrition, diabetes, dementia, schizoaffective bipolar disorder, severe intellectual disabilities, Down syndrome, and vascular dementia. R2's Minimum Data Set, (MDS), dated [DATE], documents resident is severely cognitively impaired with minimal hearing deficit. R2's MDS documents she requires substantial assistance with eating, and is dependent on staff for all other activities of daily living, (ADL's). R2's Care Plan, dated 12/21/24, documented R2 is at risk for abuse and neglect due to cognitive impairment and use of psychotropic medications. Care plan interventions include assuring resident is in a safe and secure environment. The goal is that staff will monitor well-being of others and R2 will have zero episodes of abuse and neglect throughout next review. On 4/19/24, the care plan documented V6 visitation is to occur only with window visits and phone visits supervised by staff. Also assess R2 for abuse and neglect upon admission and quarterly, assure resident that she is in a safe and secure environment with caring professionals, assure resident she is in a safe and secure environment with caring professionals, assure resident staff members are available to help, continue to in-service the staff about abuse and neglect, identify areas that put resident at risk, immediately report any episodes of unknown injury, abuse or change in R2's behavior for immediate intervention and review, monitor for any changes in behavior during and following V6 visits, observe the resident for signs of fear and insecurity during delivery of care. No further interventions regarding visits are documented in the care plan. Facility's initial report phoned to the state hotline documented, On 12/29/24 at 1 pm, (V6), (R2's) brother, came into the facility and beat (R2). (V6) put his hands on (R2's) face and said, 'hold your head up or I will break your f****** neck.' (V1, Administrator), called police and police stopped (V6). (V6) was suspended and cannot come into the building until the investigation is complete. V6 was previously banned, and this appears to be an ongoing issue was also documented on the intake investigation. R2's Progress Notes, dated 12/29/24 2:40 PM, documented by V8, Licensed Practical Nurse (LPN), stated it was reported to her by V7, LPN, that V5, Certified Nurse's Aide (CNA) had reported to her that V6 was feeding her lunch and yelled I will break your f****** neck. When V5 went into check on R2, V5 stated V6 had shoved R2's head. The note documented V1 and V3 were notified. R2's Progress Note on 12/29/24 at 2:47 PM, documented V5 reported to V8 that V6 was feeding R2 and yelled using profanity, and stated he would break her neck, and when V5 entered the room she stated she saw V6 shove her head. V5 then told V7. On 12/29/2024, a written witness statement was provided by V5, which documented on 12/29/24, around noon, she was sitting at the nurse's station across from the main dining room. V5 documented she overheard V6 yelling very angrily and aggressively. V5 heard V6 him say, I will break your f***** neck. V5 decided to check on R2, and as she walked into the doorway of R2's room, V6 had shoved R2's head up, leaving her hair ruffled. V5 asked R2 and V6 if everything was okay, and V6 said yes. V5 asked R2 and stated she did not respond. V5 told V6 that R2 had ate all her breakfast. V6 told V5 he had asked two aides if R2 had eaten. V5 told V6 she was on the hall, and he must have asked the wrong aide. V5 then walked away, and stated she reported it to the first nurse she saw, which was V8. On 12/31/24, at 2:45 PM, V5 stated she was sitting at the nurse's station, and she heard V6 yelling angrily about her f******* neck. V5 got up to see what was going on, and as she approached the doorway, V5 witnessed V6's hand coming off R2's head and R2's body coming back from the momentum, with her hair raised up from the physical placement of his hand. V5 stated V6 was pushing R2's head up very abruptly. V5 stated when she approached the doorway, V6 looked at her and didn't say anything. V5 stated V5 immediately went into de-escalation mode. V5 told V6 that R2 had eaten all her breakfast this morning, and it had taken her a long time to do so. V5 added R2 didn't finish breakfast until 9:30 am or so. Since it was around 12:00 pm, V5 explained to V6 it hadn't been that long since R2 had eaten, and that she might not be hungry. V6 replied he had already asked two nursing assistants how she had eaten, and that they did not know. V5 stated she told V6 he had asked the wrong CNAs, since she was the CNA assigned to R2. V5 did not notice any redness on her head, but she did state it was an aggressive shove. V5 added no one should be talking to any resident like this. V5 stated V6 always yells when he talks to her, but this time his tone was out of his norm. V5 stated after this occurred, V6 stayed about an additional 20 - 30 minutes. V6 returned after he had initially left because he had left behind his phone on R2's table. V5 stated the next thing she knew, she was talking to the police officer. V5 stated she has also heard V6 talk derogatory to some of the nurses. About 3-4 months ago, V5 was walking out of the facility and V6 had said to his dog, see that white woman there - get her. V5 stated V6 is known for saying out of line things. V5 stated V1, Administrator, has not contacted her. V5 stated she did write out a statement of the incident like she was asked. V5 stated she has not spoken with any of the management directly. On 12/30/24 at 12:55 PM, V1, Administrator, stated she called the Illinois Department of Public Health (IDPH) hotline and reported the allegation of abuse against R2 by her brother, V6. V1 stated she is still investigating the allegation, and has banned V6 from the facility pending the investigation results. V1 presented a written statement by V5 dated 12/29/24. On 12/30/24 at 1:15 PM, R1 was asked if he ever heard yelling coming from R2's room. He stated R2 yells all night. When R1 was asked if he had ever heard any male voices yelling, he stated that her brother, (V6), yells all the time. R1 stated V6 will yell at R2 to take a bite and to shut the f*** up. R1 stated V6 usually visits R2 at least daily around a mealtime. R1's room is located next to R2's room, on the same side of the hallway. On 12/30/24 at 3:00 PM, V9, CNA, stated V6 has been visiting in the facility without restrictions for at least the past 3 months. V9 stated she has heard V6 yell and curse at R2 in the past, even prior to the abuse that was reported by the paramedic in April of this year. V9 stated she has not worked R2's hall for several months, so she has not recently witnessed V6 interacting with R2. V9 stated she has not issues getting R2 to eat, and she verbally cues R2 to keep her head up, and R2 complies. On 12/30/24 at 3:00 PM, V11, LPN, stated, The facility kept (V6) out of the facility for about 3-4 weeks back in the spring, when the ambulance people witnessed him abusing her, then the facility implemented supervised visits for a while. V11 stated she does not know what interventions have been in place to keep R2 safe when V6 visits, since the supervised visits stopped, and he was allowed to be anywhere throughout the building. On 12/20/24 at 3:21 PM, V4, MDS Coordinator, stated she has worked for the facility for about 2.5 years. V4 stated V6 is allowed to visit anywhere in the facility. V4 added there have been so many incidents with (V6). She receives reports on how V6 talks to R2 and to the staff. V6 is also known to make racial and sexual remarks to staff. V4 stated R2 has spoken with V1, facility owner, and facility lawyers. V4 stated there are no interventions in place to keep R2 safe. V4 stated the previous Administrator had left in August or September. V4 stated R2's current care plan does document the interventions that were put into place in April of this year, after R2's brother, V6, did abuse R2. These interventions document V6 can only visit through R2's window or on the phone with staff supervision. On 12/30/24 at 3:30 PM, V2, Assistant Administrator, stated the facility owner had talked to V6. V2 was unable to remember which of the owners it was. V2 stated V6 had supervised visits with R2 in the conference room, but she would have to ask an owner when these visits started and stopped. V2 stated after there had been no behaviors from V6 during the supervised visits, it was agreed to let him visit in R2's room unsupervised sometime after August. V2 was unaware the previous abuse claim from April 2024 was substantiated. On 12/30/24 at 3:40 PM, V1 was asked when V6 was allowed back in the facility. V1 stated she wasn't sure, but she thought there was a reassessment done due to R2 declining. V1 stated R2 would call out for her bubba. V1 added she would have expected the change in visit status would have been entered on the care plan. On 12/31/24 at 8:17 AM, V13, CNA stated V6 is very aggressive with R2, and he bangs his hands on R2's table. V13 stated V6 curses all the time at R2, and she heard V6 tell R2 to shut the f*** up a couple of weeks ago, and her partner V17, CNA, said she was reporting the incident to management. V13 stated she has no issues getting R2 to eat, she verbally cues her to hold her head up, and sometimes with help her lift her chin. On 12/31/24 at 9:15 PM, V14, police officer, returned call. He stated there are no reports generated from the 12/29/24 police visit to the facility. V14 checked the CAD (computer aided dispatch) program, and stated on 12/29/24 at 1:40 PM, they received a call from V1, and the reason was described as a welfare check. V14 reviewed the visiting officers' notes, which stated no crime appeared to have occurred. There were no witnesses beside the CNA, who reported the incident, and she did not observe any physical contact. The officer observed R2 while V5 was present, and did not see any signs of injur,y and attempted to talk with R2 to the best that her baseline status allowed. V14 added they had dealt with V6 in the past when he had trespassed in the facility. V1 had told police officer V6 was only allowed to drop off food at the nurse's station. V6 received a trespass warning, which involves that he is not permitted to return to the facility, or he will receive criminal charges. V14 stated he reviewed V6's record and found no criminal charges within the county, other than a few traffic citations. V14 stated V6 is hot headed and has an opinion that he will let you know about. V14 stated there was an incident on 5/4/23, which was a domestic report when he pushed the Administrator, and on 5/19/24, a battery report that V6 slapped R2's arm. States Attorney declined to file charges. On 12/31/24 at 9:47 AM, V2, Assistant Administrator/former facility Administrator, stated she went through her emails and texts last night, and she created a timeline of events regarding R2 and V6's issues. V2 stated the facility does not have any interdisciplinary team (IDT) notes, nor documentation in R2's chart. V2 stated she put together a soft file, with a timeline from her texts and emails, regarding enhanced visitation for R2 and V6. This documented that on 8/2/24, V6 had been calling up to the facility asking when he is allowed to come in and see his sister. Corporate team agreed to supervised visits. On 8/4/24, V6 was in the parking lot with a police officer, and it was decided V6 could have supervised visits for 2 weeks in the conference room, with V2 present for breakfast and lunch and reassess in 2 weeks. On 8/19/24, it was decided there were no issues with the supervised visits, and V6 could come back into the facility to assist R2 with feeding all meals. On 8/20/24, visits were permitted in R2's private room. On 12/31/24 at 9:53 AM, V1 stated the maintenance people came to her a couple of weeks ago and reported they witnessed V6 tell R2 to shut the f*** up. V1 stated that she did not report it. V1 just went and talked to R2 about it, and asked her how she was feeling. On 12/31/24 at 10:15 AM V15, Maintenance, stated on 12/19/24 around 1 PM, V15 and V16, maintenance, heard someone yelling very loudly. We saw (V6) was in (R2's) face screaming and telling her to 'shut the f*** up.' V15 reported this to V1. V15 stated became very clear to him that the proper steps were not going to be taken. V15 added, There are people that do their job, and those that don't. (V1) had a very laid-back attitude. I immediately told (V1), and she did not report it to the state. We care for the residents. I pulled (V6) out of (R2's) room, and took (V6) to the conference room, and told him that if I heard that again he would never come in the facility again. V15 stated he has heard V6 saying sexual and vulgar comments to staff. V15 added, (V6) makes our staff feel very uncomfortable. V16 agreed with all the statements provided by V15. On 12/31/24 at 10:37 AM, V1 reported to surveyors she was suspended, and any further questions should be directed toward V2. V1 stated she is leaving because she has been suspended for not reporting the allegation of abuse the maintenance men reported to her a couple of weeks ago about V6 verbally abusing R2. 12/31/24 10:52 AM, V2 stated she started back here in July. V2 stated V6 called nonstop, wanting to visit R2. The nurses stated R2 was not eating and crying out all the time. V2 called her boss, and her boss stated they would discuss supervise visits. In the meantime, V6 came to the facility on a Sunday (she is not sure of date but sometime in August) with a police officer demanding to come in. V2 stated she called her bosses and told them what was happening. V2 stated her bosses said to allow (V6) to visit Monday - Friday, with administration present. (V6) came to feed R2 breakfast and lunch, and was well behaved for those two weeks. (V6) then requested to visit in (R2's) room. The bosses stated to go ahead and allow him back in her room. This occurred around August 20th. No precautions were put into place other than staff were told to keep an eye on (V6 )with R2 from the hallway when they passed by. On 12/31/24 at 11:00 AM, V3, Director of Nursing, stated V6 can be a problem for other people. She added staff don't like him. V3 stated at a previous survey with federal surveyors, V6 yelled and cussed when V3 had to cut the belt off R2's wheelchair tray so it would not be considered a restraint. V3 has not witnessed V6 speaking abusively to R2, but she has witnessed him talk inappropriately to the staff. On 12/31/24 at 11:23 AM, V17, CNA, stated she did witness V6 tell R2 to shut the f**k up a couple of weeks ago. V17 stated she did not remember the exact date. V17 stated she reported it to an agency nurse, whose name she does not recall her. This agency nurse replied that V6 does this all the time. V17 stated she has witnessed V6 cursing and yelling at R2 ongoing for a long time, and management is aware, but nothing is ever done about it. On 1/2/25 at 2:05 PM, V2 stated there has not been any investigation started regarding the verbal abuse allegations against V6 in the middle of December reported by two CNAs, V13 and V17. Abuse Policy and prevention program, dated 10/2022, documented the facility affirms the right of the residents to be free from abuse and neglect. To do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse and neglect. 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 and neglect who have needs that might lead to conflict. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Employees are required to report any incident, allegation, or suspicion of potential abuse, or neglect they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. The nursing staff is responsible for reporting the appearance of suspicious bruises as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor or designated individual. Following the discovery of any suspicious bruises, the nurse shall complete a full of the resident for other bruises. Accused individuals not employed by the facility will be denied unsupervised access to the residents while the investigation. If classified as an injury of unknown source, the person gathering facts will document the injury the location and time it was observed, any treatment given and notification of the resident's physician, responsible party. The Department of Public Health will be notified. The investigator will report the conclusions of the investigation in writing to the administrator within five working days of the reported incident. The final investigation report shall contain the resident information, the original allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence, facts determined during the process of the investigation, review of medical record and interview of witnesses, conclusion of the investigation based on known facts. The Immediate Jeopardy that began on 12/19/24 was removed on 1/9/2025, when the facility took the following actions to remove the immediacy: 1. The affected resident corrective actions: Residents: A. The administrator initiated the abuse investigation. B. To ensure the safety and well-being of R2, the DON (Director of nursing) completed an assessment on 12/30/24. The result of the assessment was documented in the resident's EHR (electronic health records), and the attending physician will be notified. C. The following actions were taken to prevent alleged aggressor from perpetrating additional abusive behaviors. a. Visitor was banned from visitation pending investigation. b. Police were notified of incident. c. Interdisciplinary team (IDT) will review and revise R2's care plan and implement interventions to ensure R2's safety. d. The care plan review and revision were completed by the DON/MDS (minimum data set) Nurse on 1/2/25. D. All residents have the potential to be affected by the alleged deficiency. 2. Immediate Actions: Initiated on 1/7/2025. The facility took the following immediate actions to address the citations and prevent any additional residents from suffering an adverse outcome. A. Administrator and DON education. RNC/designee will provide training to administrator and DON. The training will include buy not limited to following: a. Abuse prevention. b. Allegation of abuse checklist c. Reporting abuse within required timeframe d. Completing investigation per policy and protocols e. Reporting and investigation injuries of unknown origin f. Immediate action to ensure all potential abuse allegations are identified, reported, and investigated as abuse to safeguard the residents' safety. g. Protection of residents from further abuse from alleged perpetrators. B. Staff Education - the administrator will provide training to all staff. The training will include but not limited to the following: a. Abuse prevention including identification of the Abuse Coordinator b. Reporting abuse allegations to the administrator c. Abuse investigation procedures and documentation process. d. Reporting and investigation of injuries of unknow origin e. Immediate action to ensure all potential abuse allegations are identified, reported to the administrator to safeguard the residents' safety. f. Protection of residents from further abuse from alleged perpetrator C. The training will be started on 1/2/2025. D. All staff who are not available and/or currently on vacation will also receive the same education upon their return to work. The administrator will provide the same training. E. The facility will provide similar training to the agency staff. F. Residents were interviewed to identify if they felt safe and/or if they have experience verbal or physical abuse while living in this facility. No concerns were identified. G. Care plan meetings. The IDT will review care plans at least quarterly and as needed. H. As part of monitoring, the Administrator will monitor through facility audit tools five staff members daily for one week and then weekly x4 weeks to ensure any allegations of abuse are reported to the abuse coordinator and investigated and reported to organizations.

Based on record review and interviews, the facility failed to ensure physician visits were alternated with the Nurse Practitioner visits every 60 days after the first 90 days of admission for 4 of 4 residents (R1, R2, R6 and R7) reviewed for physicians' visits in the sample of 8. Findings include: 1.R1's Face Sheet, dated 12/31/24, documented R1 was admitted to the facility on [DATE] with diagnoses of hemiplegia, diabetes, weakness, gastroesophageal reflux disease (GERD), convulsions, depression, hemiplegia, cardiomyopathy, hypertension, and congestive heart failure. R1's Minimum Data Set, dated dated [DATE], documented R1 is cognitively alert. He uses a wheelchair for mobility due to right sided weakness. R1's Care Plan, dated 12/26/24, documented R1 is a bleeding risk, he has a self-care deficit with activities of daily living (ADLS), diabetic risk, seizure risk, skin complication risk, altered communication, heart failure risk, and fall risk. R1's electronic medical record (EMR) documented he was seen by the nurse practitioner (NP) 26 times on the following dates:1/6/24, 1/17/24, 2/1/24, 2/12/24, 2/21/24, 3/6/24, 3/20/24, 4/9/24, 4/22/24, 5/22/24, 6/11/24, 7/10/24, 7/29/24, 8/9/24, 9/4/24, 9/6/24, 9/27/24, 10/8/24, 10/9/24, 10/10/24, 10/24/24, 10/29/24, 11/12/24, 12/12/24, 12/17/24 and 1/10/25. Further review revealed he was seen by the physician, V34, only one time in the entire last year, on 3/26/24, with a physician progress note dated on that date. On 1/13/25 at 11:45 AM, R1 stated he has not seen his physician in a long time. 2. R2's admission record, dated 12/20/24, documented she was originally admitted to the facility 12/23/2017, with diagnoses of metabolic encephalopathy, severe protein-calories malnutrition, diabetes, dysphagia, dementia, schizoaffective bipolar disorder, wedge compression fracture of the third lumbar vertebra, severe intellectual disabilities, hyperlipidemia, rheumatoid arthritis, heart failure, osteoporosis, Down syndrome, vascular dementia, and GERD. R2's MDS, dated [DATE], documents resident is severely cognitively impaired, with minimal hearing deficit. She requires substantial assistance with eating and is dependent on staff for all other ADLS. She is always incontinent of urine. R2's EMR documented in the last year, she was seen by the nurse practitioner (NP) 32 times on 1/2/24, 1/10/24, 1/25/24, 1/31/24, 2/8/24, 2/16/24, 3/1/24, 3/14/24, 4/6/24, 4/12/24, 5/20/24, 5/22/24, 6/13/24, 7/2/24, 7/16/24, 7/18/24, 8/7/24, 9/5/24, 9/19/24, 9/26/24, 10/10/24m 10/15/24, 10/11/24, 11/26/24, 11/27/24, 11/29/24, 12/4/24, 12/16/24, 12/23/24, 12/28/24, 12/31/24 and 1/2/25. Further review revealed that she was seen by the physician, V35, only one time in the entire last year on 8/27/24, with a physician progress note provided with that date. 3.R6's undated face sheet documented R6 was originally admitted on [DATE], with most recent admission occurring on 1/10/2024. His diagnoses include metabolic encephalopathy, morbid obesity, acute and chronic respiratory failure, chronic obstructive pulmonary disease, vascular dementia, depression, congestive heart failure, hypertension, dementia, atrial fibrillation, and lumbago. R6's MDS, dated [DATE], documented resident is severely cognitively impaired. He requires use of a wheelchair for mobility. He is always incontinent of bowel and bladder. He requires substantial assistance for toileting hygiene, showering, lower body dressing, personal hygiene and taking on and off footwear. He requires partial assistance with oral hygiene and upper body dressing. R6's Care Plan, dated 11/28/24, documented focus problems that he requires assistance with daily care needs, bleeding risk, CHF complication risk, diabetic risk, displayed sexual behaviors, elopement risk, abuse and neglect risk and fall risk. R6's electronic medical record (EMR) was reviewed, and it revealed in the last year he was seen by the Nurse Practitioner (NP) 25 times on 1/2/24, 1/4/24, 1/5/24, 1/12/24, 2/9/24, 2/16/24, 3/5/24, 4/30/24, 5/9/24, 5/20/24, 6/10/24, 7/22/24, 8/5/24, 9/2/24, 9/26/24, 10/3/24, 10/7/24, 10/8/24, 10/22/24, 11/7/24, 12/3/24, 12/27/24, 1/2/25 and 1/8/25. Further review revealed he was seen by the Physician, V31, only on 2/6/24 and 12/20/24. 4.R7 was admitted to the facility on [DATE], with diagnoses of cerebral infarction, chronic obstructive pulmonary disease, acute resp failure, difficulty in walking, multiple pelvis fractures, severe protein calorie malnutrition, atrial fibrillation, leukemia, coronary artery dissection, depression, and neuropathy. R7's MDS, dated [DATE], documented resident is cognitively intact. He requires use of a wheelchair for mobility. He requires supervision for toileting hygiene. He requires partial assistance for personal hygiene, showering, lower body dressing and applying and removing footwear. He is independent with eating, oral hygiene, and upper body dressing. He is always incontinent of urine and frequently incontinent of bowels. R7's Care Plan, dated 12/26/24, documented he requires assistance with daily care needs to weakness, risk for bleeding, fall risk, altered cardiac function risk, oxygen use at 6 liters per minute continuously, potential for breathing difficulty and skin complication risk. Most recent orders documented OT and PT clarification, pain management referral, regular diet with fortified potatoes and lunch and dinner and super cereal at breakfast. R7's electronic medical record (EMR) was reviewed, and it revealed since admission on 9/18/24, he was seen by the Nurse Practitioner (NP) sixteen times on 9/19/24, 10/1/24, 10/4/24, 10/10/24, 10/15/24, 10/18/24, 10/25/24, 11/18/24, 11/27/24, 12/5/24, 12/6/24, 12/10/24, 12/11/24, 12/16/24, 12/24/24 and 12/30/24. Further review revealed he was seen by the Physician, V31, on 09/25/24 for an admission visit with a physician progress note for that date. There was no other documentation that indicated he was seen by the physician after 09/25/24. On 1/13/25 at 11:40 AM, R7 stated it has been a long time since he has seen his physician. On 1/13/25 at 11:40 AM, V29, Nurse Practitioner, stated she has not yet heard back from V31, whom she had text earlier, regarding his expectations of frequency of staff visits. On 1/13/2025 at 9:20 AM, V2, Assistant Adminstrator, stated the current company began providing physician coverage in November 2023. V2 provided progress notes for one physician visit each for R1, R2 and R7, and two visits for R6. She stated these are the only times they have been seen by a physician since November 2023. On 1/9/25 at 12:08 PM, V1, Administrator, stated the facility does not have the physician visit documentation for the four residents requested, and the facility doesn't have anything to show how often the physician visits. On 1/13/25 at 2:15 PM, V33, Regional Director of Operations, stated he would expect the policy to be followed, and physician visits to be made every 60 days, alternating visits with the Nurse Practitioner. The facility's physician visit policy, dated 1/2010 and updated last on 7/23/24, documented each resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 days thereafter. Must be seen means that the physician must make face to face contact with the resident. A physician visit is considered timely if it occurs no later than 10 days after the date the visit was required. At the option of the physician after the initial visit, may alternate between personal visits by a nurse practitioner (NP), clinical nurse specialist or physician assistant (PA). However, the physician must visit resident when the resident's condition makes that visit necessary.

