Every finding on record at Oakwood Rehab and Nursing Center

Based on observation, interview, and record review, the facility failed to ensure that individual food preferences/food choices were assessed, and menus were provided to accommodate those preferences for 6 of 6 residents (R1-R3 and R5-R7) reviewed for food preferences. This failure affects all 102 residents in the facility.Findings include: 1.R1's face sheet shows R1 is a [AGE] year-old female and was admitted to the facility on [DATE], with the diagnoses of quadriplegia, constipation, hematuria, and urinary tract infection. R1's 04/22/2026 MDS (Minimum Data Set) showed R1's cognition was intact.On 06/29/2026 at 12:10 PM, R1 stated that the food here does not taste good. R1 said they give them a piece of plain bread with no spread on their tray most of the time. R1 stated when she was admitted to the facility, no one talked to her about her food preferences, likes, or dislikes. In June, after she had been in the facility for about 2 months, someone from the kitchen came and told R1 she would be getting a menu card to choose what food items she would like to have. R1 said as of today, she has never received any menu card. R1 said she gets what they send her and if she doesn't like it, she doesn't eat. 2. R2 was admitted on [DATE] with the diagnoses of anemia, protein-calorie malnutrition, gout, and kidney disease. R2's MDS dated [DATE] showed R2's cognition was intact. On 06/29/2026 at 1:30 PM, R2's lunch tray was on her side table, and she said she didn't like what they sent. R2 said she didn't think the food was edible for anyone and said no one asks whether she wants something different than what is being served.On 06/30/2026 at 1:00 PM, R2 was in her room and said she could not eat what she was given for lunch. R2 said she has been in the facility since September, and no one has ever asked her about her food preferences, likes, or dislikes. R2 said she doesn't receive menus to choose from.3. R3 was admitted on [DATE] with the diagnoses of anemia, hypokalemia, constipation, and muscle disorder. R3's MDS dated 05/08 2026 showed R3 cognitively intact. On 06/30/2026 at 1:19 PM, R3 said she does not like the fruit-flavored drink they give her and prefers water. R3 denied receiving a menu card to choose from or being asked if she needed different food when she does not like to eat. Sometimes they give her coffee if she asks for it.4. R5's most recent admission to the facility was 02/01/2027 with the diagnoses of protein-calorie malnutrition, chronic kidney disease, anemia, heartburn, gastroesophageal reflux disease, and type 2 diabetes. R5's MDS dated [DATE] showed R5 is cognitively intact. On 06/30/2026 at 2:02 PM, R5 said he tries to eat the food even though he doesn't like it and cannot recall anyone asking him about his preferences upon admission or getting menus to choose from. 5. R6 was admitted on [DATE], and R6's diagnoses are protein-calorie malnutrition, vitamin D deficiency, irritable bowel syndrome, fracture of the neck of the right femur, and fracture of the end of the radius. R6's MDS dated [DATE] showed R5 is cognitively intact.On 06/30/2026 at 1:02 PM, R6 said since her admission, no one has asked her about her food preferences, likes, or dislikes and she has not received any menus to choose items from. 6. R7 was admitted on [DATE] with diagnoses of chronic kidney disease, muscle wasting, inflammatory arthritis, and pressure ulcer. R7's MDS dated [DATE] showed R7 is moderately cognitively impaired.On 06/30/2026 at 1:15 PM, R7 had eaten about 20 percent of her lunch. R7 said she did not like the food or her drink. R7 said no one talked to her about her likes and dislikes regarding food or gave her any menus to choose from.On 07/01/2026 at 2:15 PM, V5 (Director of Dietary Services) said she was supposed to do the nutritional risk assessment for all residents upon admission, quarterly, and as needed. V5 said she was 67 percent behind on completing her nutritional risk assessments and has completed only a few of the 24 new admissions since April of 2026. V5 said she selects residents' likes and dislikes from the menus they complete. The writer asked V5 to produce the completed menus for R1, R2, and R7, but V5 said she doesn't have them because they didn't ask for them.The facility's job description for the Dietary Director, in part, indicated that V5's responsibilities included meeting with residents upon admission, conducting a nutritional assessment, and ascertaining food preferences,. and, upon consultation with a registered dietitian, modifying the resident's diet accordingly, and making rounds during mealtimes to check residents' acceptance of the food served.

Based on observation, interview, and record review, the facility failed to ensure a comfortable homelike environment due to a lack of supplies needed for basic daily living.This failure affects all 99 residents in the facility.Findings include:1. On 06/06/2026 at 10:01 AM, R2 was in her room watching TV and stated that the facility was short on paper towels, hand soap, and other items, including Kleenex and wipes. R2's sink was located in the bedroom, and the bathroom doesn't have a sink. No paper towels or hand soap were available at the sink.R2's 5/27/2026 MDS (Minimum Data Set) showed R2's cognition was intact and her face sheet showed R3 had hemiplegia, kidney failure, and anemia.2. On 06/06/2026 at 10:36 AM, R3 was in his room and stated he had not been at the facility long, but since he was admitted , the facility has not had enough supplies, including paper towels and soap. R3 stated he gets his own soap, adding nobody seems to care. The paper towel dispenser in R3's bathroom was empty, and the soap dispenser was also empty. There was a small stack of paper towels on the sink and they were half-wet.R3's MDS indicated that R3's cognition was intact, and his face sheet showed his diagnoses include low back pain, and major depression.3. On 06/06/2026 at 11:48 AM, R4 was in her room. R4's bathroom sink did not have any soap in the soap dispenser or other gel/wash to use when cleansing.R4's face sheet showed her diagnoses include sepsis, urinary tract infection, bacteremia, toxic encephalopathy, and respiratory failure. 4.On 06/07/2026 at 12:00 PM, R5 was in her room watching TV. R5 said that this place never has any supplies and that she buys most of her own. R5 showed her personal paper towel and soap supply to the Surveyor.R5's 3/15/2026 MDS showed R5's cognition was intact. 5. On 06/07/2026 at 10:30 AM, R6 was in her room and said the facility doesn't keep towels and soap for the sink. R6's room sink had no paper towels, and the soap dispenser was empty, with no other hand soap available.R6's face sheet showed R6 had diagnoses including end-stage renal failure dependent on dialysis, anemia, type 2 diabetes, and gastrostomy status. 6. On 06/07/2026 at 11:49 AM, R7 was in his room and said the facility doesn't have towels and soap most of the time. R7 had no paper towel dispenser in the room and there were no paper towels available.7.On 06/07/2026 at 12:00 PM, R8 was by the door to his room in his wheelchair. R8 said he does not have soap in his room and he had asked someone for it. R8's room sink did not have a paper towel dispenser or any towels. R8 stated nothing new.R8's 4/10/2026 MDS showed R8's cognition was intact. 8. On 06/07/2026 at 12:30 PM, R9 was in bed. There were no paper towels available in the paper towel dispenser.On 06/07/2026 at 1: 02 PM, R10 said that since the new management took over, the facility has had chronic issues with supplies, including paper towels and hand sanitizer.On 06/07/2026 at 1: 08 PM, V14 (R11's family member) said they have to beg for any supplies, and she personally bought extra-large incontinence products, wipes, paper towels, and soap. V14 stated it's not fun being here and she is not trying to be a complainer.On 06/07/2026 at 11:55 AM, V9, V11 (Certified Nursing Assistants), and V10 (Restorative Aide) said they frequently don't have adequate supplies in the unit and that they buy their own supplies to care for residents. V9-V11 showed their own supply bins and said they keep some in their cars to use when needed so that residents get the care they need.On 06/07/2026 at 3:05 PM, V15 (Housekeeping Aide) stated she has been working at the facility for a month. V15 stated she doesn't have a key to the dispensers and she tries to fill the paper towel rolls as much as she can from the dispenser's push-bar area. V15 said every housekeeping aide should be able to have the keys to open the dispensers.On 6/07/2026 at 3:25 PM, V5 (Maintenance Assistant) said they are not keeping the paper towel dispensers full because residents remove so much paper that it clogs in the bathrooms. When V5 was asked why then that paper towels would be kept by some of the sinks instead of the dispenser, V5 was unable to answer.On 6/07/2026 at 3:25 and between 3:32 PM and 4:00 PM, the facility's storage area was checked and toured with V5, V15, and V16 (Laundry Aides). There were no cases of paper towels or hand soap bottles. On 06/06/2026 at 12:10 PM, V2 (Director of Nursing) said residents have the right to a home-like environment, that she is new, and that the facility needs to do a better job for residents.On 06/07/2026 at 3:30 PM. V1 (Administrator) said he was not aware of concerns with a paper towel and soap shortage. V1 said he is new to the facility and that these are necessities that should be available to residents. V1 said the facility will have to assess the quantities needed of any supplies and then order accordingly. V1 said every room and resident should have access to paper towels and soap. V1 looked for a supply binder and stated the facility didn't have one.06/09/2026 at 11:50 AM, V1 said they estimate that each resident room uses about 20 paper towels per day. V1 stated they have 67 resident rooms, so this is about 1,340 per day, according to the calculation done with the V17 (Environmental Service Director). V1 said that for hand soap, they estimate a room uses less than 1 bottle every 2 weeks. V1 said they were expecting an order on 06/05/2026 last Friday, but it did not arrive until today on 06/09/2026.The review of the facility-provided document on products received over the past 90 days showed the facility received 17 cases of paper towels, with 4,000 towels per case, totaling 68,000 towels. Per the facility calculations, they required 120,600 paper towels, which amounts to approximately a 13 case shortage. The facility received four cases of hand soap over 90 days, with each case containing 12 bottles, for a total of 48 bottles. Per the facility-provided calculation, they would need to have 400-plus bottles to cover 90 days, making a shortage of 29 cases (352 bottles) of soap.On 06/09/2026 at 1:03 PM, V17 (Maintenance Director) stated he has been at the facility for a month and is responsible for supplies, audits, and bookkeeping. V17 said he is trying to take care of it and acknowledged that residents should have enough supplies.The policy on home-like environment dated 01/2025 stated, in part, that the facility will provide a safe, clean, and comfortable home-like environment, ensure the facility remains a pleasant place to live, and make frequently used items accessible.