Based on interview and record review, the facility failed to report an injury of unknown origin and allegations of abuse to the Administrator and Illinois Department of Public Health for 2 of 4 residents (R2, R8) reviewed for abuse in a sample of 8. Findings include: 1. R2's Face Sheet documented R2 was admitted to the facility on [DATE], with diagnoses of metabolic encephalopathy, severe protein-calories malnutrition, diabetes, dysphagia, dementia, schizoaffective bipolar disorder, wedge compression fracture of the third lumbar vertebra, severe intellectual disabilities, hyperlipidemia, rheumatoid arthritis, heart failure, osteoporosis, Down syndrome, vascular dementia, and gastroesophageal reflux disease. R2's Minimum Data Set, MDS, dated [DATE], documented R2 is severely cognitively impaired with minimal hearing deficit. She requires substantial assistance with eating and is dependent on staff for all other activities of daily living, (ADL's). R2's Care Plan, dated 12/21/24, documented R2 is at risk for abuse and neglect due to cognitive impairment and use of psychotropic medications. The Care Plan also documented, (R2) exhibits a very strong bond with (V6, R2's Family), and growing up, tough love was shown in their home to ensure (R2)'s needs were met. Interventions added include assuring resident is in a safe and secure environment. The goal is that Staff will monitor well-being of others and R2 will have zero episodes of abuse and neglect throughout next review. Interventions include that on 4/11/24 V6 visitation was suspended. On 4/19/24 V6 visitation is to occur only with window visits and phone visits supervised by staff. Also assess R2 for abuse and neglect upon admission and quarterly, assure resident that she is in a safe and secure environment with caring professionals, assure resident that she is in a safe and secure environment with caring professionals, assure resident that staff members are available to help, continue to in-service the staff about abuse and neglect, identify areas that put resident at risk, immediately report any episodes of unknown injury, abuse or change in R2's behavior for immediate intervention and review, monitor for any changes in behavior during and following V6 visits, observe the resident for signs of fear and insecurity during delivery of care. R2's progress note, dated 10/2/24 at 10:14 AM, documented, This writer was notified by CNA (Certified Nurse's Aide) that while performing morning care, she noticed a 3x3 cm bruise on pt (patient's) L (left) upper arm. CNA notified this writer. This writer evaluated the bruise of unknown origin. This writer asked pt if they were in any pain. Pt is AXO (alert and oriented) 1-2 and did not express any pain verbally nor using facial grimace with this writer apply stimuli to the area. This writer assessed pt v/s (vital signs), all v/s are WNL (within normal limits). It continues, This writer notified family and facility NP (Nurse Practitioner) of bruise of unknown origin. R2's Incident Report, dated 10/2/24, documented incident description: bruise of unknown origin, resident unable to give description. It continues, IDT (Interdisciplinary Team) meeting to discuss bruising to arm from 10/2/24. Resident is alert with confusion, severely cognitively impaired. Resident requires substantial to max assist with ADLs (activities of daily living) and transfers. Brother, V6, helps with resident care frequently. Incontinent of bowel and bladder. RCA (root cause analysis): bruise located to upper arm believe to be from transfer. All previously care planned interventions in place, adding monitor bruise until healed. Continue to encourage use of wheelchair. All parties agree with plan of care. Care plan reviewed and updated. On 1/2/24 at 10:02 AM, V3, Director of Nursing, stated the facility did not report R2's bruises of unknown origin that was documented on 10/2/24. V3 stated it was on R2's care plan that R2 frequently had bruising on her arms. V3 stated she did not investigate the bruises of unknown origin, and she just determined the bruises were from a transfer because of the location of the bruising. V3 stated she did not interview any employees regarding R2's bruises of unknown origin, and the facility does not have any investigation documentation of R2's bruises that were documented in her EMR (Electronic Medical Record) on 10/2/24. On 12/31/24 at 8:17 AM, V13, CNA, stated R2's brother, V6, is very aggressive with R2 and V6 bangs his hands on R2's lap tray. V13 stated V6 curses at R2 all the time and she heard V6 tell R2 to shut the f*** up a couple of weeks ago. V13 stated she did not report the incident to anyone because her partner, V17, said she was reporting the incident to management. On 12/31/24 at 11:23 AM, V17, CNA, stated she did witness R2's brother V6 tell R2 to shut the f*** up a couple of weeks ago. V17 stated she reported the incident to a nurse, but cannot recall the nurses name because she was an agency nurse. V17 stated the nurse replied, he does this all the time. V17 added she has witnessed V6 cursing and yelling at R2 ongoing for a long time, and management is aware, but nothing is ever done about it. On 12/31/24 at 9:53 AM ,V1, Administrator, was asked if the facility had any abuse investigations for R2 from a couple of weeks ago, and V1 replied, The maintenance people came to me a couple of weeks ago and reported they witnessed (V6) tell (R2) to 'shut the f*** up.' I did not report it nor investigate it. I just went and talked to (V6) about it. I should have reported it. On 12/31/24 at 10:15 AM, V15, Maintenance Director, stated, On 12/19/24 around 1 PM (V16, Maintenance Assistant), and I heard someone yelling very loudly. We saw (V6, R2's brother), was in (R2's) face screaming and telling her to 'shut the f*** up.' I reported this to (V1, Administrator), and it became very clear to me that the proper steps were not going to be taken. There are people that do their job and those that don't. (V1) had a very laid-back attitude. V15 stated he pulled V6 out of R2's room and took V6 to the conference room along with his assistant V16, and he told V6 if he ever sees that again, he (V6) will never come into the facility again. V16, Maintenance Assistant, was present during this interview, and V16 stated he also witnessed V6 screaming at R2 and telling R2 to shut the f*** up. On 12/31/24 at 10:37 AM, V1 stated, I am leaving because I have been suspended for not reporting the allegation of abuse the maintenance men reported to me a couple of weeks ago. On 1/2/25 at 11:20 AM, V19, Regional Director of Operations, was asked if she expects the facility to investigate bruises of unknown origin, and V19 replied, I would have to look at our policy. V19 then stated, We would expect the Administrator to report abuse. (R2's) care plan does say 'tough love', we know this individual (V6) and have talked to him several times. V2 and V19 stated they do not know if the allegation witnessed by V13 and V17 was ever reported or investigated. 2. R8's Face Sheet, undated, documented R8 has diagnoses of cerebral infarction with hemiplegia, altered mental status, epilepsy, delusional disorder, unspecified visual loss, unspecified hearing loss, anxiety disorder, and bipolar disorder. R8's MDS, dated [DATE], documented R8 is moderately cognitively impaired. The facility's initial incident report to IDPH (Illinois Department of Public Health), dated 1/8/25 at 9:00 AM, documented V25, LPN (Licensed Practical Nurse) stated he wanted moved off 400- hall. He could not work with R8 any longer. V25 stated he went to R8's room because R8 was yelling out, she asked me why V25 gave her two Imodium tablets. V25 said he informed R8 that he was not her nurse currently, and he did not give her any medication. V25 stated R8 went on to say to V25, What did you think you were doing when you rubbed your dick all over my face. V25 asked R8 why she would say that, and she repeated her statement. V25 went on to say he left R8's room and did not go back in there for the remainder of his shift. V25's emailed statement, dated 1/8/25 at 9:27 AM, documented, Went to resident's room (R8) because she was yelling out and being disruptive. When I went into this resident's room to ask why she was yelling out, she asked me why I gave her two Imodium tablets. I informed her that I was not her nurse currently and I did not give her any medication. (R8) then went on to say '(V25) what did you think you were doing when you rubbed your d*** all over my face.' I asked her why she would say that she repeated her statement, so I then left this resident's room and did not go back in there for the remainder of my shift. I reported this incident to the nursing director. On 1/9/25 at 1:40 PM, V3, Director of Nursing, stated V25 worked the night shift of 1/7/25, and V25 called her on his way home after his shift on the morning of 1/8/25 to let her know what R8 was saying about him, because V25 was upset. V3 stated V25 told her R8 was saying things that were inappropriate. V3 stated she did not ask V25 what time R8 made the allegation during his shift. V3 stated she did not think V25 immediately reported the statement by R8 because he didn't feel like he had done any abuse; he V25 felt like he was being abused. On 1/9/25 at 3:29 PM, V25 stated on Tuesday night (1/7/25) around 7-8 PM, R8 requested to see V25 and that R8 asked him why he had given her an Imodium, and that he explained to R8 that he was not her nurse. V25 stated R8 then stated to him what did you think you were doing when you put your d*** all over my face. V25 stated he felt like the victim at this time. V25 stated initially he didn't think R8's accusations appeared serious, but when R8 was continuing discussing it the next morning, he thought he should call management. V25 stated V3, DON, was not in the building when he left, so he called her on the phone somewhere between 8-9 AM on 1/8/25. On 1/13/25 at 8:53 AM, V2, Assistant Administrator, stated per the facility abuse policy, V25 should have immediately reported R8's abuse allegations to management. The facility's Abuse Policy and Prevention Program, dated 10/2022, documented the facility affirms the right of the residents to be free from abuse and neglect. To do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse and neglect. 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 and neglect who have needs that might lead to conflict. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Employees are required to report any incident, allegation, or suspicion of potential abuse, or neglect they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. The nursing staff is responsible for reporting the appearance of suspicious bruises as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor or designated individual. Following the discovery of any suspicious bruises, the nurse shall complete a full of the resident for other bruises. Accused individuals not employed by the facility will be denied unsupervised access to the residents while the investigation. If classified as an injury of unknown source, the person gathering facts will document the injury the location and time it was observed, any treatment given and notification of the resident's physician, responsible party. The Department of Public Health will be notified. The investigator will report the conclusions of the investigation in writing to the administrator within five working days of the reported incident. The final investigation report shall contain the resident information, the original allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence, facts determined during the process of the investigation, review of medical record and interview of witnesses, conclusion of the investigation based on known facts.

Based on interviews and record review, the facility failed to investigate allegations of verbal abuse and injury of unknown origin for one of 4 residents (R2) reviewed for investigation of abuse in the sample of 8. Findings include: R2's Face Sheet, undated, documents R2 has diagnoses of diagnoses of metabolic encephalopathy, severe protein-calories malnutrition, dementia, schizoaffective bipolar disorder, severe intellectual disabilities, Down syndrome, and vascular dementia. R2's Minimum Data Set (MDS), dated [DATE], documents resident is severely cognitively impaired with minimal hearing deficit. R2's MDS documents she requires substantial assistance with eating and is dependent on staff for all other activities of daily living (ADL's). R2's Progress noted, dated 10/2/24 at 10:23 AM, documents V20, Licensed Practical Nurse, LPN, was notified by V17, CNA, that while performing morning care, she noticed a 3x3cemtmeter (cm) bruise on R2's left upper arm. V17 notified V20 who evaluated the bruise of unknown origin. V20 asked R2 if she was in any pain. R2 is alert and oriented to person and did not express any pain verbally nor using facial grimace when V20 applied stimuli to the area. V20 notified family and facility Nurse Practitioner (NP) of bruise of unknown origin. Incident report, dated 10/2/24, documented an interdisciplinary (IDT) meeting was formed to discuss bruising to the arm. The root cause analysis (RCA) was the bruise located to the upper arm is believed to be from transfer. R2's Care Plan, dated 12/21/24, documented R2 is at risk for abuse and neglect due to cognitive impairment and use of psychotropic medications. The Care Plan also documents, (R2) exhibits a very strong bond with (V6), (R2's Family), and growing up, tough love was shown in their home to ensure (R2's) needs were met. Interventions added include assuring resident is in a safe and secure environment. The goal is that staff will monitor well-being of others and R2 will have zero episodes of abuse and neglect throughout next review. Interventions include that on 4/11/24, V6's visitation was suspended. On 4/19/24, V6 visitation is to occur only with window visits and phone visits supervised by staff. Also assess R2 for abuse and neglect upon admission and quarterly, assure resident that she is in a safe and secure environment with caring professionals, assure resident that she is in a safe and secure environment with caring professionals, assure resident that staff members are available to help, continue to in-service the staff about abuse and neglect, identify areas that put resident at risk, immediately report any episodes of unknown injury, abuse or change in R2's behavior for immediate intervention and review, monitor for any changes in behavior during and following V6 visits, observe the resident for signs of fear and insecurity during delivery of care. On 12/31/24 at 9:53 AM, V1, Administrator, stated V15, Maintenance, and V16, Maintenance, came to her a couple of weeks ago and reported they witnessed V6 tell R2 to shut the f*** up, and V1 stated she did not report it. V1 just went and talked to V6 about it, and saw that she (R2) was okay. On 12/31/24 at 10:15 AM, V15 stated on 12/19/24 around 1 PM, V15 and V16, heard someone yelling very loudly. V15 stated, We saw (V6) was in (R2's) face screaming and telling her to 'shut the f*** up.' V15 stated he reported this to V1. V15 stated it became very clear to him that the proper steps were not going to be taken. V15 added, There are people that do their job and those that don't. (V1) has a very laid-back attitude. V15 had immediately told V1, and she did not report it to the state. V15 stated they care for these residents. V15 stated he then pulled V6 out of R2's room and took to the conference room. He told him that if he heard him talk to her like that again, V15 would make sure V6 never come into the facility again. V15 stated he has also heard V6 saying sexual and vulgar comments to staff. V15 stated, He makes our staff feel very uncomfortable. On 12/31/24 at 8:17 AM. V13, Certified Nurse's Aide, CNA, stated R2's brother, V6, is very aggressive with R2 and V6 bangs his hands on R2's lap tray. V13 stated V6 curses at R2 all the time, and she heard V6 tell R2 to shut the f*** up a couple of weeks ago. V13 stated she did not report the incident to anyone because her partner, V17, said she was reporting the incident to management. On 12/31/24 at 11:23 AM, V17, CNA, stated she did witness V6 tell R2 to shut the f*** up a couple of weeks ago. V17 stated she reported it to an agency nurse, whose name she did not recall, and the agency nurse replied to her he does this all the time. V17 stated she has witnessed V6 cursing and yelling at R2 ongoing for a long time, and management is aware, but nothing is ever done about it. On 1/2/24 at 10:02 AM, V3, Director of Nursing, DON, stated the facility did not report R2's bruises of unknown origin that was documented on 10/2/24. V3 stated it was on R2's care plan that she frequently had bruising on her arms. V3 stated she did not investigate the bruises of unknown origin, and she just determined the bruises were from a transfer because of the location of the bruising. V3 stated she did not interview any employees regarding R2's bruises of unknown origin, and the facility does not have any investigation documentation of R2's bruises documented in her electronic medical record (EMR) from 10/2/24. On 1/2/24 at 11:20 AM, V19, Regional Director of Operations, was asked if she expects the facility to investigate bruises of unknown origin, and V19 replied I would have to look at our policy. We would expect the Administrator to report abuse. (R2's) care plan does say 'tough love'; we know this individual (V6) and have talked to him several times. V2 and V19 stated they do not know if the allegation witnessed by V13 and V17 was ever reported or investigated. Abuse Policy and prevention program, date 10/2022, documented the facility affirms the right of the residents to be free from abuse and neglect. To do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse and neglect. 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 and neglect who have needs that might lead to conflict. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Employees are required to report any incident, allegation, or suspicion of potential abuse, or neglect they observe, hear about or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. The nursing staff is responsible for reporting the appearance of suspicious bruises as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor or designated individual. Following the discovery of any suspicious bruises, the nurse shall complete a full of the resident for other bruises. Accused individuals not employed by the facility will be denied unsupervised access to the residents while the investigation. If classified as an injury of unknown source, the person gathering facts will document the injury the location and time it was observed, any treatment given and notification of the resident's physician, responsible party. The Department of Public Health will be notified. The investigator will report the conclusions of the investigation in writing to the administrator within five working days of the reported incident. The final investigation report shall contain the resident information, the original allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence, facts determined during the process of the investigation, review of medical record and interview of witnesses, conclusion of the investigation based on known facts.

Based on interview, record review, and observation, the facility failed to employ hygienic practices and then handled food. This has the potential to affect all the residents in the facility. Findings Include: On 10/22/24 at 12:15 PM, V23, Dietary Aide, was putting diet cards on the residents trays; she was also putting lids on the resident's tray. V23, Dietary Aide, was rubbing her nose repeatedly and rubbing sweat off the brow. The Direct Care staff were standing at the kitchen door asking her to wash her hands, but she seemed confused and did not wash her hands. V14, Area Manager, asked V23, Dietary Aide, to wash her hands. V23, Dietary Aide, then washed her hands, but immediately rubbed her nose again. V23, Dietary Aide, continued to scoop ice cream from a 5-gallon ice cream bucket and place it into bowls. V23 gave the ice cream to the direct care staff to distribute to the residents. On 10/23/24 at 12:05 PM, V26, Regional Director of Dining, stated she (V23, Dietary Aide) will no longer be on the tray line. She (V23, Dietary Aide) will have other duties. The Facility Policy Food: Preparation, dated 2/2023, documents all foods are prepared in accordance with the FDA (Food and Drug Administration) food code. Procedures: all staff will practice proper hand washing techniques and glove use. The CMS 671 Long Term Care Facility Application for Medicare and Medicaid form, dated 10/22/2024, documents the facility has 102 residents.

Based on interview, record review, and observation, the facility failed to provide the required amount of protein to serve the residents. This has the potential to affect all residents in the facility. Findings Include: The facility recipe for Oven Herb Roasted Turkey Breast documents, slices 2.5 ounces of weighed portions. Serve 2.5 ounces of weighed portions to provide 2 ounces protein serving. Use scale to weigh and portion accurately. The facility was not observed initially utilizing a scale to weigh the turkey portions. V21, District Manager, stated, It's about one slice per person. On 10/22/24 at 12:00 PM, the kitchen was serving oven herb roasted turkey, with the portions appearing small. On 10/22/24 at 12:05 PM, V21, District Manager, brought out the scale. The oven roasted turkey breast portion was weighed and it was only 2 ounces. They continued to serve out the 2 ounces of oven sliced turkey, which was one slice of turkey meat. The kitchen then ran out of the oven sliced turkey and had to offer a substitute. On 10/23/24 at 12:00 PM, V12, Dietary Manager, stated, I don't know why we ran out, it may have been the double portions or requests for more. On 10/23/24 at 10:00 AM, during Resident Council Meeting, R28, R60, R61, R87, R90, R94, all complained about food portions and running out of food. On 10/24/24 at 2:40 PM, V22, Consulting Dietician, stated, If they ran out of food, they didn't order enough food. If the recipe says give 2.5 ounces, they must get that to have enough protein. The facility Small and Large Portions policy documents altered portion sizes may be served to meet individual resident's needs. Persons on small portions will be reviewed for additional snack preferences and provided additional meal servings on request. Meat small portions is 2 ounces protein. The Facility Policy Meal Planning, dated July 15, 1999, documents each resident shall be served food to meet the resident's needs and to meet physician's orders. Meat Group: A total of 6 ounces (by weight) of good quality protein to provide 38 to 42 grams of protein daily. Three ounces (excluding bone, fat, and breading) of any cooked meat such as whole of ground beef, veal, pork, or lamb; poultry, organ meats such as liver,heart, kidney; prepared luncheon meats. The CMS 671 Long Term Care Facility Application for Medicare and Medicaid form, dated 10/22/2024, documents the facility has 102 residents.

Based on interview and record review, the facility failed to respect a resident's right to privacy and dignity during care and when care was needed by being on their cell phones in 4 of 4 residents (R60, R61, R87, R94) reviewed for resident rights in the sample of 45. Findings include: 1. On 10/23/24 at 10:00 AM, during the resident council meeting, R60 stated the CNAs are always on their cell phones; he has had one CNA that was on speaker mode on her cell phone while she was helping R60 in the bathroom, so he felt as though no privacy was being provided. 2. On 10/23/24 at 10:00 AM, during the resident council meeting, R61 stated the CNAs are always on their cell phones, when residents are needing assistance, they are ignored because the CNA is on their phone and the CNAs are on their phones while providing care. 3. On 10/23/24 at 10:00 AM, during the resident council meeting, R87 stated the CNAs (Certified Nurses Assistant) are always on their cell phones and don't respond to the resident's request for care because they are too busy on their phones. 4. On 10/23/24 at 10:00 AM, during the resident council meeting, R94 stated the CNAs are always on their cell phones and aren't responding to the residents that are needing care, they are ignoring them because they are on their phones. On 10/25/24 at 8:59 AM, V2, Director of Nurses (DON), stated the facility is having problems mainly with the agency CNAs being on their cell phones while working. V2 stated she is trying to stop it, and if she catches them on their cell phone, they are told to put it away. If it continues, the disciplinary process is followed; if it is an agency CNA, they are put on the do not return list. The Resident Rights policy, dated 8/1/22, 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 preferences.

Based on interview, observation, and record review, the facility failed to provide personal hygiene to 2 of 2 residents (R2, R43), reviewed for ADL (Activities of Daily Living Care) in the sample of 45. Findings include: 1. On 10/22/24 at 8:53 AM, R2 was observed in bed. R2's mouth was dirty with debris in it; skin on her face was dry and flaky; her hair was messy; and her nails were dirty and untrimmed. R2's Face Sheet, undated, documents R2 has a diagnosis of Hemiplegia, Weakness, Need for Assistance with Personal Care and Dementia. R2's MDS (Minimum Data Set), dated 10/1/24, documents R2 is dependent with hygiene. R2's Care Plan, dated 10/20/15, documents R2 has an ADL self-care performance deficit and requires extensive assistance of 1-2 staff for personal hygiene and oral care. 2. On 10/22/24 at 8:50 AM, R43 was observed in her room in bed. R43's mouth was dirty with debris; her hair was messy; her gown was dirty; her nails were dirty and untrimmed. R43's Face Sheet, undated, documents R43 has a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction and Encephalopathy. R43's MDS, dated [DATE], documents R43 is dependent with hygiene. R43's Care Plan, dated 1/16/23, documents R43 requires assistance with daily care needs and staff are to assist resident with ADLs. 10/25/24 at 8:59 AM, V2, Director of Nursing (DON), stated the staff are to provide morning care to the residents. V2 stated R2 is set up with morning care and R43 is set up, but is more dependent. The Activities of Daily Living policy, dated 6/2015, documents a program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. Hygiene - a residents self-image is to be maintained.

Based on interview, observation, and record review, the facility failed to ensure a resident was free from abuse, from a resident with a history of prior altercations, for 2 of 2 (R2 and R5) residents reviewed for abuse in the sample of 6. This resulted in R2 receiving physical harm, facial bruising, including right cheek, bridge of her nose, and below both eyes and utilizing the reasonable person concept, this failure resulted in psychosocial harm by R2 yelling out in fear Hit me one more time and I swear. Findings Include: R5's Facesheet documents an admitted [DATE]. Diagnosis include Dementia, Displaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Routine Healing, Chronic Obstructive Pulmonary Disease, Protein Calorie Malnutrition, and Cirrhosis of the Liver. R5's Minimum Data Set (MDS), dated [DATE], documents R5 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. R5 requires substantial/maximum assist with transfers. Wheelchair is main mode of transportation. R5 displays little interest in doing things, has sleep issues, poor appetite, and trouble concentrating. R5's Care Plan, initiated 6/20/2023, documents R5 has a diagnosis of Dementia and may display altered cognition, change in moods/behaviors related to diagnosis. R5 often refuses to change clothing; staff assistance with care; R5 will urinate in trash cans, on the floor use blankets, clothing, and towels between her legs, near perineal area and urinate on them. R5 had a resident-to-resident altercation on 10/22/2023, 12/14/2023 and 8/1/2024. R2's Facesheet documents an admitted [DATE]. Diagnosis includes Dementia, Severe Intellectual Disabilities, Severe Protein Calorie Malnutrition, and Dysphagia. R2's MDS, dated [DATE], documents R2 is severely cognitively impaired with a BIMS score of 0, indicating severely impaired cognition. R2 requires substantial/maximum assist with transfers. Wheelchair is main mode of transportation. R2 shows little interest in activities, has sleeping issues, and poor appetite. R2's Care Plan, initiated on 7/3/2023, documents Abuse: R2 is at risk for abuse and neglect related to her cognitive and physical deficits. History of physical contact made by brother, POA (Power of Attorney). R2 exhibits a very strong bond between her and her brother. Growing up, tough love was shown in their home to ensure R2's needs were met. Resident to resident altercation on 8/1/2024. Facility incident report, dated 10/22/2023, documents R5 slapped another resident in the face in the dining room. R5 stated she slapped the other resident because the resident spit in her face. Description of incident documents this writer explained to R5 that she should not physically touch another resident or staff and if someone does something to her she should let the staff know. R5 was removed from the dining room and ate dinner by the nurse's station. No signs/symptoms of pain or discomfort. All parties notified. No injuries observed. R5's Nursing Note, dated 10/22/23 at 4:45 PM, documents, Resident observed by staff slapping another resident in the face in the dining room. This writer asked the resident why she slapped the resident in the face, and she stated that the other resident spit in her face. The resident was removed from the dining room and ate dinner at the nurse's station. This writer explained to the resident that she cannot physically touch another resident and if she has a problem let the staff know. Notified Administrator POA and NP of resident status change. No s/s (signs/symptoms) of pain or discomfort noted. The only intervention added to R5's Care Plan for this altercation was 10/22/23 Resident to resident- Psych consulted and resident to eat meals in less stimulated environment. Facility incident report, dated 12/14/2023, documents housekeeping staff member reported seeing resident kick another resident's wheelchair then push him in the wheelchair forward. When other resident didn't move, R5 slapped at his head causing his glasses and hat to fall off. Description of incident when interviewed stated R5 stated she doesn't remember hitting anyone. No injuries. R5's Nursing Note, dated 12/14/23 at 10:54 AM, documents, Resident was behind another resident both in wheelchairs she kicked the other wheelchair 3 times and pushed resident forward in wheelchair when that resident didn't move, she slapped his hat and glasses off no injury noted admin don np and POA made aware. There was no new intervention added to R5's Care Plan after this altercation. Facility incident report, dated 8/1/2024 at 8:15PM, stated V1, Administrator, notified of resident-to-resident altercation between R5 (BIMS score of 3) and R2 (BIMS score 0). V8, Certified Nursing Assistant, CNA, had walked past the room and saw R5 sitting on R2's bed with blanket over R2's head. V8, CNA, stated she did not see R5 hit R2. V8, CNA, immediately separated them, had V9, CNA, move R5 out of the room and stay with her and R2 was then placed in wheelchair and brought up to the nurse's station for the nurse to assess. R2 stated, Hit me one more time and I swear. Once R2 was up nurse's station she was her typical feisty self but not yelling out and did not have any mental anguish. Power of Attorney, POA, police, and Medical Doctor, MD, were notified. R5 was sent to local hospital where she remains today for psychiatric evaluation. Per staff interviews this is not typical behavior for R5 as she is normally pleasant, sleeps well, and likes to roll around in the hall in her wheelchair. They have not witnessed R5 yelling at R2 previously or being agitated with R2 in the past. V8, CNA, an V9, CNA, were in the room [ROOM NUMBER] minutes prior and had changed R5 and assisted her to bed. V12, Nurse Practitioner, NP, assessed R2 on 8/2/2024. R2 remains herself without any mental anguish. The (Local Police Department's) Police Report, dated 8/1/24 at 8:22 PM, documents I reviewed the video and observed (R5) to be upset over (R2) making noise. (R5) proceeds to get up from her bed several times to repeatedly hit (R2) in her bed. (R5) also places a blanket over (R2) and begins to choke her. (R2) can be heard at various times shouting for (R5) to stop. (R2) also states at one point she can hardly breathe. The incident takes place over an approximately 10-minute period and ends only when (Facility) staff enters the room. R2's Nurses Note, dated 8/1/24 at 9:50 PM, documents, CNA alerted this nurse about resident-to-resident altercation. Head to toe assessment completed, no injuries at the moment. Management/MD/POA notified. R2's Nurses Note (Admin), dated 8/2/24 at 7:29 PM, documents, Late Entry: Note Text: Resident's roommate immediately moved off hall and sent to (Local Hospital) for psych evaluation. R2's Nurses Note, dated 8/2/24 at 7:29 PM, documents, Res (resident) has been yelling out and refusing to take her meds, res has a black eye and nose is bruised. Res has 1:1 care. Res in bed resting with call light in reach. R2's Nurses Note, dated 8/7/24 at 1:23 PM, documents, Resident has bruising to right cheek bridge of nose and below both eyes, denies pain POA here in conference room for supervised visit for lunch appetite good continues to yell out tries to stand up from wheelchair staff monitoring closely POA aware of behavior. R5's Nursing Note, dated 8/1/24 at 9:43 PM, documents, CNA alerted this nurse about resident-to-resident altercation. As the nurse entered the room, res was in the roommate's bed. Res had no injuries. Management/MD/POA notified. R5's Nursing Note, dated 8/1/24 at 9:44 PM, documents, Res sent to (Local Hospital) for psych eval. On 8/13/24 at 9:40 AM, V5, Certified Nursing Assistant (CNA), stated R2 was assaulted one evening by her roommate (R5). V5 stated R2's family has a video of R5 trying to smother R2 by putting a sheet over her head. V5 showed the bruising to R2's face, and stated it was much worse than that. They sent R5 to (Local Hospital) Psych to be evaluated. (R5) is back, but now in a different room. V5 stated the Police did show up to investigate the incident. V5 stated R5 seems with it most of the time, but she does have dementia. V5 stated if R5 would know what she did, she would be embarrassed because that is not who she is. V5 stated she does not recall having any issues with the two residents prior to that day. On 8/13/24 at 12:05 PM, V1, Administrator, stated all the rooms in the facility are full and they do not have a private room to put R2 in. V1 stated the hospital told her R2 did not have any behaviors while she was in the hospital. V1 was not aware of any other incidents regarding R5 and her aggressive behaviors. When V1 was advised of the other resident-to-resident altercations, V1 stated there are 114 residents in the facility at this time, with two in the hospital. V1 stated she can't put R5 on the 300-hall due to R2 being there. V1 stated one of the residents in the hospital had a private room, so she will move R5 to that room immediately. On 8/13/24 at 12:45 PM, V7, CNA Supervisor, stated R5 is a one-on-one at this time since she returned, and they are sitting with R5 and monitoring her behaviors. On 8/13/24 at 3:25 PM, V11, R5's Sister, stated, I am (R5's) sister and POA (Power of Attorney). I visit her about three times a week. They put (R2) in the room with (R5) and all she does is yell out. Who would be able to tolerate that, it wasn't a good thing. Both have dementia so that made it even worse. I watched the video of what happened between (R2) and (R5) and it was horrible. It's a good thing that it didn't end up even worse. I couldn't believe (R5) was doing that. They have her in a private room now with a sitter, so that should help. I am trying to get her into a facility that will take care of someone like her. V11 asked R5 if she remembers why she got so mad at her roommate (R2), and R5 said I don't know. On 8/13/24 at 3:30 PM, V13, CNA (Certified Nursing Assistant), was assigned to be a one-on-one with R5. V13 stated she has worked with R5 for a long time and could not believe she did something like that. V13 stated that is not like her. On 8/14/24 at 11:20 AM, V1, Administrator, stated, We don't have a copy of the video that was on (R2's) brother's phone. He did show me the video and yes, that is what happened. (R5) was sitting on (R2's) bed and had a sheet or blanket on (R2's) head. On 8/14/24 at 11:55 AM, V15, R2's Brother/POA, stated he does not have his cell phone with him, and his daughter deleted the video they had about the incident. V15 stated he saw R5 sitting on R2's bed with her back toward the camera, and she had a sheet or blanket that she was holding over R2. On 8/14/24 at 2:15 PM, R6 stated, I like having a roommate. If I had a roommate that tried to hit me or did hit me, I would run for help. I am not a violent person, and that would scare me. I would never want that to happen. Facility abuse policy, dated 10/2022, states, This facility affirms the right of 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. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation of property, deprivation of goods and services by staff and mistreatment of residents.

Based on observation, interview, and record review, the facility failed to ensure a safe transfer was done for 1 of 3 residents (R3) reviewed for transfers in the sample of 6. This failure resulted in R3 being sent to the hospital and receiving 7 staples to his head. Findings include: R3's Physician Order Sheet for January 2024 documents a diagnosis of Unspecified Protein calorie malnutrition, Need for assistance with personal care, weakness, other reduced mobility, deforming dorsopathies, dysphagia, polyp of colon, barretts esophagus without dysphasia, disorientation, abnormal weight loss, Personal history of traumatic brain injury. R3 has an order for pureed diet, health shakes twice a day, super cereal at breakfast, and fortified pudding at lunch and dinner. Resident is also supposed to wear hip protectors every shift. R3's Minimum Data Set, dated dated [DATE], documents R3 was severely impaired for cognition. For eating he requires substantial /maximal assistance, dependent on staff for toileting, is dependent on staff for all efforts for chair/bed to chair transfer and does not walk. R3's Care Plan documents (R3) requires assist with daily care needs related impaired functional and cognition deficits. Resident is dependent on staff for transfers, toileting, peri-care, dressing and grooming and eating. (R3) is a high risk for falls related limited physical mobility, contractures, poor cognition, and poor safety awareness. R3's Progress Notes, dated 1/5/2024 at 4:57 PM, Note Text: 4:28 PM: Hall CNA (Certified Nursing Assistant) reported to this writer that the resident rolled out of the bed as she was preparing him for transfer, as she left to get assistance. Upon entry the resident was lying on his right side. Two open areas noted to the mid and left of his forehead. Resident moaning and grimacing in pain. ROM (range of motion) WNL (within normal limits), Contracted. Resident assisted back to bed x 2 attendants. 4:33 PM: EMS (emergency medical services) contacted for transport. R3's Initial Report, dated 1/5/2024 at 4:28 PM, Dependent resident who requires mechanical assist with transfers was observed on the floor from fall that resulted in 2 lacerations to right side of forehead requiring staples. On 1/9/2023 at 12:22 PM, R4, Roommate of R3, stated,(R3) was up in the air with the machine they use to pick you up and move you around. There was only one girl in her in the room when (R3) fell out. I did not know the girl; she was not one of our regular CNA's. I could see (R3) on the floor and there was blood everywhere even with my curtain pulled I saw him on the ground. Then when staff ran in here because there was a big boom the pad was still on the chair up in the air, and (R3) was on the floor and the pad was hanging with one hook. (R3) got a nasty cut on his head. Staff tried to then say (R3) fell from his bed and that is not true. He fell from the machine. He usually has two staff when they use that machine on him. That day he only had one staff. My curtain was pulled and I could see (R3) on the floor bleeding, and I saw the shadows through the curtain of him up in the air. Now they are trying to tell everyone he fell out of the bed and that is not true. R4's Minimum Data Set, dated dated [DATE], documents R4 is cognitively intact for decision making of activities of daily living. R3's Investigation from 1/5/2024 documents a Statement from V6, CNA, I dressed patient, cleaned patient up and put (mechanical lift) pad under patient. Curtain was pulled, bed in lowest position, Patient was resistance (sic), but I was able to do care. I left the room to get another CNA, we came back and (R3) was on the floor. We alerted the nurse, rolled patient side to side while nurse assessed him. Under the nurse's orders we lift patient into bed, nurse called EMS (emergency medical services). Multiple attempts were made to contact V6 and she did not return any calls, and was not working in the facility during this survey. R3's Fall investigation on 1/5/2024 documents a Statement from (R4), Resident states it was only one CNA in the room during the event in question. Resident states the CNA entered the room, put the resident up in the (mechanical lift) and left out of the room to get some help. Resident states when the CNA re-entered the room (R3) fell out of the (mechanical lift) and on the floor. This nurse asked the resident was the position of his room curtain at the time of the fall in question, resident stated the curtain was closed but he saw the resident's shadow through the curtain so that's how he knows the resident was up in the (mechanical lift) at the time of the fall. R3's Investigation from 1/5/2024 documents a Statement from V7, Licensed Practical Nurse (LPN), documents, This writer was told by hall CNA that resident in room (R3's) room had rolled out of the bed and was bleeding from his head. CNA was asked how that happened. She stated that she had just cleaned resident up and placed him on a (mechanical lift) pad, she then stated she left the room to get assistance when she returned the resident was laying on the floor. Upon entry resident was laying on the floor on his right side, noted with two open areas to middle right side of forehead. After evaluation of the resident, I instruct both hall CNA's to assist resident back to his bed. I did not return until EMS arrived. A Statement from V4, EMT (Emergency Medical Technician), dated 1/5/2024 at 4:38 PM, documents, I responded to facility for a traumatic injury, Dispatch indicated a [AGE] year-old man fell from a (mechanical) lift and suffered two head injuries. On our arrival, nursing facility staff directed is to the patient's room in the 200 hall. We located the patient (R3) in his bed and retracted to his right side. Initial assessment on (R3) revealed he had two lacerations on left and right side of his bed as I stood at the foot end. He appeared alert and orientated x 0. His verbal response included moaning sounds. (V9) asked several facility employees what happened as they entered the room. No one could report on the incident, and indicated they were not with (R3). They didn't appear to know who was with him when the injury occurred. (V9) asked them to seek out they employee who was with (R3) when the injury occurred. One employee returned and indicated she could not locate the involved employee (s). (R3's) roommate (R4) recognized several employees who entered the room by name. He appeared alert and orientated x 4. He told us the staff uses the (mechanical lift) on him, and the device requires two people. He only saw one employee using the mechanical lift when (R3) fell from the device. He said, (R3) was way up there. We lifted (R3) from his bed to the stretcher with the use of bed linens. He continued to lay in a retracted position on his right side. He did not make any significant movements or appear he could sit up without full assistance. As we walked down the 200 hall with (R3) on the stretcher, we encountered another employee who identified herself as knowing about the incident. She stated (R3) did not fall from a (mechanical lift), but she found him on the floor next to his bed. R3's Hospital Report, dated 1/5/2024, also documents, EMS reports original EMS call was for patient falling out of (mechanical lift). EMS reports upon arrival nursing home staff reluctant to come with information about fall and reported patient fell out of bed. Patient's roommate who is alert and orientated x 4 reported to EMS the nursing home staff had patient in (mechanical lift) and dropped him out of (mechanical lift). Patient has laceration to left and right forehead. Patient is alert and orientated x 0. R3 received 7 sutures at the hospital for his head. On 1/9/2024 at 2:41 PM, V8, Local Police, stated, they (city) were contacted regarding the dispatch on 1/5/2024, and they stated they received a call on 1/5/2023 at 4:37 PM regarding a fall from a resident that was preparing to transfer with a (mechanical lift) and the resident fell . On 1/10/2024 at 9:48 AM, V7, Licensed Practical Nurse (LPN), stated, I am an agency nurse I was working at the facility ,and the aid working on the 200/400 hall, I believe her name was (V6), came and got me and told me a resident had fell off the bed and was on the floor. I ran to the room and the resident has contractures and I saw that his bed bolsters were in place. (R3) was on the floor. The mechanical lift was in the room, but it was pushed to the side. I believe the pad was on the bed. (R3) was on the floor. There was blood and (R3) had a cut to his head. I asked (V6) to get help and transfer (R3) to his bed and I went and called for help. I did not assist with the transfer or with (R3) being transferred back to bed. On 1/12/2023 at 11:04 AM, V4, Emergency Medical Services Technician, stated, We received a call from the facility alerting us that a resident was being transferred with the mechanical lift and fell from the machine. When I arrived at the facility, I got an interview with (R4), the roommate, who corroborated the event. When I tried to talk to staff, nobody knew anything, and nobody would admit that anyone had fallen. (R3) is so fragile, and thin and vulnerable. When we arrived at the facility, the mechanical lift was outside of the room, there was blood on the floor and on the mechanical lift. It does not make sense because they are the ones who made the call about someone falling from the lift. The Facility Fall Policy, with a review date of 9/2023, documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Based on observation, interview, and record review, the facility failed to ensure respiratory therapy is administered with a physician's order and monitored during administration for 3 of 4 residents (R1, R2 and R3) reviewed for respiratory care in the sample of 7. This failure resulted in R2's oxygen blood saturation levels being low, emergency service being dispatched, and R2 being sent to local hospital for medical evaluation. Findings include: 1.R2's Physician Order Sheet (POS), dated August 2023, documents a R2 had diagnoses of Type 2 diabetes mellitus with diabetic neuropathy, weakness, need for assistance with personal care, acute on chronic systolic (congestive) heart failure, hepatic encephalopathy, acquired absence of left leg below the knee, cardiac arrhythmia, and aortic valve stenosis. R2's Physician Order Sheet did not have an order for R2 to receive oxygen. R2's Minimum Data Set (MDS), dated [DATE], documents R2 was moderately impaired for cognition for decision making of activities of daily living. The MDS also documents R2 uses a wheelchair and has impairment on his lower extremity. R2's Care Plan documents R2 was admitted to the facility for skilled stay requiring physician ordered, medically necessary services, including direct therapy services, skilled nursing care, management and evaluation of the patient care plan, observation, and assessment of the patient's condition and/or teaching and training activities related to the reason for stay or in preparation to transition to less care environment. R2's Progress Notes, dated 7/24/2023 at 10:51 AM, documents, Resident put on 2 liters of oxygen related to shortness of breath. Spoke with wife she stated she wanted resident sent out to (Hospital) for further evaluation. R2's Hospital Records, dated 7/25/2023 at 11:40 AM, documents, Patient report chest pain and SOB (shortness of breath) on and off this weekend. Denies chest pain at this time. Plan to admit and treat for unstable angina. Patient seen and examined. Reports that his chest pain has been intermittently present over the past month and associated with some radiation to the left elbow with some shortness of breath associated. R2's Progress Notes, dated 7/29/2923 at 8:00 AM, documents, Resident back at the facility, alert, and orientated x 3 with confusion. BP (Blood pressure) 128/69, pulse 50 and O2 (oxygen) 99% on 2 liters of oxygen. R2's Progress Notes does not document why he was on 2 liters of oxygen or if the physician was contacted. R2's Oxygen Saturations were documented as being taken on 7/30/2023 at 11:55 PM, and was documented as being 98% on room air. R2's medical record does not document when R2 was started on oxygen or when R2 was taken off of oxygen. R2's Progress Notes, dated 7/31/2023 at 8:10 AM, (Written by V13, Licensed Practical Nurse/LPN) documented, Informed by staff resident was unresponsive. Upon assessment resident noted to be in room lying in bed. Labored breathing noted with decrease spo2 (oxygen level) 69% with o2 via NC (nasal cannula). O2 increased to 4L/Nc (liters/nasal cannula). Uneven respirations noted. Resident not alert and minimal response to sternum rub. HOB (head of bed) elevated 911 called at this time. Call made to spouse no answer. 8:24 AM, 911 EMS (emergency medical service) here to assist at this time. 8:30 AM Resident transported to ER (emergency room ) at this time. Attempt to call spouse regarding resident status no answer at this time. R2's Ambulance Service Report, dated 7/31/2023, documents, Dispatched to local skilled nursing facility. For [AGE] year-old male (R2) patient, not responsive. Facility staff stated they found the patient in this condition with his oxygen concentrator alarming. No one was able to advise us of his first known normal or baseline orientation aside from more alert than this. They stated they checked his pulse oxygen, and it was in the 60's so they brought a portable oxygen tank and place him on 4 liters by nasal cannula with minimal improvement they called us. Patient's (oxygen pulse level) on 4 liters/pm was 88%. The Report documented his lung sounds were clear and equal bilaterally and he had strong radial pulses. R2's Hospital Records, dated 7/31/2023 at 2:38 PM, documented, (R2) is an [AGE] year-old male admitted [DATE] with sepsis. He is a nursing home resident and was found unresponsive by staff with an empty oxygen tank. SPO2 (oxygen) when he was found was 60 %. He was transported to hospital for further care. On arrival he was noted to be hypotensive and started on Levophed. He was seen and evaluated in the ED (Emergency Department) prior to transfer to the ICU (Intensive Care Unit). On 8/22/2023 at 3:45 PM, V23, Medical Doctor from the hospital, stated R2 was not sent back to the facility with an order for oxygen on 7/29/2023 when he returned to the facility. R2's Medical Records does not document any order for the use of oxygen and or monitoring of oxygen before 8/4/2023. On 8/16/2023 at 3:04 PM, V5, Certified Nursing Assistant (CNA), stated, I use to care for (R2); he was my buddy. He came here for rehab because he lost his leg. He has some heart issues, and he went downhill and passed away. He was here just last month. It makes me sad. On the day (R2's) oxygen was broken, there was no nurse working the 200-hall. I cannot say why there was no nurse that day. On 8/16/2023 at 3:13 PM, V9, CNA stated, I remember (R2); he was in a wheelchair and was here for rehabilitation because he lost his leg. I did not have any problems with him. He passed away here in the building. I am not aware of any issues with oxygen, but I know we were out of oxygen tanks today, and we're waiting for a delivery of new tanks. V9 stated he was not sure how long the facility had been out of tanks. V9 stated, Maybe 24 hours or less. On 8/16/2023 at 2:33 PM, V22, Emergency Medical Technician, stated, I was told by the nurse (R2) was found unresponsive by staff with an empty oxygen tank and his SPO2 (oxygen) when he was found was 60 % and reported it to the hospital, but I cannot confirm or deny this if this was accurate, or if the oxygen tank was empty. When we hooked (R2) up to the oxygen, his oxygen stats improved. At 8:26 he was at 88 (%), at 8:31 he was at 97 (%) and at 8:51 he was at 100%. On 8/17/2023 at 1:04 PM, V15, Licensed Practical Nurse (LPN), stated, I know why you are calling me. The facility is trying to get rid of me because on 7/31/2023 at 11:30 AM, I heard a nurse saying (V16) she was going to send (R2) out. I went down the 200-hall, which was not my hall, and I saw (R2) was lethargic and was mouth breathing. I was working the 300-hall. (V16, LPN) was working the 100 hall and (V18, LPN) was working the 400/500 hall. We found out later (V17, LPN) was a no show/no call off and did not report to work. (R2), who was on the 200 hall, was diabetic and I went and took a blood glucose level, and he was 202. I started rubbing his sternum because he was unconscious. I went and checked his oxygen level, and he was at 60%, so I turned his oxygen up, and told the nurse to go and get a crash cart. His oxygen levels did not change. (R2) was on an oxygen concentrator in his room, that was not working. The Physical Therapist was pregnant, and she came, and she brought me an oxygen tank and we hooked him up on tank since the concentrator was not working. The oxygen concentrator was broken, so we put him on a portable oxygen tank, which are also hard to find sometimes too. We had a nurse call off that day, and there was no nurse assigned to that hall because of the No show, no call off nurse. Later, (V16) the other nurse came to me and asked me if I was working that hall, and I told her no and nobody bothered to tell me that no nurse was assigned to the hall, and nobody was monitoring the residents on the 200- hall. (V16) said she was not told that either, and was not checking on the 200 hall residents either. (R2) was talking and came into the facility for therapy because he lost a leg. I went to the DON (Director of Nursing) and (V1, Administrator) and told them the oxygen concentrator was not working. They immediately went into his room and removed it. I am not going to lose my license over the facility not assigning a nurse to the 200-hall. I was really upset about (R2), and I also reported to the EMT (Emergency Medical Technician) what had happened. There was no nurse working that hall that day, and nobody was checking on (R2), and whoever put that oxygen concentrator on him should have been monitoring it, so they would have known he was not getting his oxygen with that oxygen concentrator. I know (V11, Wound Nurse) gave the medications that morning, but she was not working that hall other than giving out the medications. On 8/17/2023 at 2:23 PM, V16, LPN stated, I was working the day (R2) was having issues with his oxygen. He was not his normal self when I saw him. I was not working that hall that morning. I am not sure who was supposed to be working the 200-hall, but it was not me. I was assigned to a different hall. I went to help (R2), and we (V15, LPN) and I were getting low oxygen saturations levels on him, and I called the EMT (emergency medical team), and we had him sent off. On 8/17/2023 at 2:41 PM, V19, Occupational Therapist (OT), stated, I remember going into (R2's) room. He had been a patient here off and on over the years and we all liked him. When I went into his room, he was breathing different, he had shortness of breath. I immediately went and got the nurse. I do not remember who the nurse was. The nurse began changing the tank, so I left. That is all I remember. On 8/22/2023 at 3:43 PM, V21, Medical Director, stated, I would expect a resident on oxygen to have a working oxygen tank and for staff to be checking the oxygen levels and post oxygen/saturations ensuring the resident is 94% or higher, resting comfortable. If a resident is lower than 94%, I would expect the facility to contact me and send the resident out. I am not aware of any issues with oxygen tanks not working. 2. R1's August 2023 POS documents R1 has diagnoses of acute and chronic respiratory failure with hypoxia, chronic kidney disease, stage 3, congestive heart failure, and dementia. R1's MDS, dated [DATE], documents she was cognitively intact for decision making of activities of daily living. R1's Nurse's Notes, dated 8/16/2023 at 5:02 PM, documented, This nurse was in dining room and noted (R1's) oxygen wasn't in place reporting that she was waiting for a new tank as her previous tank wasn't working correctly. (R1) was talking with ease with respirations between 18-20. (R1) denied any difficulties and continued conversation with other resident. On 8/17/2023 at 4:50 PM, R1 was in the dining room. R1's oxygen tank was on the back of her wheelchair, but the tubing was in the back not within reach of R1. R1 was not wearing any nose cannula and was not getting any oxygen. On 8/17/2023 at 5:05 PM, R1 stated, My tank is not working. They are supposed to be getting me another one. I am supposed to be on oxygen 24 hours, seven days a week. I have a machine at my bed and that works okay but this portable one does not work. I am not wearing it because no air is coming out. They don't seem to care that I am not wearing my oxygen, but I am not wearing it because it is not working. This is not a one-time thing. It happens a lot when I leave my room. On 8/17/2023 at 12:47 PM, V14, Nurse Practitioner, stated, I was in the facility yesterday and I observed (R1) without an oxygen tank on while she was in her room and was only on room air. When I asked staff why, I do not remember the names of the staff, but they told me the facility was out of oxygen tanks. I would expect the facility to always have oxygen tanks available for residents 24 hours a day, seven days a week. I would expect staff to monitor residents especially residents on oxygen. They told me they were expecting some tanks to be delivered later that day. If a resident needs oxygen but is not getting that oxygenj that can lead to hypoxia. Hypoxemia is a below-normal level of oxygen in your blood, specifically in the arteries and can cause significant harm if left untreated. 3.R3's August 2023 POS documents R3 had diagnoses of Respiratory failure and sleep apnea. R3's MDS, dated [DATE], documents R3 was cognitively alert for decision making. On 8/16/2023 at 10:33 AM, R3 stated the facility had run out of oxygen, and they were waiting for some tanks to come in today. She was not sure how long, but it had been a few days now. It was not uncommon for the facility to run out of tanks, and she needs the tanks so she can do therapy. On 8/16/2023 at 10:39 AM, V20, Physical Therapist, stated, I have had to replace the tanks on (R3) when she came in to do therapy. She is the only resident on the top of my head that I have that uses oxygen. I know sometimes when she comes in here, she does not always have a full tank of oxygen. The Oxygen Administration Policy, with a revision date of 9/2022, documents, It is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulations and the standard of care.