Based on observation, interview, and record review, the facility failed to provide supervision for a resident (R2) to prevent a fall. This resulted in R2 obtaining a fracture to her right clavicle. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 6.The findings include:R2's electronic face sheet dated 4/26/26 showed R2 has diagnoses including but not limited to chronic obstructive pulmonary disease, type 2 diabetes, heart failure, depression, muscle wasting and atrophy, and osteoporosis.R2's facility assessment dated [DATE] showed R2 has moderate cognitive impairment.R2's care plan dated 10/14/25 showed, (R2) is at risk for falls related to general weakness, overestimates abilities, poor coordination, unsteady gait, use of narcotics, decreased safety awareness, impulsiveness with attempts to stand or self-transfer without assistance from staff despite repeated direction/education .Interventions: observe frequently and place in supervised area when out of bed, toilet and lay down promptly after meals.R2's nursing progress notes dated 3/19/26 showed, I was doing my rounds heard resident calling for help, observed on the floor in front of her wheelchair laying on her right side. She then verbalized that she was trying to fix her shoes and fell forward and hit her head and right shoulder. Slowly repositioned her in supine (face up) position, noted a bump on her right temple, ice pack applied, vital signs taken, and neurological check initiated. Complains of pain on her right shoulder, immobilized. Assisted back in bed with 2 staff assist and she was able to help stand and transfer.R2's nursing progress notes dated 3/19/26 showed, Resident returned back to facility via ambulance. Per report received from emergency room nurse, x-ray to right shoulder shows fracture to right clavicle. Resident is to wear sling to right arm as much as possible. Resident able to move fingers to her right hand, denies pain and discomfort .R2's local hospital records dated 3/19/26 showed, Diagnosis: traumatic closed fracture of distal clavicle with minimal displacement, closed head injury.On 4/26/26 at 12:24PM, V2 (Director of Nursing) stated, (V8-Certified Nursing Assistant-CNA) just got (R2) off the toilet and she requested to stay in her room to watch tv and she bent down to fix her shoe and fell forward out of the wheelchair. (R2's) fall prevention measures in place right now are to keep her in high supervision areas when she is awake. We also put her where a tv is at too so that she can watch it, (non-slip pad) in her wheelchair, and try to keep her in activities. Her room would not be a supervised area because there are not always staff members in the hall by her room. If she wheels herself to her room, we redirect her to come back out. At the time of her fall, it was what she was comfortable with, so we were abiding by her requests at the time. If we don't do what they ask, then we aren't abiding by her rights. I think there is a tv in the dining room and maybe one in the area across from the nurse's station that we could have tried to get her to watch. She is alert and oriented with forgetfulness so needs a lot of reminders not to get up on her own.On 4/26/26 at 12:26PM, V5 (Registered Nurse) stated, (R2) was in the bathroom before she fell, the aide took her to the bathroom and when she came out of the bathroom, she wanted to stay in her room, so we left her in her room. She does that from time to time. I was passing by her room, and I saw her on the floor. She told me she was trying to fix her shoes, and they were slip on shoes. She must have had poor trunk control and fell forward on her right side. She fractured her clavicle. She didn't want to go to the hospital, but we convinced her to do it because she was on a blood thinner and she needed to be checked out. Monitoring is a big thing for her fall prevention measures. From time to time, she slides down in the wheelchair. We usually put her by the nurse's station, and we are constantly monitoring her and reminding her to sit back. I do rounds 4-5x/shift. Sometimes she sits in her room by herself and watches tv and plays on her cell phone. On 4/26/26 at 12:52PM, V6 and V7 (CNA's) stated, We try to keep (R2) in activities but she likes to be in her room in her wheelchair. We put movies on in the dining room to try to keep her in there. She can be in her room by herself if she wants to be. She requests to be in here on her own and watch movies and plays on her phone. We try to encourage her not to so that we can keep an eye on her but at the end of the day it's her choice if she wants to be in her room.On 4/27/26 at 11:18AM, V8 (CNA) stated, The day (R2) fell I was the aide taking care of her. It was sometime after lunch and I put her on the toilet and when she was done she asked me if she could stay in her room to watch tv. I left the room and she was up in her wheelchair. I'm not sure what time it was. After she had her fall they told me she needed to be out in the hallway so we could watch her but that it's her right to be in her room if she wants to be. I don't really know about the care specifics with the residents. I only work there PRN (as needed) so I think I can look in the computer if I need to know something but I'm not sure if it's updated or not. I would think whatever I needed to know would be given to me in our shift report from the previous shift.R2's nursing progress notes and care plan showed no documentation related to R2's preference to stay in her room nor was there documentation of R2's power of attorney or family having discussions with the facility regarding alternative fall prevention measures.The facility's policy titled, Safety and Supervision of Residents revised 3/2025 showed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. 4. Implementing interventions to reduce accident risks and hazards, while maintaining resident rights, may include the following: a. communicating specific interventions to all relevant staff. b. assigning responsibility for carrying out interventions. c. providing training, as necessary. d. ensuring that interventions are implemented; and e. documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently. b. evaluating the effectiveness of interventions. c. modifying or replacing interventions as needed; and d. evaluating the effectiveness of new or revised interventions .2. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .

Based on observation, interview and record review, the facility failed to ensure that residents received provisions of care and services required when a licensed nurse left the assigned unit resulting in lack of consistent nursing supervision and nursing care. This failure directly affected 3 residents (R2, R3 and R7.)The findings include:1.R2 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure, asthma, morbid obesity, type II diabetes, anemia, hyperlipidemia, bipolar disorder, anxiety, hypertension, left wrist pain, cellulitis, chronic kidney disease, insomnia, gout, depression, hypoglycemia, depression, hypoxemia. R2's minimum data set (MDS) dated [DATE], showed R2 was cognitively intact.On April 20, 2026, at 10:30 AM, R2 said that on April 04, 2026 at 11:45 PM, R2 hit the nurse call button for anxiety medication. R2 said that V14 (CNA/Certified Nursing Assistant) came into the room and R2 asked V14 to get V18 (LPN/ Licensed Practical Nurse). R2 came back sometime later and told R2 she was unsure of where V18 was but would let her know as soon as she saw her. Sometime after midnight V15 (LPN) came down to the first floor to assist R2. R2 said at 1:45AM, V18 was still missing from the unit. R2 said that she looked outside of the window and observed V18 asleep in the car with the headlights on. R2 said several other residents had been looking for V18 throughout the night so R2 called the nonemergency line for the local police department. R2 said she looked out the window as an officer pulled into the parking lot. R2 said that she watched as the officer walked up to the car and shined a light through the car. R2 said it took a minute to get V18's attention. V18 turned the car off a few minutes later and returned to the facility. R2 said that she went into the hall and a few minutes later she observed the paramedics coming into the community and going down the hall to R3's room. R2 said that V18 then walked over to the med cart. The paramedics informed V18 that a male resident called 911 and stated that they were on the floor and could not find the nurse. R2 said V18 left the floor again at 5:00 AM to go buy coffee. R2 said that she informed staff the next morning and was told that a grievance was put in place and that V2 (DON) would follow up with her. R2 said a week went by and she had not heard from V2 so R2 reported the situation again. R2 said V2 entered her room asking what is it that she wanted to know. R2 informed V2 that she wanted to know about the follow up on the grievance that was submitted. R2 said that V2 told R2 the nurse was sent home the next day but that R2's story did not align with the CNA's that worked that night and no other residents had an issue. R2 said that there has been many issues and concerns with V18 and that V18 is not allowed to give R2 medications because V18 gave R2 the wrong medications once before. R2 said they do not discipline V18 they just take V18 off the schedule a day or two then hide V18 on a different unit. 2. R3 was admitted to the facility on [DATE] and discharged on April 09, 2025. R3 has multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, hyperlipidemia, cerebral infarction, hemiplegia, hemiparesis, hypertension, bipolar disorder, benign prostatic hyperplasia, depression, anxiety disorder, constipation, pain, pulmonary embolism, medication noncompliance.R3's care plan showed R3 has difficulty breathing with exertion at night and is unable to lie flat due to shortness of breath. R3 prefers to sleep on his sides. Staff should give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Head of bed elevated or out of bed upright in a chair during episodes of difficulty breathing. 3. R7 was admitted to the facility on [DATE] with multiple diagnoses including heart failure, asthma, respiratory failure, convulsions, morbid obesity, anxiety, hypertension, sleep apnea, hyperkalemia, anemia, migraine, chronic pain, lymphedema, and major depressive disorder.R7's MDS showed R7 is cognitively intact. R7 said that she was asleep during the events of April 04, 2026 but said she had heard about it from several residents. R7 said that V18 is not allowed to administer medications to R7 due to V18 refusing to administer R7 their pain medications once before. On April 21, 2026, at 10:00 AM V14 said that they were working on the overnight shift on April 04, 2026. V14 said that on April 04, 2026, V18 left the floor for several hours and was unable to be found.V14 said that both V15 (LPN) and V16 (CNA) attempted to call and text V18 several times without response. V14 said that V18 gave V15 their phone number previously and told V15 to call if someone needed something. V18 was eventually found sleeping in their car. R2 called the police to inform them that the nurse could not be found, and several residents needed assistance. V14 said that she saw the police flash their lights into the window of V18's car. V18 rolled the window down and the police officer spoke to her and then left. The initial officer did not come into the facility. V18 came in a little bit after. Around 2:00 AM the paramedics came in and said they were there for a male resident who said they were not being assisted by the nurse and had fallen on the floor. V18 was unaware of what was going on and attempted to tell the paramedics that the gentleman was crazy. The paramedic and police stated that they still had to check and did a room check of the entire building. V14 said this was not the first time V18 had left the floor for several hours. V14 said during V18's time away R3 was anxious and having breathing problems. V14 said that they had also told V18 at the beginning of the shift that a resident needed a wound dressing changed. V18 did not change the dressing and the resident continued to call throughout the night while V18 was in the car. V14 said R2 was having anxiety and so V14 had to go to the second floor to ask V15 to assist. V14 said a statement was submitted to human resources and the DON but no one responded to them. V14 said that V18's practices are unsafe for the CNA's and nurses. On April 20, 2026 at 11:00 AM, review of grievances and employee files did not show any concerns or disciplinary actions regarding the events on April 04, 2026. V1 (Administrator) and V2 (Director of Nursing) both confirmed that all disciplinary actions and corrections were located in employee files. V18's file did not have any coaching or corrective actions inside. Progress notes entered by V18 and V15 showed V18 went on break at 12:00AM and was met by an officer at 12:20AM. However, review of the police report for the wellbeing check showed that officers were dispatched at 1:55AM. One officer arrived at 1:55 AM and another arrived at 1:58AM.On April 20, 2026, at 12:00 PM, V2 said that she was aware of the incident on April 04, 2026. V2 said that R2 has an issue with V18. V2 said that V18 went on break around 12:00 PM or 12:30 PM and was not gone that long before the police came. V2 said that R2 showed V2 the police call sheet. V2 said there is a discrepancy on the timing of the police report because it does not line up with what V14 and V15 informed her. V2 said she did not talk to any other residents except for the resident who called the paramedics to determine why the call was made. V2 said she did not review camera footage because V2 did not have access to the camera's footage. V2 said there were at least two residents on the first floor that V18 is not supposed to pass medications to. Investigation notes and interviews were requested for the incident at 12:00 PM. V2 said all documentation is in the employee files and stated she was going to grab the reports. A report was submitted at 3:08 PM that showed V18 received coaching on break times with V18 and V15's progress notes attached to it. The coaching was not signed by V18. There were no additional staff or resident interviews submitted and V14's report was not submitted either. V2 said that there had been previous grievances against V18 from residents that do not like V18. There was nothing in V18's employee file regarding the grievances mentioned. On April 21, 2026, at 12:16 PM V15 said that she was told by V14 that V18 had left the unit and R2 was requesting medicine. V15 said this was around 12:30PM and then V15 went back upstairs to manage the second floor. V15 said she did not see what time V18 came back into the building. V15 said when she came back down to the first floor at 2:00AM, V18 was in the building and was standing at the nurse's cart. V15 said she did not see the police and paramedics enter the building. They were talking to R2 when V15 came downstairs. V15 said she is not involved in the suspension of staff members. Review of the nurse's schedule showed V18 on shift as of April 10, 2026 working on different units.

Based on observations, interviews and record review, the facility failed to serve food at a palatable temperature acceptable to residents.This applies to 8 of 13 residents (R2, R4, R9, R5, R10-R13) reviewed for poor preparation/cold foods in the sample of 13.The findings include: On March 16, 2026, at 12:10 PM, R2 stated The food is horrible. Most of the time it is cold. R2 stated that she receives room trays and that she eats her meals in her room.On March 16, 2026, at 1:43 PM, R4 stated Food is hot sometimes but a lot of times it's cold. Most of us eat in the room. On March 17, 2026, at 12:34 PM, R9 stated Food is lukewarm at best. Their carts are a problem. They don't have an efficient way of keeping the food warm or transferring it. R9 stated that he had filed a complaint about a CNA/Certified Nursing Assistant who would not heat up his meal after he had dialysis treatment. R9 continued It takes a lot for me to speak up. But she flipped a switch.On March 19, 2026, at 11:12 AM, R5 (Resident Council President) stated I can vouch that frequently we get our food cold, for variety of reasons. Sometimes they use plastic covers and not insulated covers. The other day it came up covered in just saran wrap and I don't know how they think that it will keep the food warm. They also do not have warming pellets as they eliminated those. Some residents complain that when they ask for food to be warmed up, they (CNAs) say that they will do it once and after that they are on their own. That is not reasonable, as most of the residents are in wheelchairs. Food is at least palatable when its warm.On March 17, 2026, at 11:35 AM, the meal service was observed at the facility kitchen during start of service for the second-floor residents. V18 (Dietary Aide) was at the steam table plating the food. When asked if she had taken the food temperatures at the start of service, V18 stated not today. V18 was using plastic plates initially that were not warmed and China plates that were warmed in the oven. [NAME] warmers were seen stacked on a rack and were not used. V17 (Food Service Manager), who was in the vicinity stated that the plastic plates are used for residents of the Dementia unit and cannot be heated up. V17 stated that the facility does not have a plate-warmer and therefore the pellets are not warmed. V17 stated that they do the best they can to heat most of the China plates in the oven. The food was covered with an insulated domed cover and put in free standing carts covered with a black zipped cover and taken to the units. Additionally, a small metal cart was also seen loaded with plated foods. It was noted that towards the end of service, the facility ran out of domed covers. On March 17, 2026, at 12:06 PM, the second-floor cart with plated food was taken up via an elevator.On March 17, 2026, at 12:24 PM, on request, temperatures from a test tray were taken by V19 CNA (Certified Nursing Assistant) after R2's tray was passed and showed as follows in degrees Fahrenheit: Hamburger 103.6, Corn 113.7, Pinto Beans 114.6.R10-R13's trays were passed out around the same time or after R2 received her tray. On March 18, 2026, at 3:36 PM, V14 (Dietitian) stated that the temperature of the food at the point of service should be between 120-135 degrees Fahrenheit. V14 stated that ideally it should not be below 120 degrees Fahrenheit for hot foods. V14 stated that food temperatures can be affected by various factors including the time it takes to reach the resident, cover not used and ensuring that plates and pellets are preheated.Facility policy titled Serving tray line-safety and palatability included as follows:Policy: The temperatures of all food on the serving line will be measured and recorded at every meal.Procedure: 3. Temperatures are taken prior to service to ensure hot foods and cold foods are maintained at the appropriate temperatures. For a palatable food temperature range for residents, hot foods can be slightly under 135 degrees Fahrenheit, between 120-130 degrees Fahrenheit, but should not be under 120 degrees Fahrenheit.Facility week at a glance menu for week 4 Tuesday included hamburger as the main entree with sides of seasoned pinto beans and seasoned corn.

Based on observation, interview, and record review, the facility failed to serve portion sizes as shown on the menu for the lunch meal.This applies to 7 of 13 residents (R2, R4, R5, R10-R13) reviewed for meal prep and service in the sample of 13.The findings include: Facility week at a glance menu for week 4 Tuesday included hamburger as the main entree with sides of seasoned pinto beans and seasoned corn. The menu spreadsheet for the same showed to use #10 scoop plus one ounce broth for the mechanical soft consistency diets.On March 16, 2026 at 12:10 PM, R2 stated The food is horrible. They give you small portions. R2 stated that she receives room trays and that she eats her meals in her room.On March 16, 2026, at 1:43 PM, R4 stated Portions are sometimes good and sometimes not. You could feed your grandkids with the (small) portion they give us. On March 19, 2026, at 11:17 AM, R5 (Resident Council President) stated Often times the residents are complaining that the portions are small and going to the vending machines. When the new company took over the food is really bad. They have cut back and there is no reason people are hungry and to me that's inexcusable. There have been evenings that I have been hungry. I am supposed to get double protein. But couple weeks ago we had jerk chicken and there was hardly any meat to cover the bun. Last Sunday I got a bowl of cereal in a dessert bowl. On March 17, 2026, at 11:35 AM, the meal service was observed at the facility kitchen during start of service for the second-floor residents. V18 (Dietary Aide) was at the steam table plating the food. V18 was noted to use a small black scoop to serve mechanical soft ground hamburger and R10, R11, R12 and R13 received the same. When asked what size scoop she is using, V18 stated that she does not know. No menu spread sheet was seen at the steam table. V18 was also asked if she follows a menu spreadsheet and she responded, I don't look at the spreadsheet. V17 (Food Service Manager), who was in the vicinity, stated that both she and V18 are new in their positions and are still in training. V17 stated that V18 should have used a #12 green scoop to serve the mechanical soft diet. V17 also looked up the color code/scoop equivalent and stated that the black scoop that V18 was using was a 1 oz/ounce portion.On March 18, 2026, at 3:36 PM, V14 (Dietitian) stated that the recipe for Ground Hamburger should show the serving size to use for the item which should be followed. V14 stated that this is to ensure that the portion is big enough to meet the caloric and protein needs of the meal. V14 stated that if the wrong scoop is used, it affects the meal planning.Recipe for Ground Hamburger with Broth showed 1 (one) serving portion as #10 scoop with 1 ounce broth.Instructions included serving 2 oz ground protein portion with #10 scoop plus 1 oz hot broth to keep moist.Facility scoops equivalent chart showed that #30 black scoop=1.07 oz, #12 green scoop=2.90 oz, #10 ivory scoop=3.33 oz.Facility diet order listing showed that R10-R13 were on mechanical soft consistency diets.

Based on observation, interview and record review the facility failed to ensure staff wore personal protective equipment when caring for residents who are positive for COVID-19 to prevent to spread of infection for 6 of 9 residents (R14-R18 and R20) reviewed for infection control in the sample of 23.The findings include:1.The facility provided COVID Isolation List shows that R20 is on isolation due to being COVID positive. The facility's COVID positive line list shows that R20 tested positive on 1/15/26.On 1/23/26 at 10:01 AM, there was a sign on R20's door that said that she was on contact/droplet Isolation. V14 (Receptionist) was in R20's room. V14 had gloves, gown and a surgical mask on. V14 exited the room with her personal protective equipment still on and disposed of her gown and gloves in a housekeeping cart. 2. The facility provided COVID Isolation List shows that R14 is on isolation due to being COVID positive. The facility's COVID positive line list shows that R14 tested positive on 1/18/26. R17 and R18 are not on the COVID Isolation List.On 1/23/26 at 10:26 AM, R14, R17 and R18 were in the dialysis room. R14 did not have a mask on. V15 (Dialysis Tech.) and V16 (Dialysis Registered Nurse) were in the room with R14, R17 and R18. V15 had a surgical mask on. V16 had a surgical mask and gown on. On 1/23/26 at 11:50 AM, V15 said that R14 is no longer on isolation. V15 said that R14 was dialyzed in another room for 8 days when he was on isolation for being positive for COVID-19. V16 said that residents are dialyzed in a separate room if they are positive for COVID-19 and personal protective equipment (PPE) of gloves, gown and surgical mask are used when providing care to them. V16 said that they use their regular glasses as eye protection.3. The facility provided COVID Isolation List shows that R16 is on isolation due to being COVID positive. The facility's COVID positive line list shows that R16 tested positive on 1/14/26.On 1/23/26 at 11:00 AM, R16 was in the dialysis room. V15 was providing care to R16. V15 had a surgical mask and gloves on. 4. The facility provided COVID Isolation List shows that R14 and R15 are on isolation due to being COVID positive. The facility's COVID positive line list shows that R14 and R15 tested positive on 1/18/26.On 1/23/26 at 11:40 AM, R14 and R15's door did not have a sign indicating that they were on contact/droplet isolation but did have a sign that showed what PPE should be used and how to use it. V13 (Certified Nursing Assistant) entered R14 and R15's room. V13 only had a surgical mask on. R14 and R15 were both in the room. On 1/23/26 at 11:40 AM, V13 said that she does not know if R14 and R15 are on isolation. V13 said that one person told her that they were and one person told her that they were not. On 1/23/26 at 12:28 PM, V2 (Director of Nursing) said that if a resident tests positive for COVID-19, they are placed on contact/droplet isolation for 10 days. V2 said that a sign is placed on the resident's door to alert staff that they are on isolation. V2 said that staff should apply gloves, gown, N95 mask and a face shield before entering the room. V2 said that staff should remove all of their PPE before exiting the room. V2 said that residents that are COVID positive are still able to go to dialysis but they have to wear a surgical mask if they are out of their room. The facility's PPE and Source Control Policy shows, If a resident is suspected or confirmed to have COVID-19, HCP (Health Care Personnel) must wear an N95 respirator, eye protection, gown and gloves.The facility's Acute Respiratory Illness Management Policy shows, Apply appropriate transmission-based precautions (TBP).Residents who are placed in TBP for acute respiratory infection should remain in their rooms except for medically necessary purposes. If they must leave their room, they should practice physical distancing and wear a facemask for source control.The facility provided Viral Respiratory Pathogens Toolkit shows that residents with COVID-19 should be placed on contact/droplet isolation for 10 days.