Based on observation, interview and record review, the facility failed to follow their abuse policy. This failure placed residents at risk of both physical and verbal abuse from a resident with a known history of verbal and physical abuse toward other residents. This affected 4 of 4 residents (R39, R57, R63 and R240) in a sample of 33 reviewed for abuse. This failure led to R63 being afraid to be in R63's room due to verbal abuse from R57, R39's wound on face being re-injured and R240 being verbally and physically abused by R57. Findings include: 1. R39's Admission Minimum Data Set, (MDS), dated [DATE], documents cognitively impaired and displayed no behaviors. R57's Quarterly MDS, dated [DATE], documents severely cognitively impaired and displayed no behaviors. R57's Care Plan, dated 6/9/2021 documents displayed symptoms towards others. Resident can become verbally and physically aggressive with others which includes staff and peers. There are no progressive interventions documented on R57's care plan since 6/9/2021. Facility's Census, (room change report), documented R57 and R39 were roommates from 7/28/2022 through 8/9/2022. R39's Nurse's Note, dated 8/9/2022 at 11:56 PM, documents, CNA heard yelling from room. When entering room residents, (R39 and R57) were near each other still yelling. Immediately separated and brought resident to this nurse for assessment. Resident noted to have an open area below left eye 1.4 cm, (centimeters), x 0.5 cm which was an old injury from previous fall. Resident unable to explain what happened except that, she was trying to get me to do things I didn't want to do. Resident denies being hit or scratched by other resident, but still cannot explain how area below the eye was opened up. Administration/DON, (Director of Nurses), Physician notified and verbal order for UA with C&S, (culture and sensitivity), for tomorrow. POA notified of incident and MD, (Physician), new lab order. Resident (R39), immediately relocated to a different room. Currently resting comfortably in bed, denies pain. Pleasant affect, call light in reach. R57's Nurse's Note, dated 8/9/2022 at 11:20 PM, documents, Resident was heard yelling at roommate (R39.) CNA entered room and both residents were near each other yelling. Roommate (R39) had small injury noted to L, (left), side of face. CNA brought that resident, (R39), to nurse for assessment. Separated residents. Resident, (R57), continues to come out of room and attempt to approach roommate (R39.) Hard to redirect, roommate, (R39), is given different room. Resident, (R57), currently residing in room. Attempt to do skin assessment resident refuses. Will try again at a later time. Administration/DON notified; MD notified. Family notified and updated on incident and new lab order. Resident, (R39), currently resting in room. No injuries observed. Call light in reach. 2. R63's, Quarterly MDS, dated [DATE], documents moderately cognitively impaired and displayed no behaviors. R57's Nurse's Note, dated 9/29/2022 at 8:42 AM, documents, Night shift report that resident was disruptive all night and made threats to new roommate (R63). New roommate (R63) was afraid to be in the room. Resident was loud and aggressive. Upon DON (V17) arrival before 6:00 AM with in the hall talking very (sic) loudly about she has her junk all of my room and I don't know her. We went to her room and showed me the belongings she was talking about. I assured that the items she was referencing were in fact her items that are overflow. She needs to tell her family to come picks up the items, because we do not have room to keep them in storage. Resident then mapped out a space that the roommate, (R63), can have in the room. I informed the resident that she and the roommate, (R63), both live in the space and they would have to share. I gave the resident the option to have a private room, but she would have to pay a private room rate. She did not have an answer to the option at this time. The resident did verbalize understanding of sharing the space and not being aggressive to other person. (R63's) Nurse's Note, dated 9/29/2022 through 9/30/2022, shows no documentation of a resident-to-resident altercation or that she felt threatened or afraid of R57. On 11/17/2022 at 8:00 AM, R63 was observed lying in bed with her eyes open. R63 stated, I recall being roommates with (R57) and it was hell! She always yelled at me and then we got to scrapping, (fighting), one day and staff moved my room. I don't recall if I was injured or not, but I got a couple licks in. 3. R240's Undated Face Sheet documents she was admitted on [DATE]. Facility's Census, documented R57 and R240 were roommates from 11/4/2022 through 11/10/2022. R240's Undated Face Sheet, documents R240 was admitted to the facility on [DATE]. R57's Nurse's Note, dated 11/10/2022 at 11:37 PM, documents, Resident became physically aggressive towards (R57's) roommate, (R240), hitting and bumping her with wheelchair. This incident was witnessed by another resident passing by. Myself, the nurse was providing care to resident at the time. As a result, and resident refusal to accept that she now has to share a room resulted in the roommate, (R240), being moved to 300 hall. After the altercation resident c/o, (complained of), pain to her right hand and some bruising was noted. STAT X-RAY was ordered and completed on 11-10-22. Administrator, POA and MD notified. Will follow up. R57's Radiology Results Report, dated 11/10/2022 documents, No fracture or displacement in R57's right hand. R240's Social Service's Note, dated 11/10/2022 at 3:55 PM, documents, This writer followed up with resident regarding incident last week. Resident continues to adjust well with recently moving from another facility. No signs of mental anguish have been displayed. Resident presented writer with a smile. R240's Nurse's Note, dated 11/10/2022 at 12:02 AM, documents, Resident moved to another room after a physical altercation with her roommate, (R57.) On 11/17/2022 at 7:45 AM, R240 observed sitting in the dining room with 5 other residents at the table. R240 didn't respond to the questions when asked. On 11/15/2022 at 10:30 AM, R57 observed sitting in a wheelchair at the end of 100 hall. Upon approach, R57 showed the IDPH surveyor her right hand and a light purple bruise was noted on her right middle knuckle and top of right hand. R57 stated, another resident, (name unknown), squeezed her hand so hard she tried to break my hand. I had to get it x-rayed, my right hand still hurts! On 11/17/2022 at 9:30 AM, V11, LPN (Licensed Practical Nurse) stated, (R57) is usually calm and cool, but when it comes to her sharing her room, she isn't nice. (R57) wants her own room and she fights with her roommate often she's had a few roommates and they have altercations. She wasn't aware of R57 having a bruise on her right hand. On 11/17/2022 at 10:00 AM, V9, LPN, stated, (R57) is aggressive and demanding and gets into resident-to-resident altercations often. She's had several roommates in the past, but it didn't work out because (R57) would yell and sometimes hit her roommate. V9 didn't know anything about a bruise to R57's right hand. If a resident was afraid of their roommate staff should find a new roommate immediately. V9 wasn't aware of a roommate being afraid of (R57.) On 11/17/2022 at 10:30 AM, V13, LPN, stated, (R57) is confused and she is calm and cool, until it comes to her having a roommate. The most recent incident was with (R240), when (R57) sustained a bruise on her right hand after having a resident-to-resident altercation with (R240). (R57) doesn't currently have a roommate because she always fights with them. On 11/17/2022 at 11:30 AM, V16, CNA (Certified Nursing Assistant), stated, (R57) is a fighter; she fights with any roommate they give her, and I always hear (R57), yelling at other residents. (R57) is very territorial and she's hit residents in the past. On 11/17/2022 at 12:00 PM, V18, CNA, stated he worked at the facility 2 weeks and observed (R57) yelling at a few residents, and staff told him that's what she does all the time. On 11/17/2022 at 12:30 PM, V21, LPN, stated, (R57) has a temper and she fights with her roommates often. V21 didn't understand why management won't let R57 have her own room because she fights with every roommate. On 11/18/2022 at 8:20 AM, V1, Interim Administrator, stated, It seems like a pattern of behavior for (R57); she doesn't seem to like having a roommate and she doesn't want to pay for a private room. (R57) doesn't currently have a roommate because we don't want to continue having resident-to-resident altercations between (R57) and the roommate. On 11/18/2022 at 8:25 AM, V2, Interim DON (Director of Nursing), stated, (R57) wants her own room but she doesn't want to pay for a private room, so she bullies all her roommates, so they are transferred to other rooms. On 11/18/2022 at 3:15 PM, V17, Former DON, stated, (R57) never likes roommates, and she would threaten to beat them up until her roommates were scared enough to want to move out of her room. She recalled R63 was moved into R57's room on 9/28/2022, and when she got to work at approximately 6:00 AM on 9/29/2022, R63 was up at the nurse's station crying, and staff reported R57, yelled at R63 and made her get out of her room on the night of 9/28/2022. R63 stated staff offered to let R63 go to a different room for the night, but she refused because, she wanted to stay at the nurse's station because she was afraid of R57. Corporate told V17 she had to continue to take admissions and fill the resident rooms up, so if R57 didn't pay for a private room she couldn't have a private room, even though she was mean to all her roommates; they had to fill the bed per corporate. The Facility's Policy reviewed 9/2017 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, record review and interview, the facility failed to implement pressure relieving interventions, prevent infection and the worsening of pressure ulcers for one of 4 residents (R17) reviewed for pressure ulcers in the sample of 37. This failure resulted in R17's facility acquired shear pressure injury deteriorating with the need for surgical debridement (removal) of necrotic (dead) tissue. Findings include: The Minimum Data Sets ((MDS) dated [DATE] and 10/01/19 documents R17 is severely impaired with cognition, requires extensive assistance with bed mobility, transfers, personal hygiene and is incontinent of bowel and bladder. R17's MDS, dated [DATE], documents R17 was still at risk for pressure ulcers, but has none. This MDS documents R17 has open [MEDICAL CONDITION]. R17's Initial Skin Alteration Record, dated 6/24/19 documents-Healed/closed. There is no documentation of pressure ulcers for R17. R17's Weekly Skin Record, dated 7/9/2019, documents a facility acquired, PU (pressure ulcer) 2.0 cm (centimeter) X (by) 4.3 cm, open area to coccyx (tailbone), left buttock 1 cm X 1 cm, beefy red in color, free of drainage. There was no documentation of the Stage of the ulcer. R17's Care Plan, revised 8/13/2019 documents, in part, potential for pressure ulcer development related to incontinence and need for staff assistance to remain clean and dry and free from odors. Wound to coccyx. The Care Plan documents, follow facility policies/protocols for the prevention/treatment of [REDACTED]. A physician's orders [REDACTED]. Wound to coccyx. V21's, Wound Physician, Initial Wound Evaluation and Management Summary for R17, dated 8/26/2019 documents R17 was first seen and assessed by V21. The Summary documents, in part, (R17) has a shear wound of the left buttock for at least 3 days duration. There is moderate serous (clear, thin, watery) drainage. Site 1-Shear wound sacrum (a large wedge-shaped vertebra at the end of the spine) measuring 2.5 X 4 X 0.2 cm, 50 % (percent) thick adherent devitalized necrotic tissue. Alginate calcium apply once daily for 30 days, Dry protective dressing once daily for 30 days, Santyl, apply once daily for 30 days. Limit sitting to 30 minutes. Off load wound. Reposition per facility protocol. With clean surgical technique, curette (a surgical instrument) was used to surgically excise 5.0 cm2 (squared) of devitalized (dead) tissue and necrotic muscle and surrounding fibers were removed at a depth of 0.3 cm. V21's documented R17 had a shear wound to the left buttock measuring 1.5 cm x 1.5 cm with depth not measurable. The treatment and surgical debridement for the left buttock is the same as the sacral/coccyx ulcer. The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure injury as localized damage to the skin and underlying soft tissue over a bony prominence related to a medical or other device. NPUAP continued The Injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The Initial Wound Evaluation and Management Summary for R17, dated 8/31/2019, from V21 documents R17's sacral ulcer measured 3.5 X 5.0 X 0.5 cm, again with 50% necrotic tissue, surface area 17.5 cm2, and had deteriorated. The treatment remained the same. The Summary further documents, Site 1-Curette was used to surgically excise 8.75 cm2 of devitalized tissue and necrotic muscle and surrounding fascial fibers (fibrous connective tissue containing collagen). Site 2-Shear wound of left buttock-2 X 2 cm, surface area 4.0 cm2, 40% necrotic tissue. Curette was used to surgically excise 1.6 cm2 of devitalized (dead) tissue and necrotic subcutaneous fat and surrounding connective tissue. The treatment remains the same. Once again, V21 recommended Limit sitting to 30 minutes, Offload wound, reposition per facility protocol. V21's weekly treatments for R17's pressure ulcers remained the same until The Initial Wound Evaluation and Management Summary dated 9/16/2019. The Summary documents, in part, She (R17) has a shear wound to the sacrum for at least 23 days duration. There was no pain associated with this condition. Site 1-Shear wound sacrum, 3.5 X 5.0 X 1 cm, surface area 17.5 cm2, moderate serous drainage, 50% thick devitalized necrotic tissue, wound progress-no change. Site 2-shear wound of left buttock, 2 X 2 X 0.1 cm2, surface area 4.0 cm2, 40% necrotic tissue. Once again, both wounds were surgically debrided to obtain margins of viable (good) tissue. V21's plan of care added the antibiotic, [MEDICATION NAME] 500 mg (milligram) to be crushed and added to the current treatment of [REDACTED]. The Initial Wound Evaluation and Management Summary for R17, dated 9/23/2019, documents [MEDICATION NAME] (antibiotic) ointment was added to the same treatment regimen as of 9/23/2019. V21's Initial Wound Evaluation and Management Summary for R17, dated 10/07/2019, documents, in part, Site 1-shear wound sacrum-3.0 X 5.0 X 1 cm, surface area 15.0 cm2, 50% necrotic tissue. This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of biofilm (slimy film of bacteria that sticks to a surface). Site 2-left buttock, 1.5 X 1.5 X 0.1 cm. surface area, 2.25 cm2, 20% necrotic tissue, Wound progress, no change. On 10/8/19 at 11:53 AM, R17 was in bed on her right side. R17's pressure relieving boots were in the geriatric chair. R17's feet were directly on the mattress. At 12:13 PM, V8, Certified Nurse's Aide (CNA) stated, She (R17) has a sore on her butt. They turn her from side to side. On 10/8/19 at 12:19 PM, R17 was positioned on her back in bed. Her heels were directly on the mattress. R17's pressure relieving boots remained in the geriatric chair. At 2:17 PM, R17 remained in bed on her back. She had the pressure relieving boots to both feet; however, the heels of the boots were directly on the mattress. On 10/10/19 at 9:23 AM, R17 was up in a reclined geriatric chair, placing pressure directly on her coccyx and buttocks. R17 was wearing pressure relieving boots to both feet, but her heels were on the foot rest of the chair. At 9:54 AM, 10:16 AM, 10:21 AM, and 10:38 AM, R17 remained up in the reclined geriatric chair on her back. At 10:45 AM, V16, CNA stated, I got her (R17) up at 6:30 AM. She eats really good, doesn't talk much. Smiles a lot. She can't T&P (turn and position) herself. I know they repositioned her after her treatment was done this morning. On 10/10/2019 at 10:50 AM, V17, Licensed Practical Nurse (LPN) reported R17's wound treatments were done by the midnight shift, before she arrived at work. On 10/10/19, at 11:06 AM, R17 was still in the same position in her geriatric chair, on her back, with pressure on her coccyx. At 11:16 AM, R17 was still in the same position. At that time, R49, R17's roommate, stated, She (R17) was up in that chair before I got up at 6:30 (AM) this morning to shower. I'm worried about her. On 10/10/19 at 11:20 AM, V17, LPN, stated, She (R17) got the pressure ulcer here. It's an area that keeps coming and going. She eats good. She has a nonhealing wound. (V21, Wound Physician) has been seeing her for several months, once a week. On 10/10/19 at 12:11 PM, V1, Administrator and V15, Assistant Director of Nursing (ADON), were in R17's room. R17 was still in the geriatric chair on her back. V15 removed the pressure relieving boot to her right foot. A red, blanchable area, the size of a quarter was on R17's inner right heel. V15 checked for pedal pulses and reported they were present to both of R17's feet. The back of R17's calves had been resting directly on the chair. Indentations were noted to back of both calves, where they laid on the chair. V15 floated her feet on a pillow at this time. V1 stated, Let me get someone to reposition her. It's time for her lunch. On 10/10/19 at 12:22 PM, V16, CNA entered R17's room, then went to get a mechanical lift. V16 stated, We usually feed her, take her to the dining room, and then we will lay her down. On 10/10/19 at 12:24 PM the mechanical lift pad was attached to R17, and she was lifted for less than 3 minutes from the chair. There was no pressure relieving cushion in the geriatric chair. There was a large indentation in the chair where her buttocks were sitting. On 10/10/19 at 12:26 PM, R17 was lowered back into geriatric chair by V8 (CAN) and V15 (ADON). R17 was slightly repositioned to the left side with a wedge cushion under her right arm. R17 still remained sitting on her buttocks with the pressure on her coccyx. At 12:28 PM, R17 was wheeled into the dining room for lunch. R17 had been up in the chair over 3 hours, with her heels not floated and without the benefit of being repositioned or offloading her coccyx. R17 had not been repositioned in the geriatric chair since she had been placed in the chair on the midnight shift, over 7 hours, except for the less than 3 minutes before lunch when she was lifted by the mechanical lift. On 10/10/19 at 1:30 PM, R17 was transferred to bed by V17(LPN) and V20, LPN and her incontinent brief was removed. The brief was wet with urine. V17 removed the dressing dated 6/10/2019 to the coccyx. A large deep, beefy red open area was on R17's coccyx. The center of the wound was white, possibly revealing bone. R17 had a smaller Stage II pressure ulcer on her inner left buttock. On 10/10/19 at 1:42 PM, V17 stated, (V21, Wound Physician)) is calling this wound unstageable shearing. We crush the [MEDICATION NAME] (antibiotic), mix with equal parts Santyl and [MEDICATION NAME] ointment and paint the wound with it. No tunneling that I see. V17 applied the mixture and packed both wounds with Calcium Alginate. V17 covered the area with a non-adhesive, moisture resistant dressing. R7 was pulled up in bed and positioned to the left side. Her buttocks and upper thighs were heavily creased, red but blanchable. V17 reported she did not know what stages the wounds were. The NPUAP (National Pressure Ulcer Advisory Panel) at https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf documents the definition, Unstageable Pressure Injury: Obscured full- thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. On 10/10/19 at 1:48 PM, V17 and V20 positioned R17 slightly to the left side with a wedge behind her back and a pillow between her knees. They covered her and left the room. Both V17 or V20 failed to provide incontinent care at all. R17's feet were directly on the mattress. R17's pressure relieving boots remained on the geriatric chair. R17's Progress Note, dated 9/27/2019 at 4:34 PM, from V23, Dietitian documents, in part, Continued to have a deep tissue injury on left buttock per skin record on 9/16-wound showing no change, [MEDICATION NAME] (appetite stimulant) discontinued on 9/23/2019. She has been consuming 75-100% at meals. Now receiving 2 times protein at meals per previous RD (Registered Dietitian) recommendation. Weight 183.4 pounds as of 8/28/2019. On 10/11/19 at 10:29, V2 Director of Nursing (DON), stated, I just started here 10/3/2019. I'm trying to educate staff. I looked at her wound today. There is no necrosis. There is healthy tissue to the coccyx, I would say it's a Stage III, 3 cm X 3 c, X 1 cm, no tunneling, with a Stage 2 to the left buttock-1 X 1 X 0.5 cm. We will be turning her every hour now. On 10/11/19 at 10:43 AM, when V21 was asked why he does not Stage wounds, V21 stated, I don't stage wounds. It (R17) started as a shearing to the coccyx. Necrosis will happen. I debride the wound every week using a sterile technique. When V21 was Informed of the facility's failure to T&P R17 for over 4 hours, he stated, They should keep her clean and follow their facility protocol. The wound is improving very slowly. The standard for T&P is every 2 hours. They should not keep her up for over an hour at a time. The facility's policy and procedure, reviewed 1/2014 and entitled, Preventative Skin Care Policy documents, in part, To provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. Any resident identified as being a high risk for potential skin breakdown shall be turned and repositioned at minimum of every 2 hours. Slightly elevate bony prominences/pressure areas off the mattress. Pressure relieving devices may be used to protect heels and elbows. Practice care in moving and lifting residents. Prevent shearing forces during moving and transfers. Prevent pulling resident across the sheets. Keep incontinent residents clean and dry.