Based on observation, interview and record review the facility failed to ensure resident rooms were cleaned routinely for 5 of 6 residents (R1, R6, R11, R12 and R13) reviewed for clean, comfortable and homelike in the sample of 23.The findings include:On 1/23/26 at 9:30 AM, there were no housekeepers seen on the first floor.At 10:01 AM, V14 (Receptionist) was going into resident rooms and emptying their garbage cans.On 1/23/26 at 11:57 AM, R11's bathroom toilet was filled with toilet paper and stool. R11's bathroom smelled of stool. V13, Certified Nursing Assistant (CNA) said that R11's toilet has been in that state for at least three weeks.On 1/23/26 at 12:04 PM, R12's garbage bin in her room did not have a trash bag in it. The garbage bin in the bathroom did not have a trash bag in it as well. R12's room floor was sticky and had splatter marks of an unknown substance throughout the floor. R12 said that she does not remember when the last time was that her floor was cleaned and the spots have been on her floor for at least a month. R12 said that her biggest concern is that when they empty her garbage, they do not put another garbage bag in the bin. R12 said that she does not get her room cleaned daily. On 1/23/26 at 12:04 PM, R13's garbage bin was filled above the rim. R13 said that they do not clean her room daily and her main concern is that her garbage can get really full and they do not empty it. R13 said that it has been a long time since they cleaned her room. On 1/23/26 at 10:15 AM, R1 showed a picture of the garbage bin in her bathroom. The garbage bin was filled above the rim and there was what appeared to be incontinence briefs in the bin. R1 said that she does not use incontinence briefs, but her previous roommate did and she moved out a while ago. R1 said her garbage had been full since Sunday and on Thursday evening, she finally had to ask an aide to get rid of it for her. R1 said that housekeeping does not come and clean her room daily nor empty her garbages.On 1/23/26 at 9:00 AM, R6 said, Housekeeping has gotten bad. We used to have our rooms cleaned every day. Now there is no cleaning for a week at times.On 1/23/26 at 12:14 PM, V1 (Administrator) said that he is currently managing housekeeping due to not having a manager. V1 said that resident rooms should be cleaned daily. On 1/23/26 at 12:40 PM, V14 (Receptionist) said that she used to be a housekeeper. V14 said that all resident rooms should be cleaned daily and should include emptying the garbage, cleaning high touch surfaces, sweeping and mopping the floors and cleaning the bathroom. V14 said that she was helping with emptying garbages and spot cleaning this morning since there was not a housekeeper but then she had to go back to her reception duties. On 1/23/26 at 11:40 AM, V13 (Certified Nursing Assistant) said all rooms do not get cleaned daily. V13 said that she asked the housekeeper if all rooms are cleaned daily and she said that it is more of a lottery on what rooms get cleaned per day. October 2025 Resident Council Minutes show, Resident stated concerns floors occasionally being sticky after mopping.Residents stated concerns with dining room not being cleaned after meals and activities.November 2025 Resident Council Minutes show, Residents stated concern with dining room not being cleaned after meals and activities.December 2025 Resident Council Minutes show, Residents would like to request additional garbage bins for their bedrooms/restrooms.A routine resident room housekeeping policy was requested and was not provided.

Based on observation, interview and record review, the facility failed to supply clean linens in sufficient quantities for resident care needs. This applies to all 98 residents residing in the facility. The findings include: Facility Midnight Census Report, dated 1/30/25, shows the facility census was 98 residents. On 12/30/25 at 2:23 PM on the first floor, the linen carts had only one washcloth and no towels available for resident care. The one washcloth had the seam missing on two sides of the cloth and the edges were frayed. On 12/30/25 at 2:39 PM on the second floor, one linen cart had no washcloths, no bath towels, three bed sheets, 1 pillowcase and 1 blanket. At 2:42 PM on the first floor, a second linen cart had only 1 washcloth, 3 bed sheets, 3 blankets, and 3 gowns on the cart. At 2:45 PM on the first floor, a third linen cart had no washcloths and 2 stained bath towels. On 12/30/25 at 2:46 PM, V2 (Director of Nursing) was shown the stained towel on the linen cart and V2 stated, I wouldn't want to use it. V2 stated the staff call the laundry for linen when needed and the residents prefer disposable wipes instead of the towels.On 01/02/26 at 4:15 PM, V2 stated the CNAs (Certified Nursing Assistants) voiced concerns regarding not having enough linen to provide resident care. On 1/2/26 at 10:21 AM, 1st floor linen carts had no washcloths or bath towels in them. On 1/2/25 at 10:54 AM, 2nd floor linen cart on odd side rooms had only 2 washcloths & 2 bath towels left. On 12/31/25 at 11:13 AM, R18 stated they were concerned the facility eliminated the use of disposable wipes and switched to using washcloths for cleaning residents. R18 stated she was unable to find a washcloth in the facility that was usable because some still appeared soiled after being laundered. R18 stated some of the linens appeared so stained that she did not want to put them on her body. R18 stated she threw some linens away because they came to her stained and she also cut up towels to make washcloths for herself. R18 stated the residents at the resident council meeting the day prior expressed several concerns regarding the lack of, and condition of, facility linens. On 12/30/25 at 10:45 AM, R19 (Resident Council [NAME] President) stated residents complain about the towels and linens. R19 stated on 12/30/25 there were no towels on the first floor for use during her shower and R19 went upstairs to look for towels. R19 stated the second-floor linen carts had no towels so she washed up with a paper towel. R19 lifted her bed sheet and there was a large round brown stain on her fitted sheet. R19 stated her fitted sheet was placed on her bed with the stain already present and R19 placed two incontinence bed pads on top of it because she thought it was nasty. R19 stated the towels were not clean and most were stained, had feces on them, and stink. R19 stated she spoke with V2 (Director of Nursing) about the facility obtaining more linen and the facility CNAs (Certified Nursing Assistants) call down to the laundry to request more linens. R19 stated she spoke with V1 (Administrator) and V1 reported he ordered more linens. R19 stated V1 was ordering linens and the residents/staff were cutting up the towels to make washcloths or throwing the towels out. R19 stated the linens were a concern for more than three weeks and some of the family/residents/ staff were purchasing their own disposable wipes themselves. On 1/6/ 26 at 10:15 AM, R26 stated he purchased his own towels and supplies because the facility ran out of linens. On 1/2/26 at 10:27 AM, R25 said there were several days on which she asked for washcloths and the staff replied there were no washcloths. R25 stated she had to cut towels to use the towel pieces as washcloths. On 12/30/25 at 2:22 PM, R24 stated the facility washcloths used for residents were stained and dirty and there were not enough linens in the facility for resident incontinence care so R24 was purchasing her own disposable wipes. On 12/30/25 at 2:28 PM, V7 (CNA - Certified Nursing Assistant) stated, It's horrible regarding the linen supply situation at the facility. V7 stated there were no washcloths or towels available for resident care in the facility. V7 stated she personally purchased her own washcloths for use on residents during her shift and disposed of them after use. V7 stated the staff were supposed to use linens supplied by the facility and placed on linen carts but there often were none in stock. V7 stated she worked at the facility for two months and there were not enough linens each time she worked since she started. On 12/30/25 at 2:40 PM, V5 (LPN - Licensed Practical Nurse) stated, The linens are disgusting. Would you use them?! On 12/31/25 at 5:16 PM, V5 stated there were not enough supplies, and she had seen linen come off the cart improperly cleaned. On 12/30/25 at 2:48 PM, V6 (CNA) said there was a lack of linens at the facility and when she did not have enough linens, she used a piece of tissue to pat the resident dry and put their diaper on during incontinence care. On 12/31/25 at 12:22 PM, V19 (CNA) stated the facility does not have enough linens so she brought her own wipes from home to care for the residents. V19 stated when the linens come back from the laundry, they appear dirty and stained. On 12/30/25 at 3:00 PM, V11 (Laundry) stated she had no back up face cloths in the laundry room and was waiting on an order to come into the facility. V11 stated the facility makes a mid-day announcement to send down soiled linens to laundry for cleaning but the CNAs send soiled linens down toward the end of V11's shift and she could not clean the linens fast enough. V11 stated there were stains on some of the washcloths and towels, and she attempts to wash them twice to get the stains out, but some stains will not come out. Resident Council Meeting Minutes, dated 10/21/25, 11/18/25, and 12/30/25, shows the residents stated they wanted their linen changed more frequently. Resident Council Meeting Minutes, dated 12/30/25, show the residents requested more of a variety of linens to be available and requested stronger/different materials facial wash cloths.

Based on interviews and record reviews, the facility failed to staff sufficient nurses for proper incontinence care and timely medication administration. This applies to 11 residents (R6, R8, R10, R12, R15, R17, R19, R20, R22, R25, and R27) reviewed for staffing in a sample of 35.The findings include: 1. R17's care plan showed an alteration in skin integrity with a stage 2 pressure sore on the left buttock and is at risk for additional and or worsening of skin integrity issue related to incontinence of bladder, incontinence of bowel, impaired mobility status, diabetes, comorbidities. On 12/31/25 at 12:58 PM, R17 stated he had not had incontinence care since he got out of bed in the morning. V19 (CNA/Certified Nursing Assistant) performed incontinence care on R17 who was wearing two incontinence briefs. R17's brief had a small amount of thick feces and blood, his buttocks, sacrum and scrotum were excoriated, and the left abdominal fold was excoriated and bleeding. R17 stated wearing two incontinence briefs was standard procedure so he did not urinate through his clothing while waiting for assistance. V19 stated she usually placed two incontinence briefs on R17 because she is unable to get to him with so many people to care for. V19 stated she sees everyone every two hours, so she puts the extra undergarment on as a liner to keep his clothes dry. At 12:22 PM, V19 stated when she has been assigned sixteen residents, and she does not get everything done, she informs the nurse. V19 said if she cannot provide incontinence care or lay them down, she will relay it to the nurse. V19 stated R17 has some excoriation from sitting in a wet brief all day and the urine tears his skin up. V19 stated R17 does not refuse to lay down to have his brief changed. V19 stated R17 was last changed at about 7:30 AM when he got out of bed. 2. R20's Care Plan includes incontinence of bowel and bladder, with a goal to remain free from skin breakdown due to incontinence and brief use. R20's interventions included to clean peri area with each incontinence episode. On 12/30/25 at 4:12 PM, V6 (CNA/Certified Nurse Assistant) provided incontinence care to R20. V6 opened R20's brief and R20 was wearing two incontinence briefs. R20's brief was saturated with urine and stool and his scrotum was large and reddened. At 4:30 PM, V6 stated the two briefs were placed on R20 by the previous shift. V6 stated residents should not have two disposable briefs on at the same time because it was bad for the resident's skin. On 01/02/26 at 4:15 PM, V2 (DON/Director of Nursing) stated none of the residents should have two incontinence briefs on unless they were educated and care planned for resident preference. V2 said using double briefs may lead to skin break down and UTIs if they were not changed. V2 said incontinent residents should be checked every two hours and as needed. The facility policy Incontinence Care, dated 1/2025, states residents will be checked periodically for bowel and or bladder incontinence and be provided perineal and genital care. The document states a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. 3. The EMR (electronic medical record) showed R19 was cognitively intact. On 12/30/25 at 10:45 AM, R19 (Resident Council [NAME] President) stated the facility residents complain about receiving late medications, waiting long periods for their call lights to be answered, and not having enough staff at the facility.Review of R19 medication administration times on document titled Medication Admin Audit Report showed: -On 1/2/26, Buspirone, Lamotrigine, Dicyclomine was scheduled for 5:00 PM and was administered by the nurse at 6:39 PM. R19's Trazadone, Ezetimbe, Dicyclomine and Lidocaine patch were scheduled for 9:00 PM and was given at 10:22 PM. R19's Mirtazapine was scheduled for 9:00 PM and was given at 10:23PM. -On 1/3/26, Lomotil was scheduled for 4:00 PM and administered by the nurse at 6:26 PM, and R19's Dicyclomine Gabapentin and Buspirone was scheduled for 5:00 PM and was administered at 6:27PM. -On 1/4/26, Lomotil was scheduled for 4 PM and was administered by the nurse at 6:24 PM, Biofreeze cream was scheduled for 5:00 PM and administered at 6:26 PM, Dicyclomine, Gabapentin, Buspirone was scheduled for 5 PM and was given at 6:27 PM, Lamatrogine and Propranolol was scheduled for 5:00 PM and was given at 6:28 PM, and Micatin cream was scheduled for 4:30 PM and was given at 6:31 PM. Facility document Policy and Procedure Administering Medications with issue date 1/1/2020 revision date 1/2025. The document shows Purpose to sure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure.6 Medications should be administered within one (1) hour of prescribed times. 4. The EMR showed R22 was cognitively intact. On 1/2/26 at 2:28 PM R22 stated the nurses say they are busy and tell the residents they will get there medication when they get there. R22 stated the medications, especially as needed pain medications, are administered late by nurses. Review of R22's medication administration times on document titled Medication Admin Audit Report showed: - On 1/2/26, Zinc Oxide Cream was scheduled at 3:00 PM and was administered by the nurse at 7:47 PM - On 1/3/26, Buspirone was scheduled at 5:00 PM and given at 6:15 PM, Metformin was scheduled at 5:00 PM and was given at 6:18 PM, Probiotic capsule was scheduled at 5:00 PM and given at 6:15 PM, Bupren/nalox was scheduled at 5:00 PM and given at 6:15 PM, Omeprazole was scheduled at 5:00 PM and was given at 6:15 PM and blood glucose monitoring (Accucheck) was scheduled for 5:00 PM and was performed at 6:15 PM. -On 1/4/26, Bupren/nalox was scheduled at 9:00 PM and given at 10:22 PM, Lipitor was scheduled at 9:00 PM and given at 10:40 PM, Gabapentin was scheduled for 9:00 PM and given at 10:40 PM, Glargin YFGN sol was scheduled for 9:00 PM and was given at 10:40 PM, Trazadone was scheduled at 9:00 PM and was given at 10:40 PM, and Amitriptylin was scheduled for 9:00 PM and given at 10:40 PM.5. Review of R25's EMR showed R25 was cognitively intact. On 1/5/26 at 3:00 PM, R25 stated their blood glucose check was supposed to be completed on 1/3/25 and the nurse was out of testing strips. R25 stated the nurse told R25 she had to get testing strips from upstairs, and that she should not have to look for supplies. R25 stated she called the nurse at 9:00 PM because her blood sugar should have been checked at 5:00 PM and R25 should have received insulin at 6:00 PM but R25 had not yet received them. R25 stated several residents complained nurses gave the wrong medications, gave insulin too late, and gave the wrong dose of medications at the facility. Review of R25's medication administration times on document titled Medication Admin Audit Report showed: - On 1/3/26, Insulin Glargine was scheduled for 6:00 PM and was administered by the nurse at 8:30 PM. - On 1/4/26, Insulin Lispro was scheduled for 5:00 PM and was administered at 7:13 PM, Dicyclomine was scheduled at 5PM, and was administered at 7:19 PM -On 1/4/26, Insulin Glargine-yfgn was scheduled at 6:00 PM and was administered at 7:19 PM. 6. The EMR showed R12 was cognitively intact. On 1/5/26 at 3:27 PM, R12, stated there have been issues with medications being late and his medications were often late. R12 stated they received medications late this weekend. Review of R12's medication administration times on document titled Medication Admin Audit Report given by facility personnel showed: -On 1/4/26, Colesevelam was scheduled at 5:00 PM and was administered by the nurse at 6:18 PM and Colace was scheduled at 5:00 PM and was administered at 6:30 PM. 7. The EMR showed R27 was cognitively intact. On 1/5/26 at 2:50 PM, R27 stated the afternoon 3:00 PM -11:00 PM shift nurses pass medications late. R27 stated he was supposed to get his diabetic medications at 6:00 PM but did not get the medication until 9:00 PM. R27 stated he asked the nurse at 7:00 PM for his medications due at 6:00 PM and the nurse replied she would get it when she could. R27 stated the nurse had a bad