Based on interview and record review, the facility failed to prevent falls, analyze root causes of falls and failed to provide progressive interventions to prevent future falls for 2 of 4 residents (R14, R17) reviewed for falls in the sample of 45. This resulted in R17 falling and sustaining a fracture to the shoulder twice. Findings include: 1. R17's undated Admission Record documents she was admitted on [DATE] with [DIAGNOSES REDACTED]. R17's MDS dated [DATE] documents R17 has moderate cognitive impairment. The MDS documents R17 requires extensive assist (resident involved in activity, staff provide weight-bearing support) of one-person physical assistance with all activities of daily living including bed mobility, transfers, and totally dependent on staff for locomotion on and off the unit. R17's Fall assessment dated [DATE] documents a Fall Risk score of 15 (Score of 10 or greater, the resident should be considered at High Risk.). R17's Care Plan, with initiation date of 5/21/19 documented At High Risk for Falls related to decreased safety awareness related to confusion. Primary mode of locomotion is wheelchair, incontinent of bladder at times. Family assist resident to the bathroom and with mobility at times. Has a history of falls and orthostatic [MEDICAL CONDITION] prior to admission. She will attempt to transfer self at times and has decreased safety awareness. Goal: Will remain free of falls causing hospitalization s related to injury thru next review. The Care Plan Intervention, dated 5/19/19, documented Resident educated on use of call light and not transferring self without staff present. R17's Progress Note, dated 5/19/19 at 9:00 AM documented This nurse entered resident's bathroom to observe resident on the floor. The Note documented Stated she was trying to self-transfer from the toilet to her wc (wheelchair) and slipped on the floor. The Note documented Resident re-educated to use call light for staff assist when needed to transfer. A Final Illinois Department of Public Health (IDPH) Incident Notification undated documents, Date of Incident: 5/21/19. On 5/21/19 (R17) was noted with a 6 centimeters (cm) by 5 cm discoloration on her right shoulder. Review of medical record reveal resident had a fall on 5/20/19. She was observed on her right side in her bathroom. Resident complained of right shoulder pain on 5/21/19 and orders for X-ray were obtained. Revealed acute distal clavicular fracture (collar bone). The facility concluded that the discoloration was from her fall that occurred on 5/20/19,The facility was not able to provide the Fall Investigation Report for 5/20/19 and the X-ray result done on 5/21/19. There was no documentation in R17's medical record that the facility reassessed R17 for possible causes of R17 falling. R17's Care Plan Intervention, dated 5/21/19, documented Nurse educated resident on using and waiting for staff assistance. R17's Progress Note, dated 6/13/19 at 11:05 PM documented Resident observed lying on floor between bed and bathroom. Resident states that she was trying to get OOB (out of bed) unassisted and lost her balance. Small hematoma noted to right upper forehead with no active bleeding noted. Incident Report dated 6/13/19 documents R17 fell at 11:05 PM. The Report documented Nursing Description: Fall in resident's room. Resident Description: fell while trying to get up unassisted to use the bathroom. Description of Action Taken: First aid unnecessary. Neuro checks initiated. and findings within normal limits. Investigative Conclusion, undated, documents, Resident observed laying on floor when asked what happened resident reported she was trying to go to bathroom. Bed in low position. Plan of Action to Prevent Reoccurrence: Floor mat next to bed. There was no documentation in R17's medical record that the facility reassessed R17 for possible causes of R17 falling or need for increased supervision. No progressive interventions were documented to prevent R17 from falling again. The Final IDPH Incident Notification, undated documents, Date of Incident: 6/14/19. Resident was observed attempting to ambulate unassisted to her room. Comprehensive investigation concluded as nurse was going down the hall she observed (R17) up going to the restroom and before she could get to her, she began losing her balance causing her to fall. Resident was immediately assessed. Resident complained of left shoulder. No other injuries identified. (Physician) and POA (Power of Attorney) notified. New orders were received to send to ER for evaluation. Resident was treated and released from hospital with left proximal humeral diaphysis fracture (shoulder) the same day. Resident returned to facility with a left arm sling and medication for pain management. Incident Report, undated, documents, Date of Incident: 6/14/19 06:55. Immediate Action Taken: Call EMS Emergency Medical Service). The Hospital Radiology Report dated 6/14/19 documents X-ray Supine Chest: Impression: Pacemaker, [MEDICAL CONDITION], and left humeral neck. There was no documentation in R17's medical record that the facility reassessed R17 for possible causes of R17 falling or need for increased supervision. There were no progressive interventions developed to R17 from falling again. Incident Report undated documents, on 7/5/19 at 11:17 PM Nursing Description: Resident found on restroom floor in a room in 500 Hall. Sitting upright. Admits to hitting head and lump found to posterior scalp noted. Denies pain with assessment with the exception of left shoulder pain with previous injury. Neuro checks within normal limits. Neurochecks to continue per protocol. Resident Description: 'I was trying to use the restroom.' Investigation Conclusion, undated, documents, Plan of Action to Prevent Reoccurrence: Midnight shift to ask/assist resident to restroom at beginning of shift. There was no documentation in R17's medical record that the facility reassessed R17 for possible causes of R17 falling No root cause analysis conducted for this fall. No progressive intervention formulated to prevent fall recurrence. Final IDPH Incident Notification undated, documents, Date of Incident: 7/12/19. Comprehensive investigation completed. (R17) was sitting on commode with staff in attendance. As staff turned to reach for wipe to provide pericare resident attempted to stand, lost her balance causing her to fall before staff member could get to her to lower her to the floor or prevent fall. Per X-ray report from hospital, impression was comminuted left humeral fracture. Also noted to have Osteopenia. Per History and Physical from hospital indicates resident has broken left humerus multiple times. Resident has returned to facility, continues at her prior level of function. The Hospital X-ray Chest Result dated 7/12/19 documents, Impression: 1, Comminuted proximal left humeral fracture. Incident Report, undated, documents, Date of Incident: 7/12/19 03:00. Nursing Description: fell in bathroom. Resident Description: fell in bathroom. Immediate Action Taken: Sent to ER for evaluation and treatment. No root cause analysis conducted for this fall. No progressive intervention formulated to prevent fall recurrence. On 8/14/19 at 3:45 PM, V26, Regional Nurse, stated she expects all fall investigations to include root cause analysis and to have progressive interventions in place. On 8/28/19 at 11:45 AM, V57, Physician, stated R17's falls could have been prevented, there is a need for staff education which is very important. V57 stated it is everybody's responsibility, not just the nursing staff to ensure if they see a resident trying to get up to get to them right away and ask if they need something and call for help from the nurse or CN[NAME]V57 stated the facility needs to analyze the root causes of the falls and formulate individualized interventions according to each patient's need. The Facility Policy on Fall Management reviewed 3/2015, documents, Policy: It is the policy of this 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. Standard Fall/Safety Precautions: All Residents 1. At the time of admission and in accordance with the plan of care of the resident will be oriented to the nurse call device. The nurse call device will be placed within the resident's reach at all times. The location of the placement will be verbalized for those residents with visual deficits. Residents will be observed approximately every 2 hours to ensure the resident is safely positioned in the bed or chair and provide care as assigned in accordance with the plan of care. 2. R14's Minimum Data Set (MDS) dated ,[DATE] documents R14 requires two plus physical assistance extensive assist (resident involved in activity, staff provide weight -bearing support) with transfers and extensive assistance of one-person physical assist for bed mobility. R14's MDS documented he had no cognitive impairment. R14's Fall Risk assessment dated [DATE] documents R14 has a score of 22 (Total score of 10 or greater, resident should be considered at High Risk for potential falls). R14's Care Plan undated, documents, At risk for falls related to his weakness lack of coordination and cognitive status. The Care Plan documented Goal: Will have falls/injuries minimized by management of risk factors while maintaining maximum independence/quality of life through next review. R14 had 7 fall incidents from 5/2019 through 7/2019 as follows: a. R14's Nurse's Note dated 5/10/19 10:17 AM documents, Resident found sitting on buttocks on floor in front of toilet in room. Resident trying to transfer self to chair unassisted. Denies any pain or discomfort, range of motion is within normal limits. Will continue to monitor. Investigation Conclusion, undated, documents, Resident found sitting on floor in front of toilet in Bathroom in his room. When asked what happened reported he was trying to go to bathroom. Nurse assessed no injuries noted, denied pain/discomfort. Floor noted to be dry. MD (Medical Doctor) and POA (Power of Attorney) notified. Plan of action to prevent Reoccurrence: Resident brought to common areas for closer monitoring. R14's Care Plan intervention, dated 5/10/19, documented Resident out to nurse's station for closer monitoring. b. Initial Incident Notification dated 5/28/19 documents,[AGE] year-old alert and oriented resident independent with wheelchair mobility was propelling self near nurses station leaned forward in chair, lost balance and fell at 6 PM on 5/28/19. Nurse immediately assessed resident noting having hematoma to left forehead and complaints of pain to his head and hip. POA and MD notified, order received to send to ER (emergency room ) for evaluation. Facility Administrator notified at 6 AM on 5/29/19 that resident was being admitted to hospital for intracranial bleed. R14's Hospital CT (Computed [NAME]ography: special x-ray that uses cross sectional images of body using x-ray and computer) of Head without Contrast dated 5/28/19 documents, Findings: Acute subarachnoid hemorrhage (bleeding between the brain and surrounding membranes) is seen within the posterior right frontal sulci (frontal lobe of brain). There was no reassessment of R14's to determine why R14 fell and what interventions would be implemented to prevent him from future falls. R14's Care Plan Intervention, dated 5/28/19, only documented he was sent to ER. The Care Plan did not document any progressive intervention to prevent him from future falls. c. Risk Management Report, undated, documents an incident on 6/8/19 at 5:57 PM. The Report documented Resident found sitting on buttock in room. When I asked resident if he was hurting anywhere or if he hit his head he stated, 'no.' Resident stated, 'I slid out of my chair.' Investigation Conclusion, undated, documents Plan of Action to prevent Reoccurrence: Assist resident to bed. (anti-slip mat) to wheelchair. d. Incident Report dated 6/9/19 documents, Date of Incident 6/9/19 4:35 PM. Nursing Description: Resident went to dining room and fell out of wheelchair. He is getting his legs twisted up in wheelchair. He is not able to properly propel himself. Resident lying on his side, red knot on left side of forehead. MD here and does not want to send resident out. Vital signs normal. Eliquis (blood thinner) discontinued. Neurological checks negative and full range of motion. Resident legs are stiff this is his baseline, legs stiff before fall. Resident Description: My legs aren't working. Immediate Action Taken: MD here and assessed resident. Resident put in (reclining geriatric chair) by staff, ice applied to left forehead, vital signs taken. Investigation Conclusion, undated, documents, Plan of Action to Prevent Reoccurrence: Wheelchair changed to (reclining geriatric chair). No root cause analysis was conducted for this fall. No progressive intervention formulated. e. Incident Report dated 7/2/19 documents, Date of Incident: 7/2/19 5:34 PM. Nursing Description: Certified nursing aide noted resident on his bedroom floor on his left side. Resident Description: Resident says he didn't hit his head was trying to take off his shoes. Immediate action Taken: No injuries. Investigation Conclusion, undated, documents, Plan of Action to Prevent Reoccurrence: Resident reminded to have staff assist with shoes. No root cause analysis was conducted for this fall. No progressive intervention formulated. f. Incident Report dated 7/22/19 documents, Date of Incident: 7/22/19 3:47 PM. Nursing Description: Called to resident's room. Found resident lying with upper body on floor and lower body on bed. Discolored area to left side of forehead. Resident Description: I slid to the floor. Immediate Action Taken: Complete Nursing Assessment immediately. Resident denies pain at this time. Investigation Conclusion, undated, documents, Plan of Action to Prevent Reoccurrence: Staff to make frequent checks on resident when in bed. No root cause analysis was conducted for this fall. g. Incident Report dated 7/31/19 at 6:16 Pm documented Nursing Description: Notified by staff resident had slid to the floor from low bed and onto his floor mat. Immediately assessed resident. No complaint of pain and no injuries noted. Resident has confusion but stated he slid out from bed to floor while he was rolling over. Assisted back to be. Vital signs within normal range. MD notified with no new orders. Resident Description: Resident stated he slid to the floor while rolling over. Investigation Conclusion, undated, documents, Plan of Action to Prevent Reoccurrence: Mattress changed to canoe mattress. No root cause analysis was conducted for this fall. On 8/14/19 at 3:45 PM, V26, Regional Nurse, stated she expects all fall investigations to include root cause analysis and to have progressive interventions in place. On 8/28/19 at 11:45 AM, V57, Physician, stated R14's falls could have been prevented, there is a need for staff education which is very important. V57 stated it is everybody's responsibility, not just the nursing staff to ensure if they see a resident trying to get up to get to them right away and ask if they need something and call for help from the nurse or CN[NAME]V57 stated the facility needs to analyze the root causes of the falls and formulate individualized interventions according to each patient's need.