attitude when he approached her again at 8:30 PM asking for his medication and the nurse responded, You'll get it when I can get to you. Review of R27's medication administration times on document titled Medication Admin Audit Report showed: -On 1/3/26, Atorvastatin was scheduled for 8:00 PM and was administered by the nurse at 9:17 PM, Humalog Insulin was scheduled for 4:30 PM and given at 6:18 PM. -On 1/4/26 Metformin was scheduled for 5:00 PM and was given at 6:18 PM. 8. The EMR showed R15 was cognitively intact. On 12/31/ at 10:31 AM, R15, stated she felt like there were not enough nursing staff in the facility. Review of R15's medication administration times on document titled Medication Admin Audit Report showed: - On 1/2/26, Carvedilol was scheduled for 5:00 PM and was administered by the nurse at 8:36 PM, blood glucose monitoring (Accucheck) was scheduled for 5:00 PM and was taken at 8:36 PM. 9. The EMR (electronic medical record) showed R10 was severely cognitively impaired. Review of R10 medication administration times on document titled Medication Admin Audit Report showed: -On 1/2/26 Brimonidine Tartrate ophthalmic solution, timolol ophthalmic, and Zostrix cream was scheduled for 6:00 PM and was administered by the nurse at 8:20 PM. R10's blood glucose monitoring was scheduled for 6:00 PM and was completed at 8:20 PM. -On 1/3/26 R10's blood glucose monitoring was scheduled for 5:00 PM and was completed at 6:41 PM. On 1/4/26 R10's Insulin (Glargine) and Terazosin capsule were scheduled for 8:00 PM and was administered by the nurse at 9:21 PM. 10. R8 The EMR (electronic medical record) showed R8 was cognitively intact. Review of R8 medication administration times on document titled Medication Admin Audit Report showed: -On 1/2/26 Insulin Lipro was scheduled for 7:30 AM and was administered by the nurse at 10:34 AM. Insulin Glargine, Pregablin, Buspirone, Ascorbic acid, Empaglifozin, furosemide, Atorvastatin, Famotidine, Duloxetine, Folic acid, ferrous sulfate was scheduled at 9:00 AM and was given at 10:30 AM, Buprenophrine was scheduled for 12:00 PM and was given at 1:26 PM. 11. On 1/7/25 at 1:24 PM, R6 stated she waited more than two hours to receive medications and felt like there were not enough nurses to be able to pass medications when they were needed. On 12/31/25 at 11:24 AM V18 (CNA) stated R6, used the call light and sometimes complained the nurses may not give her medications because her room was on the far end of the hallway. 12. Facility Resident Council Meeting Minutes, dated 10/21/25, 11/18/25 and 12/30/25, show residents expressed concerns about call light response times and follow up from staff to residents varies. The minutes also show residents expressed concern the staff were turning off call lights prior to being requested.On 12/30/25 at 2:06 PM, V5 (LPN/Licensed Practical Nurse) stated she was the only nurse for 32 residents but months prior she only had 25 residents. V5 stated she was nonstop busy, could not take breaks, and was just surviving every shift. On 12/31/25 at 2:17 PM, V22 (Business Office Manager) stated she thought there were too many patients for 1 nurse on the first floor. On 12/31/2025 at 2:28 PM, V2 (DON- Director of Nursing) stated the1st floor had 30 residents and had 2 CNAs and 1 nurse working on the floor during all shifts. On 12/31/25 at 11:30 AM, V18 (CNA) stated the facility needed 1 to 2 more CNAs on the first floor because the census was growing on the first floor and they had more residents with mechanical lifts, who need feeding, and need to go to dialysis. V18 stated she and the first floor nurse have spoken up during meetings and requested three CNAs or have help at times on the first floor. V18 stated the first floor continued to only have 2 CNAs. On 12/31/25 at 12:36 PM, V19 (CNA) stated she worked on the first floor when there were only two CNA and she had 16 residents assigned to her. V19 stated she tried to get everything done and told the nurse if she was unable to get her tasks completed. On 12/31/25 11:15 AM, V7 (CNA) stated staffing was at the bare minimum and they were not used to working with only 2 CNAs for 30 residents. V7 stated she has worked at the facility for two months and there were only 2 CNAs for 30 residents on the first floor. On 12/ 31/2025, at 9:50 AM, V8 (Staffing Coordinator) V8 stated she staffs the facility based on the facility needs and distributes overtime to all nursing staff. On 12/31/2025 at 12:43 PM the facility provided a document titled Facility Assessment Tool dated 10/10/2025.which showed the average census of the facility was 72-90 residents. The document showed, 3.2 Staffing will be based upon census and the acuity of the patient population being services by the facility. Systems are in place to ensure that sufficient staff is on duty to meet the care needs of the residents of the facility. Facility document Policy and Procedure Staffing dated 6/14 with revision date 1/25. showed, Policy.Staffing is based on the acuity of the resident needs according to the facility assessment. The document shows the facility was to have appropriate amount of nursing staff on a daily basis and o render quality care. The document shows the staffing schedule is reviewed by the Director of Nursing/ Assistant Director of Nursing to verify appropriate number of staff based on the number of residents daily.

Based on interviews and record reviews, the facility failed provide timely medication administration per facility policy. This applies to 9 residents (R6, R8, R10, R12, R15, R19, R22, R25, and R27) reviewed for medication administration in a sample of 35. The findings include: 1. The EMR (electronic medical record) showed R19 was cognitively intact. On 12/30/25 at 10:45 AM, R19 (Resident Council [NAME] President) stated the facility residents complain about receiving late medications, waiting long periods for their call lights to be answered, and not having enough staff at the facility. Review of R19 medication administration times on document titled Medication Admin Audit Report showed: -On 1/2/26, Buspirone, Lamotrigine, Dicyclomine was scheduled for 5:00 PM and was administered by the nurse at 6:39 PM. R19's Trazadone, Ezetimbe, Dicyclomine and Lidocaine patch were scheduled for 9:00 PM and was given at 10:22 PM. R19's Mirtazapine was scheduled for 9:00 PM and was given at 10:23PM. -On 1/3/26, Lomotil was scheduled for 4:00 PM and administered by the nurse at 6:26 PM, and R19's Dicyclomine Gabapentin and Buspirone was scheduled for 5:00 PM and was administered at 6:27PM. -On 1/4/26, Lomotil was scheduled for 4 PM and was administered by the nurse at 6:24 PM, Biofreeze cream was scheduled for 5:00 PM and administered at 6:26 PM, Dicyclomine, Gabapentin, Buspirone was scheduled for 5 PM and was given at 6:27 PM, Lamatrogine and Propranolol was scheduled for 5:00 PM and was given at 6:28 PM, and Micatin cream was scheduled for 4:30 PM and was given at 6:31 PM. On 12/30/25 at 2:06 PM, V5 (LPN/Licensed Practical Nurse) stated she was the only nurse for 32 residents but months prior she only had 25 residents. V5 stated she was nonstop busy, could not take breaks, and was just surviving every shift. Facility document Policy and Procedure Administering Medications with issue date 1/1/2020 revision date 1/2025, shows Purpose to sure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure.6 Medications should be administered within one (1) hour of prescribed times. 