[NAME] Based on interview and record review, the facility failed timely identify, assess and treat wounds related to [MEDICAL CONDITION] for two of two residents (R16 and R33) reviewed for wounds in the sample of 45. This failure resulted in R16 acquiring multiple wounds. Findings include: 1. R16's Admission Record, undated, documents R16 has [DIAGNOSES REDACTED]. R16's (MONTH) 2019 physician's orders [REDACTED]. The POS did not document R16 was receiving any treatments for skin conditions/wounds. R16's Treatment Administration Record for May, (MONTH) and (MONTH) up until she was discharged to the hospital on [DATE], documented R16 was to have a weekly skin assessment. These assessments did not document R16 had any skin condition or wounds during this time frame. R16's Weekly Skin Record, dated [DATE], documents, skin remains intact. R16's Shower Sheets dated [DATE], [DATE] and [DATE] have no documentation related to R16 having open areas on her skin. R16's Minimum Data Set ((MDS) dated [DATE], documented R16 was cognitively intact. This MDS also documents R16 required extensive assistance of 1 staff member for bed mobility, dressing, toileting and personal hygiene. This MDS documents R16 requires limited assistance of 2 staff members for transfers. This MDS documents R16 is frequently incontinent of bowel and bladder. R16's Care Plan, initiation date of [DATE], documents, in part, Focus: (R16) has the potential for pressure ulcer development r/t decreased mobility, urinary incontinence, frequent [MEDICAL CONDITION] to bilateral legs, ankles and history of open areas. The Care Plan documented Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements or decline to MD. The Care Plan documented Follow facility policies/protocol for the prevention/ treatment of [REDACTED]. If (R16) refuses treatment, confer with resident, IDT (Interdisciplinary Team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. The Care Plan documented Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/s (signs symptoms) of infection, wound size, stage. R16's Care Plan, initiation date [DATE], documents She also has refused staff to assist her in showering and getting cleaned up. The Care Plan documented Focus: (R16) will demonstrate effective coping skills for the next 90 days. Interventions: Analyze of key times, places, circumstances, triggers, and what deescalates behavior and document. Assess (R16's) coping skills. Assess (R16's) understanding of the situation. Allow time for (R16) to express herself and her feelings toward the situation. Monitor/ Document (R16) observed behavior and attempted intervention in behavior log. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. See the behavior tracking manual for additional interventions. R16's Care Plan, dated [DATE], documents, in part, Focus:(R16) has an ADL Self Care Performance Deficit r/t generalized weakness, vision deficit and need for staff assistance to remain clean dry and free of odors. The Care Plan Intervention documented She requires verbal cue for changing clothes after showering. Toileting: (R16) requires supervision from 1 staff with all her toileting needs. Bathing: (R16) requires extensive assistance of 1 staff for all bathing/showering. (R16) will often refuse her shower and request a bed bath instead. Will consent to a tub bath, however requests to be left alone in the tub for dignity. (R16) needs much encouragement to change her soiled clothes on a daily basis. R16's Care Plan/Behavior Tracking Record, dated (MONTH) 2019, documents, in part, Problem Statement: Refusing to allow staff to clean her up and assist with showering. Goal: To have cooperation with showering and staff assistance with cleaning self and personal hygiene. Interventions: 1. one to one/Emotional Support/ Counseling. 2. Calming/ Redirection/Distraction 3. Try at a later time to give care. R16's (MONTH) 2019 Care Plan/Behavior Tracking Record documents 37 shifts which staff did not document at all; 52 shifts documenting R16 had no behaviors of refusing staff to clean her or assist with showering; and only one shift which she displayed behaviors of refusing showers or to be cleaned up by staff. R16's Nurse's Note, dated [DATE] at 06:19 AM, documents, R16 fell out of her wheelchair onto the floor. The Nurse's Note documented R16 was sent to the emergency room for evaluation. R16's Nurse's Note, dated [DATE] at 06:25 AM, documents, While assisting resident with incontinence care in resident's bathroom, skin assessment completed. Moist, mushy skin noted to bilateral posterior thighs with 10-centimeter (cm) x 10 cm open area noted to posterior right thigh. BLEs (Bilateral Lower Extremities) swollen and discolored, feet purplish in color. Redness noted to bilateral posterior thighs. emergency room updated on findings re: skin assessment. R16's Hospital Wound Flow sheets, dated [DATE] at 11:41 AM, documented the R16 had the following skin conditions and wounds which were present upon R16's admission: bilateral gluteal ulcerations, multiple partial opened, some scabbed and black, dry, purple and reddened; a gluteal fissure; bilateral thigh abrasions; bilateral, medial groin moisture associated skin damage MASD-moisture associated skin damage- Inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including urine, stool, perspiration, wound exudate, mucus or saliva); and a left 5th toe ulceration measuring 1.3 centimeters (cm)by 1.0 cm. R16's Local Hospital History of Physical, dated [DATE] at 1:04 PM, documents, Extremities: extremities normal, atraumatic, 2 plus [MEDICAL CONDITION] and weeping [MEDICAL CONDITION] present. Skin: multiple open [MEDICAL CONDITION] present. R16's Skin Wound Ostomy Team (SWOT) Hospital Notes, dated [DATE], documents, in part, Skin/Wound Assessment: Patient seen in room. Patient has several other apparent vascular ulcers on plantar aspect of left foot and 2nd toe on the right foot. Left thigh has a large open area with 20% slough. Patient bilateral posterior knees assessed. Both areas show reddened areas likely due to moisture. Patient rolled on left side to assess right posterior thigh. Patient has MASD with severe open areas likely due to moisture. R16's Hospital Notes dated [DATE], documents R16's wound to right posterior thigh was present upon admission. The Note documented R16's wound as MASD with the wound base being 80% reddened, 20% yellow/slough (dead tissue) and scants amount of drainage. On [DATE] at 2:24 PM, V36 Certified Nurse Aide (CNA), stated, R16 was incontinent. V36 stated she would wash R16 up in the bathroom every day. V36 stated the day R16 fell We helped her up with 2 people and a gait belt. I took her to the bathroom and stood her up with the grab bars and washed her up. She had red spots on her bilateral back of thighs. None were open that I remember. She had red spots once before and they went away. They weren't blisters. I thought it was just from her being wet. On [DATE] at 3:30 PM, V10 CNA, stated, She (R16 was able to make up her own mind and was determined to do things her way. She was particular about who worked with her. Her posterior thighs and buttocks were peeling, red, mushy with scabbed areas. Her legs were always swollen but they were intact. This was before and after the hospital. We were putting [MEDICATION NAME] on the areas. On [DATE] at 11:40 AM, V16 LPN, stated, (R16) was independent. She was alert and made her own decisions. She transferred herself to her wheelchair. She was incontinent. She would let you know when she was wet, but she didn't like to get changed. It was on going chore to get her changed. On [DATE] at 9:00 AM, V29 LPN, stated, (R16) would sit on the edge of the bed with the tray table leaning over it with her feet on the floor. Her legs were swollen, and she was very noncompliant with putting them up. She frequently refused care. She only would only let certain people care for her. (V36) could talk her into cleaning up. She would only clean up when she wanted to be cleaned up. V29 stated the morning R16 fell (V36) did come and get me while she was cleaning (R16) up and told me about an open area on her thigh and that her thighs were mushy. Her thigh did have an area to the right thigh and they were mushy. I notified the emergency room of this because this was new and there was no treatment in place for it. On [DATE] at 12:05 PM, V1, Registered Nurse (RN/previous Administrator, stated She did not like to take showers, change her incontinence brief or change her clothes. She was alert and oriented. It (being soiled) didn't bother her. No one ever reported skin issues to me. (V36) took care of her all the time and she is a really good aide. If something was wrong she would let us know. Staff should report any open areas to the nurse. On [DATE] at 1:50 PM, V51 RN, stated, (R16) was on introvert. She was alert and orientated with poor decisions. She would sit in urine for long periods of time. She wouldn't let you clean her bed or her room until she was ready. If she didn't want to do it, she wasn't doing it. It was amazing her urine was so strong, but her skin was intact as far as I knew. On [DATE] at 11:30 AM, V37 CNA, stated, If (R16) did not like a person she would not let you touch her. She liked me, but I never saw her skin. She would toilet by herself. She never let me help her. I would get her set up. I could get her to take a shower but again she would not let me see her naked. She would do it all by herself. Basically (V36) was the only one that saw her naked. On [DATE] at 12:30 PM, V43 Physician, stated, (R16) was set in her ways. If you demanded something she wasn't going to do it. She probably wasn't the cleanest, she didn't like to bathe. She had chronic [MEDICAL CONDITION] of her legs. She had scaly large legs. She refused to wear compression socks. She could verbalize her needs and could ask for help. I was not aware of any wounds. Upon looking at the wound photos from the hospital, V43 stated, The buttocks looks like it is chronic. The buttocks look like chronic picking or scratching. The thigh wound looks like a new acute abrasion or shearing possibly from a transfer with a pad. Under that wound the thigh looks like it is chronic Incontinence Associated [MEDICAL CONDITION]. The gluteal folds look moisture related possible fungal. The toe wounds are vascular. The lateral foot wound is questionable. It is odd. It is not on a place of pressure. Without feeling it and seeing it, I don't know. The heel is odd because she was up using her feet in her wheelchair. I would expect the nursing home to figure out a way to see her skin and report it to me. On [DATE] at 2:15 PM, V33 New Administrator, stated, Yes, the doctor should have been notified of (R16's) skin, the nurses should have been notified from the aides and interventions should have been put in place for (R16's) education and treatments. When a nurse charts other on the weekly skin assessment they should follow up with a detailed description of the skin issue. On [DATE] at 3:40 PM, V12 RN, stated, (R16) was alert and orientated. She was very independent. She wasn't the most hygienic person. She was noncompliant with hygiene and her ace wraps to her legs. I think it was the way the staff approached her. You had to make her think it her idea. She was using a wheelchair at the end. On [DATE] at 10:22 AM, V33 stated, I did not know (R16). I never even laid eyes on her. For someone with her skin issues, I would think the nurses would discuss and consult with the physician and maybe consult with a wound doctor. 2. R33's Face Sheet, dated [DATE], documents R33 was admitted on [DATE] with [DIAGNOSES REDACTED]. R33's MDS, dated [DATE], documents R33 has a BIMS of 5 indicating R33 is severely impaired. R33's Nurse's Note, dated [DATE], documents, in part, Note Text: New orders re: [MEDICATION NAME] cream to rash every shift to chest, back, and bilateral upper and lower extremities. R33's Nurse's Notes, dated [DATE], documents, Received call from (V55, R33's daughter) regarding sores all over her body. States that she has a sore under her neck, on left upper shoulder, between breasts. Assessed resident. Sores noted to left neck, left upper chest, between breasts, under left breast, and left groin. The Note documented called (V43's, R33's Physician) office and spoke with (staff). Updated on resident status. Will inform (V43). Called (V55) and updated on resident status. R33's Nurse's Note, dated [DATE], documents, in part, Note Text: (V43) informed of open areas on upper left chest and sternum and rash in groin area on left side and under left breast. Order given for TAO (triple antibiotic) and band aide to open areas daily and antifungal powder to breast and groin bid (twice a day) until healed. R33's Nurse's Note, dated [DATE], documents, Called (V56 Nurse Practitioner). Updated on healing blisters on left breast and sternum with appearance of 1 more blister. Sites continue to heal. NNO received. R33's TAR, dated (MONTH) 2019, documents, in part, Weekly Skin Assessment on Fridays. C - Clear, R -Red Rash, O- Other, P - Pressure, S - Skin Tear. This TAR has O documented for [DATE], [DATE],[DATE] and [DATE]. There is no documentation regarding what the O is on the TAR. There is no Nurses Note regarding what the O is. R33's TAR, dated (MONTH) 2019, documents, [MEDICATION NAME] cream 1% Apply cream to affected areas on back, upper thighs, BID (twice a day). There is no documentation the cream was applied to R33 for on the 7 AM - 3 PM and 3 PM - 11 PM shift for [DATE], [DATE], [DATE], [DATE] - [DATE], the 7 AM - 3 PM on [DATE], [DATE], and the 3 PM - 11 PM shift on [DATE] and [DATE]. R33's TAR, dated (MONTH) 2019, documents, in part, Weekly Skin Assessment on Fridays. C - Clear, R -Red Rash, O- Other, P - Pressure, S - Skin Tear. This TAR has O documented for [DATE], [DATE], [DATE] and [DATE]. There is no documentation regarding what the O is on the TAR. There is no Nurses Note regarding what the O is. R33's TAR, dated (MONTH) 2019, documents, [MEDICATION NAME] cream 1% Apply cream to affected areas on back, upper thighs, BID (twice a day). There was no documentation R33's cream was applied during the 7 AM - 3 PM and 3 PM - 11 PM shift for [DATE], [DATE], [DATE] and the 3 PM - 11 PM shift on [DATE], [DATE], [DATE], and [DATE]/-[DATE]. R33's TAR, dated (MONTH) 2019, documents, Apply [MEDICATION NAME] 1% cream to BUE (bilateral upper extremities) and BLE (bilateral lower extremities and chest rash every shift. There was no documentation R33 received [MEDICATION NAME] during the 7 AM - 3 PM and 3 PM - 11 PM shift on [DATE], [DATE], [DATE], the 7 AM - 3 PM shift [DATE] and [DATE] and 3 PM - 11 PM shift on [DATE], [DATE] and [DATE]. R33's TAR, dated (MONTH) 2019, documents, in part, Weekly Skin Assessment on Fridays. C - Clear, R -Red Rash, O- Other, P - Pressure, S - Skin Tear. This TAR has O documented for [DATE], [DATE] and [DATE]. There is no documentation regarding what the O is on the TAR. R33's TAR, dated (MONTH) 2019, documents, TAO and Band aide to open areas daily Left upper chest and sternum. There is no documentation this was done on [DATE]. On [DATE] at 12:30 PM, V43 Physician, stated, There is no reason why (R33's) treatments should not be done. She does not refuse treatments. V43 stated she expected the treatments to be completed as ordered. On [DATE] at 2:05 PM, V33, Administrator, stated, I would expect the nurse to follow doctors' orders and document that the treatment has been done. The facility policy and procedure Eight Rights for Administration of Medications, dated [DATE], documents, in part, Sign out medications as soon as they are given. Always use your medication book. Documents if the medications are refused and the reason. The facility policy and procedure, dated (MONTH) 2014, documents, in part, Policy: To provide preventative skin care through repositioning and careful washing, rinsing drying, and observation of the resident's skin condition to keep clean, comfortable, well- groomed, and free from pressure ulcers. Procedures: 1. All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly x 4 then will be reassessed at least quarterly and / or as needed. 2. Staff on every shift and as necessary will provide skin care. 3. After thorough cleansing of the skin, lotion may be applied, and observations of any reddened areas will be reported to the Charge Nurse. 4. A thin layer of body lotion and / or barrier cream may be applied as a protective barrier to area(s) exposed to incontinence. 14. Keep incontinent residents clean and dry. B. Based on interview and record review, the facility failed to assess for possible changes in condition, monitor vital signs and oxygen saturation levels (SpO2) after hospitalization of one of one resident (R16) reviewed for quality of care after hospitalization in the sample of 45. This resulted in R16 not receiving nursing care and dying 35.5 hours after readmission. Finding includes: 1. R16 Admission Record documented she had admitting [DIAGNOSES REDACTED]. R16's Care Plan, dated [DATE], documents, in part, Focus: (R16) is has the potential for complications R/T [MEDICAL CONDITION] and is incontinent of urine at time. Interventions: Assist (R16) with ADL's (Activities of Daily Living) and ambulation needed. Auscultate heart and lung sounds per MD (medical doctor) orders or as condition warrants and document findings. Elevate feet when sitting up in chair to help prevent dependent [MEDICAL CONDITION]. Monitor and report changes in mental status: lethargy; tiredness; fatigue; tremors; [MEDICAL CONDITION]. Monitor vital signs as directed by MD. R16's Nurse's Note, dated [DATE] at 06:19 AM, documents, R16 fell out of her wheelchair onto the floor. The Nurse's Note documented R16 was sent to the emergency room for evaluation. The Nurse's Note documented This LPN (Licensed Practical Nurse) was summoned to 400 hall per (V36 CNA (Certified Nurse's Aide)). (V36) states she observed resident on floor. The Nurse's Note documented Neuro-checks initiated and findings WNL (Within Normal Limits). Resident c/o pain to posterior scalp. 6 cm x 6 cm bruised hematoma noted to upper forehead. The Nurse's Note documented (V43, Physician) called with new orders to send to ER (emergency room ) for evaluation. R16's Local Hospital ED (Emergency Department) Notes, dated [DATE] at 6:54 AM, documents, Summary statement: 89 yo (year old) female presenting with C1 and odontoid fx (fracture vertebrae of the neck) after falling from her wheelchair. Given these injuries, plus her [MEDICAL CONDITION] and mild hypothermia upon arrival, will admit for further workup, Spine consultation. R16's Hospital Discharge Summary, dated [DATE], documents, in part, Discharge Diagnoses: [REDACTED].#1) ring fracture and odontoid base fracture. 2. Right neck mass appears to be arising from the [MEDICAL CONDITION]. 3. hypothermia initially patient was hypothermic of unknown etiology. 4. Acute on chronic diastolic [MEDICAL CONDITIONS] poa (present on admission). 5. CKD ([MEDICAL CONDITION]) stage III present on admission. R16's After Visit Summary dated [DATE], documents, in part, Discharge Instructions: Cervical collar must be on at all times. R16's Care Plan, dated [DATE], documented R16 had a fracture to her C1 vertebrae. The Care Plan did not address that R16's cervical collar must be on at all times and what staff were to do if she did not wear it. R16's Nurses Note, dated [DATE] at 6:58 PM, documented R16 refused to eat supper, her cervical collar was on as ordered and she was receiving oxygen per nasal cannula at 2 liters. The Nurse's Note documented her vital signs as 97.7 (temperature) 80 (pulse) 20 (respirations) ,[DATE] (blood pressure) wt (weight) 202. R16's Weight and Vital Summary, dated [DATE] at 8:53 AM. No other vital signs were documented as being completed. There was no documentation R16's vital signs and oxygen saturation levels were monitored on the 3rd shift on ,[DATE], 2nd shift on ,[DATE], and 3rd shift on [DATE]. R16's Nurse's Note, dated [DATE] at 5:44 PM, documents, Resident refusing o2 (oxygen) combative when trying to encourage to apply refuses to get oob (out of bed) refusing to eat or drink dr. (Doctor) phoned awaiting return call. R16's Nurse's Note, dated [DATE] at 5:54 PM, Dr. (Doctor) updated on refusal of o2 eating and getting oob nno (no new orders), Dr. to see ,[DATE]. R16's Nurse's Note, dated, [DATE] at 3:35 AM, documents, Note Text: This nurse was called into resident's room, to verify absence of a pulse and lung sounds. No aeration heard throughout lungs fields and no heart sounds auscultated. Resident was cool to the touch and no pulse palpable. Resident code status is DNR. (do not resuscitate). This nurse and 2nd nurse call time of death at 3:37 am on [DATE]. On [DATE] at 2:24 PM, V36 Certified Nurse Aide (CNA), stated, When she (R16) came back, I worked with her on [DATE]. She was refusing everything (eat, get out of bed). She would always eat for me and she normally had a tendency to stay in bed. She wasn't complaining of pain. She just said she was sleepy. She had her neck brace on, we would do a really easy roll and then perform incontinent care on her. On [DATE], I came in at 3:00 AM, and I found her dead on my first rounds. (V37, CNA) stated she saw her not long before that. On [DATE] at 11:40 AM, V16 LPN, stated, On [DATE], she (R16) became uncooperative she was taking her oxygen and collar off. She would refuse to eat and get out of bed. Her vital signs were stable. I updated the doctor. The doctor said she would come the next day. (R16) stated she wasn't in pain. She would say 'No, I don't want to do anything. Leave me alone.' This was not out of character for her. She had bruising to the bilateral There were no neck/spine precautions just to keep the neck collar on. On [DATE] at 1:05 PM, V49 LPN, On [DATE], I had her for 4 hours on the evening shift. She had a cervical collar on. She had no complaints of pain just said that she just wanted to be left alone and she just wanted to rest. She refused to get up. Her breathing was fine, and she was not sweating. I didn't see her skin nothing was told to me about her skin. I didn't get report when I came on. On [DATE] at 3:30 PM, V10, CNA, stated, When she (R16) came back from the hospital on [DATE] she was confused but alert. She wouldn't eat dinner. On [DATE], she started screaming she said she was dreaming she was falling. She was ok she was talking to me. I left that night at 10:00 PM. On [DATE] at 9:00 AM, V29 LPN, stated, I remember taking care of her when she came back maybe the night she came back. She let us lay her down, she had oxygen on and her cervical collar. On [DATE] at 12:05 PM, V1 RN previous Administrator, stated, When she (R16) came back she seemed a little different. She kept trying to take off her neck brace. On [DATE] at 11:30 AM, V37 CNA, stated, When she (R16) came back, I did see her with a neck collar on. She wasn't comfortable. She was taking the neck brace off. She has always been feisty and needed to be in control. She just wasn't comfortable. I told the nurse. The nurse went and spoke to her about it. On [DATE], I had her that night shift. On the first round maybe 11:00 PM, I saw her. She was asleep and had the neck brace on. I thought 'Oh, that's how that goes on.' The second round between 1:00 AM and 1:30 AM, she was still asleep and breathing, I checked because at first, I thought she was dead. She was just sleeping peacefully. I didn't wake her up because she slept so badly the night before. (V36) came in at 3:00 AM. She came to me around then and told me (R16) isn't breathing would I go and check. I went in and she wasn't breathing. I was touching around her neck and chest area she was warm to the touch. On [DATE] at 12:30 PM, V43 Physician, stated, The nursing home did not call the office during the day about her refusing oxygen, her cervical collar or not eating. They probably got a hold of the after-hour doctor on call and they (the on-call physician) are going to say watch them, maybe send to the emergency room and they know I am in the nursing home on Thursdays, so they would say I will see them tomorrow. Vital signs should be done 3 times a day with oxygen saturations if they are on oxygen. If I have ordered blood pressures I expect them to be done. If someone comes back from the hospital with a broken neck or a toenail you should be assessing them and getting vital signs at least 3 times a day. The aide that just let her sleep instead of getting vitals, was she just sleeping, or was she sleeping because her oxygen, heart rate, blood pressure was low or high. We don't know because the vitals or the assessment was not done. They did not get vitals, assess or notify me of (R16's) delusions. Your seventh vital sign is a change in mental status. That is almost neglect. A neck fracture is difficult enough to heal with the best of nursing care. The fall that R16 had did hasten her death that is what I put on the death certificate as the cause. The quality of care she received after returning from the hospital also hastened her death. I am concerned that the night the aide didn't wake her up (R16) couldn't wake up. It is very difficult to say what her cause of death was; did she move her neck wrong, [MEDICAL CONDITION], pneumonia or [MEDICAL CONDITION] we just don't know. On [DATE] at 12:40 PM, V48 CNA, stated, When (R16) came back, I helped clean her up on [DATE]. I gave her a bed bath and changed her sheets. She kept saying 'I want him up and out of here'. No one was there. I did tell the nurse about this. I think it was (V49 Licensed Practical Nurse/LPN) the new nurse that just came on shift. Delusions were unusual for her. I thought it was just the pain medication. She did have her neck collar on. On [DATE] at 2:15 PM, V33 New Administrator, stated The doctor should have been notified of (R16's) new onset of delusions. On [DATE] at 1:25 PM, V52 CNA, stated, We have a sheet that lists who needs vitals that day from the nurse. On [DATE] at 1:30 PM, V30 LPN, stated, If someone is back from the hospital they get vital signs, a head to toe nursing assessment and SpO2 every shift for 3 days. We (the nurses) have vital sign sheets that we fill out for the residents that need them. The aides get the vitals and we chart them in the computer. On [DATE] at 1:54 PM, V24 CNA, stated, The nurse will write out a vital sign sheet with the name of the resident. We get the vitals and give them to the nurse when done. The nurses do the SpO2's. On [DATE] at 3:40 PM, V12 RN, stated, I was the only nurse here on [DATE] night shift another nurse (V32 LPN) came in later. When I walked through the building she was asleep. I did not assess her. (V32) called me on my phone and told me (R16) was dead. I went to (R16's) room to verify the death. She was cool to the touch. No rigor mortis had set in. She wasn't even totally gray yet. She did have her cervical collar on. I would be doing vital signs with SpO2 every 4 hours for someone like (R16). Any readmission gets vital signs and a nursing assessment every shift for 72 hours. The previous shift makes up the list of residents that need vital signs for the CNAs. On [DATE] at 3:50 PM, V16 LPN, stated, On a readmission vital signs, SpO2 (oxygen saturation levels - amount of oxygen in the blood) if on oxygen and a head to toe assessment is done every shift for 72 hours. When questioned why there is no documentation of a head to toe assessment done on [DATE] and why no SpO2 values were charted for R16, V16 stated, I would have physically done these. I probably forgot to chart it. On [DATE] at 8:15 AM, V32 LPN, stated, I am never on (R16's) hall. On [DATE] I came in at 2:20 AM. (V12 RN) was the only nurse here, someone must have called off. I did not get any kind of report. I did know she had a broken neck. I did not see her at all until (V36 CNA) came and told me (R16) was dead. I went and check her code status, she was a DNR. I went into her room and confirmed she was deceased . She was gray, and she was warm. No rigor mortis had set in. Her cervical collar was on. There was no oxygen on her. With a readmission vital signs with a head to toe assessment is done every shift. I would check the SpO2 at least once a shift. I would have assessed her and gotten vitals, but I hadn't gotten to her yet. On [DATE] at 10:22 AM, V26 stated, For an admission from the hospital, a head to toe assessment, vital signs and SpO2 should be done every shift for a minimum of 3 days. On [DATE] at 3:00 PM, V26, Regional Corporate Nurse Consultant, stated that the facility does not have a policy and procedure on when nursing assessments and vital signs are done. C. Based on interview and record review, the facility failed to obtain provide sliding scale insulin to 1 of 6, (R1) reviewed for quality of care in the sample of 45. 1. R1's Minimum Data Sheet ((MDS) dated [DATE], documents, R1 has a Brief Interview for Mental Status (BIMS) of no cognitive impairment. R1's Admission Record, undated, documents R1, has multiple [DIAGNOSES REDACTED]. R1's Care Plan dated [DATE] documents, Resident has diabetes mellitus. Receives insulin injections. Often refuses insulin and fingerstick. R1's Physician order [REDACTED]. Admelog Sliding Scale ,[DATE] = 2 units, ,[DATE] = 4 units, ,[DATE] = 6 units, ,[DATE] = 8 units, ,[DATE] = 10 units. R1's Glucose Monitoring Record, dated (MONTH) 2019 documents R1's blood glucose was checked 3 times on [DATE] at 11AM, 4 PM, and 8 PM; 3 times on [DATE] at 8 AM, 11 AM, 8 PM; 3 times on [DATE] at 9 AM, 4 PM, 8 PM. R1's Glucose Monitoring Record, dated (MONTH) 2019 documents blood sugar checks 2 times on [DATE] at 11 AM, and 10 PM; and 3 times on [DATE] at 8 AM, 12 PM, 4 PM. On [DATE] at 11:30 AM, R1 stated, she has orders for blood sugar check at 9 AM, 12 PM, 5 PM, 9 PM. R1 stated, she was only checked for her blood sugar twice on [DATE] and 3 times on certain days in previous months and stated, she could die if her blood sugar is too low and gets very sick if it is too high. R1 stated, she went out for an appointment around 11 AM and returned around 3 PM and the staff could have checked her blood sugar at 9 AM and 4 PM that day. R1 stated, nobody came to ask her to check her blood sugar at all at 9 AM and at 4 PM. R1 stated, she never refused blood sugar checks because, she could have very high or very low blood sugar with serious consequences. 2. R11's POS dated ,[DATE] and ,[DATE] document, Blood Glucose Monitoring Check and Record Before Meals and at Bedtime. Call MD if greater than 300. R11's Glucose Monitoring Record for (MONTH) 2019 documents, Accu-checks AC and HS. R11's blood sugar was checked only 3 times on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]; and 2 times on [DATE], [DATE], and [DATE]. R11's Glucose Monitoring Record for (MONTH) 2019 documents, Accu-checks AC and HS, and R

Based on observation, interview and record review, the facility failed to provide turning and reposition and failed to provide treatment to a pressure ulcer for 5 of 8 residents (R16, R12, R31, R9, R26) reviewed for pressure ulcer prevention and management in the sample of 45. Findings include: 1. R12's MDS dated [DATE] documents, R12 requires extensive assist with bed mobility, transfers, toileting and is always incontinent of bowel and bladder. R12's Braden Scale dated 7/01/19 documents, a score of 8 (very high risk) for developing pressure sores. R12's POS, dated 7/2019 documents, Cleanse coccyx with wound cleanser, apply calcium alginate and dry dressing daily. R12's Care Plan dated 7/02/19 documents, Potential for pressure ulcer development, related to incontinence and need for staff assistance, to remain clean and dry and free from odors. Goal: Will continue to have intact skin, free of redness, blisters or discoloration for the next 90 days. Interventions: Administer treatments as ordered and monitor for effectiveness. Educate resident/family/caregivers transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and proper repositioning. Weekly skin check. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress, R12's Wound Notes were requested, and Treatment Record for (MONTH) 2019 was provided with entry dated, 7/13/19 documents, 3 centimeters (cm) x 1 cm x >0.1 cm open area to coccyx; 1 cm x 0. 5 cm x > 0.1 cm open area to right of coccyx; full granulation. Treatment Record entry dated 7/15/19 documents, Same as above, Treatment Record entry dated 7/23/19 documents, Open area to coccyx/right coccyx. No other open areas noted. There was no documentation of the status of wound bed, perimeter, exudate. On 7/30/19 from 8:45 AM until 11:45 AM, R12 was in her geriatric chair without the benefit of repositioning, based on 15 minute or less observation intervals. On 7/30/19 at 11:56 AM, V14 and V31, both Certified Nursing Aides (CNAs), provided incontinent care to R12. R12 did not have any dressing to her coccyx wound. On 7/30/19 at 12:57 PM, V12, Registered Nurse, provided a dressing change to R12's coccyx wound. The wound measured approximately 1 inch by 1/4 inch, with scant amount of drainage and 100 % pink granulation. V12 cleansed with wound cleanser, then covered it with calcium alginate and dry dressing and bordered foam. On 7/30/19 at 1:15 PM, V12 stated V32, Licensed Practical Nurse (LPN), was aware there was no dressing on R12's wound that morning, but she might have forgotten to put a new one. 2. R31's MDS dated [DATE], documents, R31 requires extensive assist with bed mobility, transfers, toileting, is always incontinent of bowel and bladder. R31 is at risk for developing pressure ulcers. R31's Braden Scale, dated 7/26/19, has not been filled out to determine what R31's level of risk for pressure ulcer development. R31's Care Plan undated, documents, Resident is at increased risk for alteration in skin integrity/pressure ulcers related to: Impaired cognition, impaired communication, incontinence of bladder, incontinence of bowel, impaired mobility status, impaired nutritional status, diabetes. Interventions in part: Turn and reposition frequently. On 7/30/19 from 9:10 AM, until 12:30 PM, R31 was observed in wheelchair attending activities in the dining room, then sitting by the nurse's station after activities, then seen being wheeled to the dining room, again to wait for lunch service without the benefit of repositioning, based on 15 minutes or less observation intervals. 3. R9's MDS dated [DATE] documents, R9 requires extensive assist with bed mobility, transfers, dressing, is totally incontinent of bowel and bladder. R9 is at risk for developing pressure ulcers. R9's Physician order [REDACTED]. R9's Care Plan updated, 7/26/19 documents, Resident is at risk for alteration in skin integrity/pressure ulcers related to: Impaired mobility status, increased need for activities of daily living (ADL) care. On 7/26/19: Open areas to bilateral sit bone and coccyx. R9's Braden Scale dated 8/01/19, documents, R9 has a score of 15 (low risk for developing pressure ulcers). A more accurate assessment would have rated, R9 as high risk for having an actual pressure ulcer. On 7/30/19 from 11:01 AM until 3:31 PM, R9 was observed in his wheelchair, in the dining room partaking lunch and celebrating a birthday visit, with family after lunch, while sitting in his wheelchair, without the benefit of repositioning, based on 15 minutes or less observation intervals. On 7/31/19 at 2:12 PM, V27 and V35, both CNAs, transferred R9 to bed provided incontinent care to R9, using a gait belt. At this point V27 stated, R9 was very wet. V35 and V27 took off R9's disposable briefs and pants. R9's wheelchair seat and back of R9's pants were soaking wet with urine. R9's adult incontinent brief was overflowing with feces, along the elasticized crotch borders and smelled very strongly of feces and urine. R9 had a dressing on the coccyx and a dressing each on the sit bone area, all dated 7/31/19 and all were soiled with feces. On 7/31/19 at 2:29 PM, V1, Administrator, provided dressing change to R1 in bed. R1 had, one small open area on the coccyx measuring 0.2 cm by 0.3 cm by 0.1 cm, with pink granulation, a 0.2 cm by 0.3 cm, on the left sit bone and approximately same size, open area on the right sit bone. R1 applied, hydrogel to all 3 areas and covered with bordered foam. 4. R26's MDS dated [DATE] documents, R26 requires extensive assist with bed mobility, transfers, dressing, toileting, totally incontinent of bowel/bladder and at risk for the development of pressure ulcers. R26's Braden Scale dated 5/14/19 documents, R26 is at risk for developing pressure ulcers. R26's Care Plan, updated 5/21/19 documents, Resident has the potential for pressure ulcer development, related to decreased mobility, need for staff assistance to remain clean, dry, free from odors. R26's skin is fragile, and she gets skin tears easily. Interventions, in part: Follow facility policies/protocols for the prevention/treatment of [REDACTED]. On 7/30/19 from 9:00 AM until 12:15 PM, R26 was observed in wheelchair, participating in activities in the dining room and then waiting in dining room for lunch service, while remaining seated in wheelchair, without the benefit of repositioning based on 15 minute or less observation intervals. On 8/15/19 at 8:49 AM, V33, Current Administrator, stated she expects staff to turn and reposition residents who need help with mobility, every 2 hours when they are in bed or wheelchair. The Facility Policy on Pressure Sore Prevention Guideline dated 1/2014 documents, Policy: To provide adequate interventions for the prevention of pressure ulcers for residents who are identified as High or Moderate risk for skin breakdown as determined by the Braden Scale. Procedure: The following guidelines will be implemented for any resident assessed at Moderate or High skin risk.: Intervention: Turn and reposition every 2 hours. Turning and positioning may be more often than every 2 hours for high risk, if indicated. Daily Skin checks (High Risk), Weekly Skin checks (Moderate risk). The Policy also documents, Care Plan Entry (High Risk and Moderate Risk) Skin Risk and appropriate interventions are to be placed on the Care Plan. If despite interventions a Pressure ulcer develops, the care plan must reflect updated interventions for further prevention of pressure ulcers. Any resident scoring a High or Moderate risk for skin breakdown will be noted and signed off by the nurse. In addition, a brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet. 5. R16's Admission Record documents R16 was admitted on [DATE]. This Admission Record documents R16 has [DIAGNOSES REDACTED]. R16's Minimum Data Set ((MDS) dated [DATE], documents R16 had a Brief Interview of Mental Status (BIMS) of 15 indicating R16 is cognitively intact. This MDS also documents R16 required extensive assistance of 1 staff member for bed mobility, dressing, toileting and personal hygiene. This MDS documents R16 requires limited assistance of 2 staff members for transfers. This MDS documents R16 was not steady and only able to stabilize with staff for balance during transitions and walking. This MDS documents R16 is frequently incontinent of bowel and bladder. R16's Care Plan, dated 10/03/2014, documents, in part, Focus: (R16) has the potential for pressure ulcer development r/t decreased mobility, urinary incontinence, frequent [MEDICAL CONDITION] to bilateral legs, ankles and history of open areas. Intervention: Apply Ace wraps to bilateral lower extremities as directed. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements or decline to MD. Educate (R16)/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent positioning. Follow facility policies/protocol from the prevention / treatment of [REDACTED]. Document alternative methods. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/s (signs symptoms) of infection, wound size, stage. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. R16's Nurses Note, dated 07/14/2019 at 06:19 AM, documents, in part, This LPN (Licensed Practical Nurse) was summoned to 400 Hall per (V36 CNA (Certified Nurse's Aide). (V36) states she observed resident on floor. When asked, resident states that fell asleep while sitting in w/c in hallway in front of her room and fell out of w/c and hit forehead on the floor. Neuro-checks initiated and findings WNL. Resident c/o pain to posterior scalp. 6 cm x 6 cm bruised hematoma noted to upper forehead. No active bleeding noted. Moves all ext (extremities) WNL (Within Normal Limits) for resident. (V43 Physician) called with new orders to send to ER (emergency room ) for evaluation. R16's Nurses Note, dated 07/14/2019 at 06:25 AM, documents, While assisting resident with incontinence care in resident's bathroom, skin assessment completed. Moist, mushy skin noted to bilateral posterior thighs with 10 cm x 10 cm open area noted to posterior right thigh. BLEs (Bilateral Lower Extremities) swollen and discolored, feet purplish in color. Redness noted to bilateral posterior thighs. emergency room updated on findings re: skin assessment. R16's local hospital H & P (history and physical), dated 7/14/2019 at 1:04 PM, documents, in part, Extremities: extremities normal, atraumatic, 2 plus [MEDICAL CONDITION] and a weeping lesion present. Skin: multiple open [MEDICAL CONDITION] present. R16's Hospital Wound Flow sheet, dated 7/14/2019, documents, in part, Wound: Right; Left; Bilateral gluteal ulcerations. Date first assessed: 07/14/2019, Time First Assessed: 11:41 AM, Present on Admission: Yes, Orientation: Right; Left; Bilateral, Location: gluteal, Type: ulceration, Wound (WDL (within defined limits)) WDL except multiple partial open some scabbed and DTI (deep tissue injury). Wound Base black; dry; purple; reddened; cobblest one. R16's Hospital Notes from the SWOT (skin wound ostomy team) dated 7/15/2019, documents, in part, Skin/Wound Assessment: Patient seen in room. Patient has suspected DTI (deep tissue injury) on left heel. R16's Hospital Notes dated 7/15/2019, documents, in part, Pressure INJURY: Present on admission: Yes. Stage DTI Location: Left Heel. Picture Taken 7/15. Wound shape: round. Wound measurements: Less than 1 cm in diameter. Wound base: 100% dark purple, Wound depth of Tissue: Suspected deep tissue. R16's After Visit Summary dated 7/16/2019, documents, in part, Discharge Instructions: Left heel- Cleanse BID/ PRN (twice a day and as needed) with CGH ([MEDICATION NAME]) wipe, allow to dry, apply Venelex ointment to wound bed and leave. R16's Treatment Administration Record (TAR), dated (MONTH) 2019, documents, in part, Weekly Skin Assessment on Fridays. C - Clear, R -Red Rash, O- Other, P - Pressure, S - Skin Tear. This TAR documents R16's as clear on (MONTH) 5, 2019 and (MONTH) 12, 2019. R16's TAR, dated (MONTH) 2019 and (MONTH) 2019, documents, in part, Weekly Skin Assessment on Fridays. C - Clear, R -Red Rash, O- Other, P - Pressure, S - Skin Tear. Both of these TAR's documents R16's skin as clear for the months of (MONTH) and (MONTH) 2019. R16's Weekly Skin Record, dated 7/5/2019, documents, skin remains intact. R16's Shower Sheets dated 7/4/19, 7/8/19 and 7/10/19 have no documentation related to R16 having an open area to her left heel. R16's Nurses Note, dated 7/16/19 at 6:58 PM, documents, in part, Note Text: resident returned from the hospital skin check done purple bruising to arms and hands redness to back of knees denies pain cervical collar on as ordered refused to eat supper states she just ate 2 plus [MEDICAL CONDITION] to lower ext (extremities) lungs clear bowels active cooperative with care alert times three incont (incontinent) of urine and bowel o2 (oxygen) at 2lt per n/c (nasal canula) applied. R16's Admission/Readmission Screener, dated 7/17/2019 at 8:52 AM, documents, in part, Skin Integrity: Does the resident have impaired skin integrity upon admission: Yes. Details: redness to back of knees r (right) foot pink. R16's Initial Skin Alteration Record, dated 7/17/2019, has no documentation on it. On 8/14/2019 at 2:24 PM, V36 Certified Nurse Aide (CNA), stated, (R16) was alert and oriented and able to make her needs known. She would transfer herself and use a wheelchair. I would wash her up every day in the bathroom when I would see her. She was always incontinent. On 7/14/2019 I came in at 3:00 AM and she was asleep. At approximately 5:45 AM she was in the hallway by her door in her wheelchair. She told me I am ready for you to get me cleaned up. I was on the hall assisting 2 other residents get up. The next thing I know she was on the floor. She said she fell asleep. She said the back of her neck hurt. We helped her up with 2 people and a gait belt. I took her to the bathroom and stood her up with the grab bars and washed her up. She had red spots on her bilateral back of thighs. None were open that I remember. She had red spots once before and they went away. They weren't blisters. I thought just from her being wet. When she came back, her thigh was open. On 8/15/2019 at 11:40 AM, V16 LPN, stated that R16 had bruising to the bilateral upper extremities, her bilateral lower extremities were [MEDICAL CONDITION] which was not unusual, and her skin was intact with no open areas, just a little pink under her knees when R16 returned from the hospital. The facility protocol is to put A&D ointment on the area. I was her admitting nurse. I was the one that did her skin assessment. On 8/15/2019 at 1:25 PM, V50 CNA, stated, I worked with her R16, on 7/17/2019 that was the first time in a long time. I went and helped V48, CNA, around 7-7:45 PM, clean her up. She was soaking wet with urine, it looked like she had been laying in it all day. Her bottom was breaking down. A medium amount of break down on the (buttocks) and on the upper buttocks where it meets the back. Her legs were extremely swollen, but I don't remember them being open. I brought in her dinner tray. When I went in she did complain of pain. The nurse was either coming in or going out of her room when she complained of pain. She would not get out of bed. She did have her collar on. On 8/15/2019 at 3:30 PM, V10 CNA, stated, Before she went to the hospital, (R16) would sit up in her room doing crossword puzzles. She would go days without changing or washing, she would sit in urine and feces. She was able to make up her own mind and was determined to do things her way. She was particular about who worked with her. Her posterior thighs and buttocks were peeling, red, mushy with scabbed areas. Her legs were always swollen but they were intact. This was before and after the hospital. We were putting [MEDICATION NAME] on the areas. On 8/19/19 at 9:00 AM, V29 LPN, stated, (V36) did come and get me while she was cleaning (R16) up (on 7/14/19) and told me about an open area on her thigh and that her thighs were mushy. Her thigh did have an area to the right thigh and they were mushy. I notified the emergency room of this because this was new and there was no treatment in place for it. On 8/19/19 at 12:05 PM, V1 RN previous Administrator, stated, When she (R16) came back she seemed a little different. She kept taking trying to take off her neck brace. She was private about her skin. (V36) told me about some gaulded areas. It did not come to me as a big concern. No one ever reported skin issues to me. (V36) took care of her all the time and she is a really good aide. If something was wrong she would let us know. Staff should report any open areas to the nurse. On 8/20/2019 at 12:30 PM, V43 Physician, stated, I was not aware of any wounds. Upon looking at the wound photos from the hospital, V43 stated, The lateral foot wound is questionable. It is odd. It is not on a place of pressure. Without feeling it and seeing it I don't know. The heel is odd because she was up using her feet in her wheelchair. I would expect the nursing home to figure out a way to see her skin and report it to me. On 8/22/2019 at 2:15 PM, V33 New Administrator, stated, Yes, the doctor should have been notified of (R16's) skin, the nurses should have been notified from the aides, interventions should have been put in place for (R16's) education and treatments. When a nurse charts other on the weekly skin assessment they should follow up with a detailed description of the skin issue. On 8/28/2019 at 10:22 AM, V33 stated, I did not know (R16). I never even laid eyes on her. For someone with her skin issues, I would think the nurses would discuss and consult with the physician and maybe consult with a wound doctor. Upon admission I expect the nurse to do a full skin assessment. The facility policy and procedure Decubitus Care / Pressure Area Policy, dated (MONTH) 2014, documents, in part, Policy: To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. Procedure: Upon identification of skin breakdown the following will be completed; 1) The pressure area will be assessed and documented. 2) Complete all areas of a wound assessment following NPUAP (National Pressure Ulcer Advisory Panel) guidelines i) Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician) ii) Document the stages of the pressure ulcers 3) Notify the physician for treatment orders 4) Documentation of the pressure area must occur upon identification and aft least once each week. The assessment may include: i) Characteristic ii) treatment and response to treatment.

Based on record review and interview, the facility failed to assess and identify a significant need to alter medical treatment for one of three residents (R1) reviewed for the use of anticoagulant medications and a change in condition in the sample of 13. This failure resulted in R1 being hospitalized for [REDACTED]. Finding includes: R1's Minimum Data Set, dated dated [DATE] documents he is severely impaired with cognition and decision making, and requires extensive assistance with all Activities of Daily Living (ADL). R1's Electronic Health Record (EHR) documents he was admitted on [DATE] with the diagnoses, in part, of Chronic [MEDICAL CONDITION] Embolism (PE), Alzheimer's Dementia with Behavioral Disturbance and Hemorrhagic [MEDICAL CONDITION]. The physician's orders [REDACTED]. R1's Medication Administration Record [REDACTED]. There is no documentation in R1's Nurses Notes in (MONTH) (YEAR) that V7, Physician or V10, Nurse Practitioner (NP) was notified of R1's refusals. V10's Progress Note documents R1 was seen on [DATE], but there is no documentation related to his medication refusals. The Progress Note documents, in part, New admit from hospital with DX (diagnoses):[MEDICAL CONDITION], Chronic PE (pulmonary embolism) Alzheimer's Dementia. Pt. (patient) poor historian r/t (related to) dementia. Remain stable. Continue to monitor. R1's MAR for ,[DATE] documents his refusal of Aspirin 81 mg on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE] and Eliquis 5 mg on ,[DATE]-8:00 PM dose, both doses on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and 8:00 AM dose on [DATE]. There is no documentation in the Nurses Notes in ,[DATE] that V7 or V10 were notified. The Nurse's Note, dated [DATE] at 2:08 PM, documents, in part, Alert and oriented X 1. Resident lethargic and sleeping most of the morning. Appetite poor and requires assistance with ADL's. Unable to make needs known. The Nurse's Note, dated [DATE] at 2:21 PM, documents R1 continues to refuse medications. That day at 5:39 PM, the Nurses Note documents (R1) is lethargic, refusing medication and has to be fed. There is no documentation V7, Physician was notified. The Nurse's Note documented by V9, Licensed Practical Nurse (LPN), dated [DATE] at 4:59 PM, documents, in part, Lethargic and sleepy, daughter (V12) here and wanting to go over med's (medication), wants Dr. (doctor) to call her when he arrives. refuses to take oral med's. There is no documentation V7 or V10 were notified. On [DATE] at 10:00 AM, V9, LPN stated, I got pulled to 500 hall to help. When we got to (R1) he was refusing to take his med's. He was lethargic, confused. (V7) was here to assist. I talked to him about Eliquis and Aspirin. That concerned me. He looked over the labs (laboratory reports). (R1) was not dehydrated. I talked with his family. I knew he had a history of [REDACTED]. No shortness of breath. Confused. On [DATE] at 10:15 AM, V11, LPN reported R1 would often refuse his medications. V11 stated, I was concerned. He (R1) needed his blood thinners. V11 reported she spoke to V10 about it, but could not remember the date. V7's Progress Note, dated [DATE], documents in part, History of [MEDICAL CONDITIONS]. Staff reports not eating or drinking or taking med's. Increased lethargy, nonverbal. V9, LPN's Nurses Note, dated [DATE] at 11:00 AM (not [DATE]) documents V7 was at the facility to assess R1, and spoke to V12, R1's POA (Power of Attorney) at that time. V9's Nurses Note, dated [DATE] at 11:00 AM documents (V7) here to assess patient (R1). (V7) wanting to know how to proceed with care related to family wishes. Resident not taking med's X 4 days. Refusing to eat or drink. Lethargic, Unable to participate in therapy. In bed with HOB (head of bed) raised. After (V7) consulted with POA (V12) agreed to transfer to hospital. Doctor reviewed lab work ordered. [MEDICAL CONDITION] or dehydrated. V9's Nurse's Note, dated [DATE] at 11:40 AM, documents R1 left by ambulance in route to the local hospital. On [DATE] at 1:06 PM, V12, Daughter, stated, They told me they were having trouble getting him (R1) to take it. I saw (R1) every other day. I was aware they had problems, but I wasn't aware he wasn't taking them at all. They should know he is at risk for PE. They dropped the ball. If they had told me, I would have taken him to the hospital sooner. On Sunday ([DATE]) the nurse called me, then I called (V7). V12 reported R1 died on [DATE] while receiving hospice services at the assisted living facility he had been discharged to on [DATE] from the hospital. On [DATE] at 12:45 PM, V10 reported she was aware R1 wasn't taking his medication, but didn't notify V7. V10 reported she spoke with V12, but barely remembers the conversation. V10 stated, I only saw (R1) one time. I didn't notify (V7) until, I believe up until (V7) saw him. On [DATE] at 10:50 AM, V7 reported he was aware R1 wasn't taking his medication, but did not say when he became aware. V7 reported it was not his responsibility to call a family representative, but it was the responsibility of the facility to do so. V7 stated, They can't make him take it. I can't discharge him because he refused it. He definitely needed it. There was no other alternative. [MEDICATION NAME] ([MEDICATION NAME] Sodium) is a SQ (subcutaneous) injection. Are we going to fight him or hold him down? On [DATE] at 10:30 AM, V1, Administrator reported she was aware there were problems with physician notification of R1's repeated refusal of taking his medications. On [DATE] at 4:15 PM, V2, Director of Nursing (DON) stated, I know (V10) knew, it's not charted. (V10) comes every Tuesday. (V7) comes every other week. I'm not sure if it's written down anywhere. I know the nurses didn't document it in their notes. R1's hospital Admission Record documents he was admitted to the Intensive Care Unit (ICU) on [DATE] at 5:35 PM. The emergency room Visit Report, dated [DATE] documents, in part, Presents to ED (emergency department) via EMS (emergency medical services) from nursing home for examination of altered mental status. According to nursing home, patient has had increased lethargy since being admitted on [DATE]. Patient is not on O2 (oxygen) at nursing home. The Hospital computed tomography [MEDICATION NAME] of chest, dated [DATE], documents Bilateral [MEDICAL CONDITION] emboli, large volume embolic material. evidence of right heat strain. Red alert: Acute bilateral [MEDICAL CONDITION] emboli with evidence of right heart strain. discussed with pulmonologist, about ED findings and plan of care. Recommends [MEDICATION NAME] and admit to ICU for breathing treatments, echo, venous doppler studies. The ED Visit Report of [DATE] documents R1's vital signs at 12:40 PM as temperature-98.5 degrees Fahrenheit, pulse-95, respirations-14, blood pressure ,[DATE], pulse oxygen concentration-low at 84 percent. R1's Radiology Report, dated [DATE], documents, in part, Chest pain, altered mental status. Multiple [MEDICAL CONDITION] emboli are identified on previous examination from (YEAR) in similar distribution but there are new emboli identified in comparison with the previous examination and the appearance on the current examination is not compatible with chronic [MEDICAL CONDITION] embolic disease. The Hospitalist History and Physical, dated [DATE] documents R1's primary [DIAGNOSES REDACTED]. Large [MEDICAL CONDITION] emboli on CT (computed tomography) scan. Patient was on Eliquis for history of PE a year ago, Started on [MEDICATION NAME] drip. Supplemental oxygen to keep saturation more than 92 percent. Now on 4 Liters oxygen. R1's Discharge Summary from the hospital, dated [DATE], documents, in part, For his (R1) PE, was placed on [MEDICATION NAME] drip and since he had large clot burden and right heart strain, he underwent catheter directed [MEDICAL CONDITION]. He is being discharged today under hospice care. The facility's policy and procedure, dated as revised (YEAR) and entitled, Change in Resident's Condition or Status documents, in part, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician and or On Call Physician when there has been: A significant change in the resident's physical/emotional/mental condition; a need to altar the resident's medical treatment significantly; refusal of treatment or medications i.e., (that is) 2 or more consecutive times; instructions to notify the physician of changes in the resident's condition. The Policy documents Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: There is a significant change in the resident's physical, mental or psychosocial status.

Based on interview and record review the facility failed to prevent unsupervised wandering outside the facility for 1 of 3 residents (R3) reviewed for wandering in the sample of 11. This failure led to R3 being found outside the facility sustaining a hematoma on the forehead and sent to the emergency room (ER) for evaluation. Findings include: R3's Quarterly Minimum Data Set ((MDS) dated [DATE] documents R3 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documents R3 needs extensive assist for transfers but independent with the use of a wheelchair on and off unit. The MDS document no wandering behavior or history of falls. R3's Nurse's Notes dated 8/6/18 at 6:50 PM, documents, Res (Resident) eloped out main doors into the parking lot, assisted back to facility per this nurse, 15 minute checks initiated, care plan made aware. Nurse's Note documents, 8/6/18 at 7:00 PM Message left for POA to call facility. Nurse's Note dated 8/7/18 9AM documents, MD made aware of elopement. R3's Care Plan dated 9/13/18 documents,Resident has potential to demonstrate verbally abusive behaviors and resist care related to Dementia, Mental/Emotional Illness. She will become impatient quickly if staff do not respond immediately to all her requests. She has also been delusional in that she does not seem to know where she is and has entered other residents' rooms and has attempted to leave the facility. She has exit seeking behaviors and often will transfer self without assistance. There are no interventions/approaches addressing R3's wandering/elopement in the care plan. There was no update on the care plan about R3's elopement on 8/6/18. R3's Incident/Accident Report dated 9/15/18 at 8:10 PM documents, Resident found outside exterior door lying on her back. Hematoma to forehead. R3's Investigation Conclusion documents,9/15/18. Found on ground assisted up by one (CNA) Certified Nursing Aide and two nurses after being assessed by nurse. Resident had no complaint of pain or discomfort, moves all extremities without difficulty. Resident alert with no change in cognition noted. MD (V8) and (V7, Power of Attorney) POA notified. Resident obtained hematoma to right forehead. Resident sent to ER for evaluation. Resident was observed by staff at dining room door at 7:45 PM as staff were on break. R3's Nurse's Notes dated 9/15/18 at 8:09 PM documents, This nurse found resident outside near maintenance door, on ground, lying on her back in the grass, wheelchair on the sidewalk facing the grass. Noted hematoma to right forehead. This nurse assessed resident's range of motion. No complaint of pain when all extremities were moved. Alert, and talking, knows names of staff present. One CNA and 2 nurses assisted back to wheelchair and wheeled into facility. Nurse phoned 911, doctor's exchange, Administrator. Ice applied to forehead. Resident refused all vital signs, talking to this nurse, laughing, complained of pain only when forehead was assessed. R3's Post Fall CNA Report dated 9/15/18 documents, What happened? (Answer) Resident was outside and fell from wheelchair. Is this resident on the Fall Program? (Answer) No. If Safety Interventions not in place, please explain: (Answer) No interventions necessary. Resident is not a fall risk. In your opinion, is there anything we could have done to prevent fall? (Answer) No alarms on door sounded. R3's Hospital History and Physical dated 9/15/18 documents, Patient presents with a hematoma to the right side of forehead after an unwitnessed fall today. Patient was sitting outside in her wheelchair and was found on the ground by staff later. L[NAME] (level of consciousness) is unknown. Pt is on aspirin daily. HPI (History of Present Illness) limited due to dementia. Unable to open her eyes and there is a large hematoma on the right forehead. Hospital Ultrasound of Forehead Soft Tissue Mass Report dated 9/15/18 documents, Impression: Large frontal scalp hematoma without drainable component. Hospital CT (Computerized Tomography) Head without (WO) contrast Report dated 9/15/18 documents, Frontal Scalp Hematoma without [MEDICAL CONDITION] or skull fracture. Hospital CT Cervical Spine WO contrast Report dated 9/15/18 documents, Advanced multilevel lumbar spondylosis without fracture. On 10/10/18 at 11:18 AM, V4, CNA, stated at 8:15 PM, she went to R3's room to put R3 to bed but could not find her. V4 stated she searched the 400 hall and alerted the nurses when she could not find R3. V4 stated she did not hear the exit door alarms sounding. V4 stated she and V6, Licensed Practical Nurse (LPN), reached R3 at the same time. V4 stated R3 was lying on the grass on her back and her wheelchair was upright facing the grass. On 10/10/18 at 12:15 PM, V5, CNA, stated R3 wheels herself around the hallways saw her a couple times coming down 300 hall trying to get out. V5 stated she redirected R3 away from the exit door and told R3 her husband is coming to visit her. V5 stated she did not hear the alarm doors sounding. On 10/10/18 at 12:28 PM, V6 stated the last time she saw R3 was in the dining room at 7:45 PM and at 8:00 PM she was alerted that staff could not locate R3. V6 stated she went out the maintenance door and found R3 lying on her back in the grass and her wheelchair positioned towards grass. V6 stated no alarms on doors sounded. V6 stated she has never seen R3 attempt to go out of the building but has seen her by the door. On 10/10/18 at 11:34 AM, V3, Maintenance Director, stated he received the call R3 was found outside and when he arrived at the facility, the ambulance was there to pick up R3. V3 stated he was told R3 was found outside near the sidewalk between the 500 side door and the 500 front door. V3 stated he checked the 500 hall front door and the 500 hall back door alarms and both alarms were working. V3 stated he or maintenance staff checks all door alarms daily. V3 stated he checked all the door alarms in the facility on 9/15/18 and all were working. V3 stated nobody ever uses the back exit by the 500 nurse's station, it was for evacuation purposes. On 10/10/18 at 9:18 AM, V1, Administrator, stated R3 was found outside on the grounds and there were two possible doors R3 could have gone out: the back exit door by the 500 Hall Nurse's Station entrance or the 500 Hall front entrance. V1 stated there are no cameras installed on any of the exit doors. V1 stated the only way it could have happened was R3 was sitting by the 500 Hall entrance and a visitor was leaving, punched the code and opened the door and R3 followed them that's why no alarm sounded. V1 stated The facility has installed those delayed egress doors with the 14 second alarm system and is pretty much the intervention for wandering/ elopement risk residents. On 10/16/18 at 1:08 PM, V14, Nurse Practitioner, stated there was one other occasion R3 was able to get out of the double doors into the parking lot and this happened about 5 weeks ago. V14 stated it is unacceptable that it happened again and this time R3 sustained an injury and had to be sent to the hospital. V14 stated she expects for all residents to get the very best care and be safe where they are. V14 stated R3 was pleasantly confused. V14 stated there were days with lucid conversations and other days when she would not make any sense at all. V14 stated she does not think R3 understood the safety issue when getting out of the building. V14 stated R3 has mild to moderate dementia. The Facility Policy on Wandering Resident dated 3/2015 documents, Policy Statement: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Interpretation and Implementation: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at risk individuals for potentially correctible risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident's care plan. 5. Staff will institute a plan of care, as indicated for residents who are assessed to have a high risk of elopement. 6. Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility.

Based on observation, record review, and interview the facility failed to prevent the formation of pressure ulcers and provide pressure relief and implement interventions to prevent pressure ulcers for 2 of 3 residents (R2, R11) reviewed for pressure ulcers in the sample of 38. This failure resulted in R2 developing unstageable pressure ulcers to her coccyx, left hip and ears and right illium. Findings include: R2's (MONTH) (YEAR) physician's orders [REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents that R2's requires extensive assistance of two staff persons for bed mobility and transfers. The MDS documents she had no current pressure ulcers but was at risk for the development of pressure ulcers. R2's Care Plan, initiated on [DATE] and revised on [DATE] documented (R2) has a potential for pressure ulcer development or skin break down related to decrease mobility and occasional incontinence. The Care Plan goal, revised on [DATE] documented R2 will have intact skin free or redness, blisters, or discoloration by/ through the next review date. The intervention, dated [DATE] documented Monitor/document/report MD (medical doctor) PRN (as needed) changes in skin status; appearance, color, wound healing, s/sx (signs and symptoms of infection, wound size (length x width x depth), stage. R2's (MONTH) Treatment Sheet documents R2's coccyx pressure ulcer was found in (MONTH) (YEAR). R2's Treat Record documented the order, dated [DATE] as Apply calmo q (every) shift to area on coccyx until healed. R2's Treatment Record documented on [DATE] description of R2's pressure ulcers as, 2.6 cm (centimeter) x (by) 6 cm x 0.1 cm open area - coccyx full granulation. The same Treatment Record documented on [DATE] R2's pressure ulcer as 5.0 cm x 3.0 cm x 0.3 cm open area to coccyx unstageable area to corner of L (Left) side of wound bed. R2's Treatment Record, dated (MONTH) (YEAR) documented the same treatment of [REDACTED]. There was no change of treatment although R2's area remained unstageable with no improvement. R2's (MONTH) (YEAR) Treatment Record documented the continued order of Apply calmo to coccyx every shift until area is resolved with the initial order dated [DATE]. The Facility's untitled report, dated [DATE] documented R2 had an unstageable facility acquired pressure ulcer to her coccyx. R2's Treatment Record documented on [DATE], Area to coccyx assessed, 5 x 5, 90 % slough, yellow gray slough firmly attached to wound bed granulation tissue note to periwound edges, N.O. (new order) to add calcium alginate Silver to wound r/t (related to) odor. New area to L (left) hip assessed, 8.5 x 4 reddened blanchable area noted c (with) 2 x 0 dark purple DTI (Deep Tissue Injury.) The Treatment Record documented order dated [DATE] cleanse coccyx wound c (with) soap and H2O (water) apply [MEDICATION NAME]/hydrogel, cover with alginate silver and dry dressing. Change daily and PRN. The Treatment Record documented order dated [DATE] cleanse L (left) hip c (with) soap and H2O, apply skin prep, cover with [MEDICATION NAME], change every three days. R2's weekly measurements on her Treatment Record dated [DATE] documents her pressure ulcer on her coccyx measures 5.4 cm x 5 cm x 1.5 cm with partial slough, grayish in color and odor. There was no description of R2's left hip pressure ulcer. R2's weekly measurements on her Treatment Record dated [DATE] documents R2's coccyx pressure ulcer measured 6 cm x 6 cm x 0 with grayish slough and R2's left hip pressures measure 4. cm x 4.5 cm and skin prep was applied. R2's weekly measurements on her Treatment Record dated [DATE] documents R2's coccyx pressure ulcer measured 8 cm x 4.5 cm x 3 cm with partial slough grayish in color. This weekly measurement documented R2's left hip measured 4 cm x 5 cm x .2 cm. R2's weekly measurements on her Treatment Record dated [DATE] documents R2's coccyx pressure ulcer is 5.3 cm x 5.2 x .3 cm. The Treatment Record documented R2's left hip pressure ulcer measures 3 cm x 3 cm with necrotic area. R2's Treatment Sheets dated [DATE] documents R2's coccyx pressure ulcer measures 5.8 cm x 6.3 cm x 2.8 cm. R2's left hip measures 3.3 cm x 3.4 cm with 100% black eschar. R2's (MONTH) (YEAR) Treatment Record documented physician's orders [REDACTED].D. (dry dressing), change BID (twice daily). The Treatment Record documented physician's orders [REDACTED]. R2's Treatment Sheet dated [DATE] documents R2's coccyx pressure ulcer measures 5 cm x 6 cm x 1.8. The sheet documented R2's left hip pressure ulcer measured 3.3 cm x 3.4 cm. The Treatment Sheet documented regarding the Left hip pressure ulcer 100 % black/grey eschar noted firmly attached to wound bed, 0.7 x 1.8 100% yellow slough @ (at) top edge of eschar. Treatments continued as ordered. R2's Treatment Sheet dated [DATE] documents R2's coccyx measures 3.6 cm x 3.5 cm x 0.5cm. R2's left hip measures 2.9 cm x 0.2 cm. R2's Treatment Sheet dated [DATE] documents R2's coccyx measures 3 cm x 3cm x 0.5 cm and R2's left hip measures 3 cm x 1.2 cm x 0.3 cm. R2's Treatment Sheet dated [DATE] documents R2's coccyx pressure ulcer measures 3 cm x 3 cm x 0.5 cm and her left hip measures 1.2 cm x 1.3 cm x 0.3 cm. R2's Treatment Sheet, dated entry of [DATE] documented R2's coccyx pressure ulcer measured 3 cm x 2.3 cm by 0.7 cm and the left hip pressure ulcer measured 1.5 cm by 1.4 cm with 100% black necrotic eschar firmly attached to wound bed. This entry documented a new area on Right illium measuring 1.5 cm by 2.0 cm by less than 0.1 cm. On [DATE] at 9:00 AM V15 Licensed Practical Nurse (LPN) entered R2's room, and informed R2 she was going to check her dressing which had been changed earlier in the morning by V15. V15 washed her hands and donned gloves and pulled the dressing back on R2's hip and coccyx. R2's left hip pressure ulcer measured approximately 3.5 cm x 1.5 cm, and her coccyx pressure ulcer measured approximately 2 cm x 2 cm x 1.5 cm. R2's left and right ear was reddened, and scabs were on both. When was asked about R2's reddened left and right ear, V15 stated They look scabbed. I will let V6 (Primary Physician) know, she is here. R2's Physician order [REDACTED]. On [DATE], at 10:30 AM, V6, Primary Physician, stated the pressure area on her ears were probably cause by the pads on the (reclining geriatric) chair or it could be pressure. V6 stated (R2) should be turned every hour. (R2's) coccyx wound was also caused by pressure. V6 stated (R2) has had the pressure ulcer to her coccyx for a long time. The Care Plan was not revised in (MONTH) (YEAR) to address R2's coccyx pressure ulcerand left hip pressure ulcer. The Care plan was not revised in (MONTH) (YEAR) when R2 developed a pressure ulcer to her right illium. The Care plan did not address or provide interventions to address R2's need for turning and repositioning or how staff should assist R2 to reduce pressure. On [DATE] at 10:00 AM when asked, when R2's pressure ulcer began on her coccyx, and why V2, Director of Nurse's (DON) stated It started in (MONTH) she stopped eating, when her husband died . The Decubitus Care/Pressure Area Policy with a Revision dated of (MONTH) 2014 documents in part, Policy: To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. 1) The Pressure area will be assessed and documented. 2) Complete all areas of a wound assessment following National Pressure Ulcer Advisory Panel guidelines. i) Document size, state, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician. ii) Document the stated of the pressure ulcer as follows: (b) Stage 1: redness, which does not resolve 30 minutes after pressure is relieved, no broken skin. 3) Notify the physician for treatment orders. The physician's orders [REDACTED].>Type of treatment Frequency of treatment is to be preformed How to cleanse, if needed Site of application No PRN order is acceptable for a pressure ulcer. This order must have specific frequencies Initiate physician order [REDACTED].>4) Documentation of the pressure area must occur upon identification and at least once each week. 2. On [DATE] at 1:07 PM, R11 was sitting up in hallway in reclining geriatric chair outside of his room with a heel protector on his right heel only. On [DATE] at 9:47 AM, R11 was sitting up in reclining geriatric chair with a right heel protector on only. On [DATE] 11:08 AM, R11 was sitting up in reclining geriatric chair in dining room waiting for lunch and continued to only have heel protector on right heel. On [DATE] 8:58 AM, R11 was up in reclining geriatric chair in his room without heel protectors on, one heel protector was noted in window sill. On [DATE] at 9:56 AM, R11 was transferred to bed by V8 and V9, Certified Nurses Assistants (CNAs) per mechanical lift. During the transfer, R11's pants were urine soaked as well as the mechanical lift sling. While V8 and V9 began incontinent care it was noted that R11 scrotum was bright red with excoriation with two areas being open. No barrier cream was present to the scrotum. Further evaluation of R11's peri area and buttocks it was noted that there were two new pressure areas noted on each sided buttocks. The area to right buttock/gluteal fold measured 6 cm x 3.4 cm x less than 0.1 cm, and left buttock measuring 1 cm x 0.6 cm x 0.1 cm. No barrier creams were applied before V8 and V9 placed a new attend on R11 and preceded to place R11 back into reclining geriatric chair for lunch. When asked what time R11 was gotten up this AM, both V8 and V9 stated 7:30 AM. R11's Minimum Data Set ((MDS) dated [DATE] documents R11's having a Brief Interview for Mental Status score (BIMS) of 3 indicating R11 is severely impaired cognitively. R11's quarterly MDS, dated [DATE], docuemnts R11 requires extensive assistance with bed mobility. This MDS documented he was at risk for pressure ulcers but did not have current pressure ulcers. R11's Braden scale (for predicting pressure sore risk), dated [DATE], documents a score of 11 indicating R11 is high risk for developing a pressure sore. R11's Physician order [REDACTED]. R11's POS, dated, [DATE] documents heel protectors on at all times, Skin prep to right heel every shift and [MEDICATION NAME] to scrotum every shift. R11's Resident-data collection, on [DATE] at 3:30 PM, documents skin condition: blister to right heel 2 cm (centimeters) x 2.5 cm and open areas to scrotum 1.5 cm x 1.5 cm open area to scrotum 1.3 cm x 1.2 cm. R11's most current POS, dated [DATE] continue to have the orders for heel protectors on at all times, Apply skin prep to right heel every shift, apply [MEDICATION NAME] to scrotum every shift. R11's Care Plan dated [DATE] documents in part, Focus: (R11) is at increased risk for alteration in skin integrity related to: incontinence, UTI (recurrent),decreased mobility. Goal: The resident will not develop any skin integrity issues thru next review. Interventions inpart, Precautions for prevention of Pressure ulcers will be completed: Good pericare and drying of skin, protective barrier cream, reposition resident frequently when in bed/chair/geri chair and or wheel chair. Off load heels as needed. There are no interventions documented related to heel protectors on at all times for the wound on right heel, skin prep to right heel every shift, or the [MEDICATION NAME] to scrotum every shift. R11's Care plan, dated [DATE], under Nursing Rehab documents in part, Bed Mobility: Assist resident in turning every two hours. 0n [DATE] at 11:06 AM, V10, Licensed Practical Nurse (LPN) completed treatment on R11's right heel with skin prep. The heel was covered with black escar (scab). V10 stated that wound measurement are done weekly. V10 applied heel protectors at that time. R11's Treatment Record for (MONTH) and (MONTH) (YEAR), the treatment of [REDACTED]. R11's Progress Notes and weekly skin assessments documented no measurements with descriptions of the wound on the right heel or the scrotum since [DATE]. R11's turning and repositioning record for [DATE], [DATE] and [DATE] document in part, [DATE], R11 was up in wheel chair at 7:00 AM remained up until 11:00 AM. On [DATE], R11 was up in wheel chair at 7:00 AM until 10:00 AM, on [DATE], R11 was up at 7:30 AM and remained up until 9:56 AM for peri care and then up in wheel chair again. On [DATE] at 9:48 AM, V2, Director of Nurses (DON) stated R11 should have his heel protectors on at all times and should be turned/repositioned every 2 hours. V2 further stated that the excoriation to the scrotum and the Heel wound should be on the Care Plan and that weekly and as needed monitoring with documentation of wound size and appearance.

Based on observation, record review and interview the facility failed to document daily fluid intake and urinary output; failed to ensure indwelling urinary catheter tubing was kept off the floor; and failed to appropriately remove the indwelling urinary catheter for one of four residents (R3) with an indwelling urinary catheter in the sample of four. This failure resulted in R3 requiring immediate hospitalization for a portion of the catheter tubing with balloon to be surgically removed under anesthesia. Findings include: The physician's orders [REDACTED]. The Minimum Data Set, ((MDS) dated [DATE], documents R3 has an indwelling urinary catheter with a history of urinary tract infections. The POS for 8/12 documents R3 receives daily anticoagulant therapy, [MEDICATION NAME] 5 mg (milligrams) placing him at risk for bleeding. R3 also receives a diuretic, [MEDICATION NAME] 20 mg daily placing him at risk for dehydration. R3's Nurses Notes were reviewed for July and August 2012. The Nurses Note, dated 8/01/12, at 6:20 AM, documents, in part, by E4 Registered Nurse (RN), "Explained to patient need to remove (indwelling urinary) catheter and replace. (Indwelling urinary) catheter cut below Y-site with scissors to deflate bulb. Approximately 4 inches of rubber catheter retracted up inside urethra and unable to remove." E4's Nurses Note, dated 8/01/12, at 6:30 AM, documents Z1, Physician was notified and an order was received to send R3 to the hospital. E4's Nurses Note, dated 8/01/12, at 7:15 AM, documents R3 left the facility by ambulance enroute to a hospital in St. Louis, Missouri. The Emergency Department Summary, dated 8/01/12 at 2:17 PM, documents in part, "This is an [AGE] year old white male from the nursing home for further evaluation of an (indwelling urinary) catheter incident. Today he (R3) was due to have the catheter changed, but apparently the nursing home staff was unable to deflate the balloon, and as a result they cut the catheter with scissors, at which point it retracted into the bladder. He was sent for removal of this retained foreign body. At this time he is actively trying to void into a urinal without success." The hospital's Discharge Summary, dated 8/02/12, documents, in part, "(R3) was admitted secondary to a botched catheter removal. Apparently they cut the catheter almost flushed with the penis in an attempt to remove and change the catheter. The catheter was retracted into the bladder. Emergency consultation was obtained by urologist. He was taken to surgery. He was anesthetized and with a cystoscope, retrieved the catheter and pulled it out. He (the urologist) replaced the catheter. The patient looks like he has 500 leukocyte esterase with negative [MEDICATION NAME]. We are waiting for the culture. The patient will be given a dose of [MEDICATION NAME] (an antibiotic). Final diagnosis, 1. Foreign body in bladder." On 8/07/12, at 11:00 AM, Z1, Physician was interviewed. Z1 reported she had been notified immediately of the catheter removal incident for R3 on 8/01/12. Z1 reported she did not feel comfortable with the situation and felt R3 should be sent to the hospital for removal of the catheter. Z1 reported she was unaware if the balloon to the catheter had been deflated. Z1 stated, "They (the facility) need to do an inservice." Z1 reported R3 suffered minor trauma to the urethra. Z1 reported this incident could have been avoided if the catheter removal was done correctly. The facility investigation of R3's catheter removal by E4, dated 8/01/12, was reviewed. The investigation documents, in part, "The facility must ensure that a resident who has a (indwelling urinary catheter) receives appropriate treatment and services." In an interview on 8/07/12, at 1:00 PM, E2, DON confirmed E4 failed to follow the facility's policy and procedure related to the current standard of nursing practice for indwelling catheter removal. The facility's policy and procedure, entitled, '(Indwelling Urinary) Catheter Removal' documents, in part, "Verify by the resident's medical record the size of the catheter balloon to ensure the aspiration of all fluid before removal of the catheter. Insert the hub of a 5 ml (milliliter) syringe in the intake lumen of the catheter and aspirate all of the fluid used to inflate the balloon. Gently and slowly withdraw the catheter completely. Clip the tip of the catheter tube, place it into the sterile specimen container, and close the container (with physician's orders [REDACTED]. On 8/07/12, at 9:37 AM, R3 was observed sitting in a wheelchair near the nurses station. The indwelling urinary catheter tubing was dragging on the floor. On 8/07/12, during a continuous observation from 1:15 PM until 2:15 PM, R3 remained in the dining room feeding himself with the catheter tubing dragging on the floor. On 8/07/12, at 1:33 PM, E11, Licensed Practical Nurse came into the dining room to assist R3 with his meal. E11 failed to notice the catheter tubing on the floor from 1:33 PM until she left the room at 2:00 PM. On 8/07/12, at 1:57 PM and 2:00 PM, E2, Director of Nursing, (DON) walked by R3 but failed to notice the catheter tubing on the floor. On 8/07/12, at 2:01 PM, E2 came to sit by the surveyor who was near R3, but failed to notice R3's catheter tubing resting on the floor. R3's daily Intake and Output (I&O) Records for July and August 2012 were reviewed. The I&O records for R3 were incomplete for every day in 8/12 and partially incomplete for 7/26, 7/30/12. On 8/07/12, at 3:54 PM, E3, Assistant Director of Nursing (ADON) was interviewed. E3 stated. "We do I & O's on all our residents with catheters, even if the doctor has not ordered it, or even if a resident is on fluid restriction, whether they have a catheter or not." The facility's policy and procedure entitled, 'Urinary Catheter Care' documents, in part, "Maintain an accurate record of the resident's daily output, per facility policy and procedure. Be sure the catheter tubing and drainage bag are kept off the floor." The facility's policy and procedure entitled, 'Intake and Output Record', documents, in part, "Any resident with a (indwelling urinary ) catheter or on a strict I & O will have their total output for the shift recorded in cc's (cubic centimeter) in the urine column." .