2. The EMR showed R22 was cognitively intact.On 1/2/26 at 2:28 PM R22 stated the nurses say they are busy and tell the residents they will get there medication when they get there. R22 stated the medications, especially as needed pain medications, are administered late by nurses. Review of R22's medication administration times on document titled Medication Admin Audit Report showed: - On 1/2/26, Zinc Oxide Cream was scheduled at 3:00 PM and was administered by the nurse at 7:47 PM - On 1/3/26, Buspirone was scheduled at 5:00 PM and given at 6:15 PM, Metformin was scheduled at 5:00 PM and was given at 6:18 PM, Probiotic capsule was scheduled at 5:00 PM and given at 6:15 PM, Bupren/nalox was scheduled at 5:00 PM and given at 6:15 PM, Omeprazole was scheduled at 5:00 PM and was given at 6:15 PM and blood glucose monitoring (Accucheck) was scheduled for 5:00 PM and was performed at 6:15 PM. -On 1/4/26, Bupren/nalox was scheduled at 9:00 PM and given at 10:22 PM, Lipitor was scheduled at 9:00 PM and given at 10:40 PM, Gabapentin was scheduled for 9:00 PM and given at 10:40 PM, Glargin YFGN sol was scheduled for 9:00 PM and was given at 10:40 PM, Trazadone was scheduled at 9:00 PM and was given at 10:40 PM, and Amitriptylin was scheduled for 9:00 PM and given at 10:40 PM 3. Review of R25's EMR showed R25 was cognitively intact. On 1/5/26 at 3:00 PM, R25 stated their blood glucose check was supposed to be completed on 1/3/25 and the nurse was out of testing strips. R25 stated the nurse told R25 she had to get testing strips from upstairs, and that she should not have to look for supplies. R25 stated she called the nurse at 9:00 PM because her blood sugar should have been checked at 5:00 PM and R25 should have received insulin at 6:00 PM but had not yet received it. R25 stated several residents complained nurses gave the wrong medications, gave insulin too late, and gave the wrong dose of medications at the facility. Review of R25's medication administration times on document titled Medication Admin Audit Report showed: - On 1/3/26, Insulin Glargine was scheduled for 6:00 PM and was administered by the nurse at 8:30 PM. - On 1/4/26, Insulin Lispro was scheduled for 5:00 PM and was administered at 7:13 PM, Dicyclomine was scheduled at 5PM, and was administered at 7:19 PM -On 1/4/26, Insulin Glargine was scheduled at 6:00 PM and was administered at 7:19 PM. 4. The EMR showed R12 was cognitively intact. On 1/5/26 at 3:27 PM, R12, stated there have been issues with medications being late and his medications were often late. R12 stated they received medications late this weekend. Review of R12's medication administration times on document titled Medication Admin Audit Report given by facility personnel showed: -On 1/4/26, Colesevelam was scheduled at 5:00 PM and was administered by the nurse at 6:18 PM and Colace was scheduled at 5:00 PM and was administered at 6:30 PM. 5. The EMR showed R27 was cognitively intact. On 1/5/26 at 2:50 PM, R27 stated the afternoon 3:00 PM -11:00 PM shift nurses pass medications late. R27 stated once he was supposed to get his diabetic medications at 6:00 PM but did not get the medication until 9:00 PM. R27 stated he asked the nurse at 7:00 PM for his medications due at 6:00 PM and the nurse replied she would get it when she could. R27 stated the nurse had a bad attitude when he approached her again at 8:30 PM asking for his medication and the nurse responded, You'll get it when I can get to you. Review of R27's medication administration times on document titled Medication Admin Audit Report showed: -On 1/3/26, Atorvastatin was scheduled for 8:00 PM and was administered by the nurse at 9:17 PM, Humalog Insulin was scheduled for 4:30 PM and given at 6:18 PM, -On 1/4/26 Metformin was scheduled for 5:00 PM and was given at 6:18 PM. 6. The EMR showed R15 was cognitively intact. On 12/31/ at 10:31 AM, R15, stated she felt like there were not enough nursing staff in the facility. Review of R15's medication administration times on document titled Medication Admin Audit Report showed: - On 1/2/26, Carvedilol was scheduled for 5:00 PM and was administered by the nurse at 8:36 PM, blood glucose monitoring (Accucheck) was scheduled for 5:00 PM and was taken at 8:36 PM. 7. The EMR showed R10 was severely cognitively impaired. Review of R10 medication administration times on document titled Medication Admin Audit Report showed: -On 1/2/26 Brimonidine Tartrate ophthalmic solution, timolol ophthalmic, and Zostrix cream was scheduled for 6:00 PM and was administered by the nurse at 8:20 PM. R10's blood glucose monitoring was scheduled for 6:00 PM and was completed at 8:20 PM. -On 1/3/26 R10's blood glucose monitoring was scheduled for 5:00 PM and was completed at 6:41 PM. On 1/4/26 R10's Insulin (Glargine) and Terazosin capsule were scheduled for 8:00 PM and was administered by the nurse at 9:21 PM. 8. R8 The EMR showed R8 was cognitively intact. Review of R8 medication administration times on document titled Medication Admin Audit Report showed: -On 1/2/26 Insulin Lipro was scheduled for 7:30 AM and was administered by the nurse at 10:34 AM. Insulin Glargine, Pregablin, Buspirone, Ascorbic acid, Empaglifozin, furosemide, Atorvastatin, Famotidine, Duloxetine, Folic acid, ferrous sulfate was scheduled at 9:00 AM and was given at 10:30 AM, Buprenophrine was scheduled for 12:00 PM and was given at 1:26 PM 9. On 1/7/25 at 1:24 PM, R6 stated she waited more than two hours to receive medications. On 12/31/25 at 11:24 AM V18 (CNA) stated R6, used the call light and sometimes complained the nurses may not give her medications because her room was on the far end of the hallway. 10. Facility Resident Council Meeting Minutes, dated 10/21/25, 11/18/25 and 12/30/25, show residents expressed concerns about call light response times and follow up from staff to residents varies. The minutes also show residents expressed concern the staff were turning off call lights prior to being requested.

Based on observation, interview and record review the facility failed to provide incontinence care utilizing techniques per facility protocols and policy. This applies to 3 of 3 residents (R13, R15, and R20) reviewed for incontinence care in a sample of 35. The findings include: 1. On 12/30/25 at 4:12 PM, V6 (CNA/Certified Nursing Assistant) provided incontinence care to R20. V6 opened R20's brief which was saturated with urine and his scrotum was large and reddened. V6 removed the soiled undergarment and wiped R20's penis and scrotum several times with the same washcloth. V6 then wiped R20's feces covered buttocks with the same washcloth and followed with wiping his rectum and buttocks with the soiled washcloth. R20's buttocks were scantly smeared with feces. V6 stated the facility did not use disposable wipes anymore to provide incontinence care and instead use non-disposable washcloths. V6 stated if disposable wipes were available, it would be used once and tossed away. V6 stated the towels usually run out at the facility. V6 stated she only had one towel for the incontinence care and she did the best she could with the supplies available. R20's incontinence care plan showed R20 was incontinent of bowel and bladder and interventions included cleaning R20's peri area after each incontinence episode. 2. On 12/30/25 at 2:43 PM, V6 (CNA) provided incontinence care to R13. V6 sated she was able to find one washcloth on the linen cart. V6 wet the washcloth and wiped R13's groin areas starting from the right side to the left side, and then down the perineal area. V6 turned R13 to the right side and used the same washcloth to wipe R13's perianal area. R13's incontinence care plan showed R13 was incontinent of bowel and bladder and interventions included cleaning R13's peri area after each incontinence episode. 3. On 12/31/25 at 10:31 AM, V7 (CNA) provided incontinence care to R15. V7 had one washcloth and one towel to provide care for R15. V7 wet the bath towel and wiped the groin, perineal area, and perianal areas with the towel. V7 turned R15 to the right side and cleaned R15's perianal area with stool. V7 then used a wet paper towel to wipe down the soapy areas from the resident's perineal area. R15's incontinence care plan showed R15 was incontinent of bowel and bladder and interventions included cleaning R15's peri area after each incontinence episode. On 01/02/26 at 4:15 PM, V2 (DON/Director of Nursing) stated the CNAs (Certified Nursing Assistants) voiced concerns regarding not having enough linen to provide resident care. V2 stated the facility did not use disposable wipes but used washcloths and bath towels for incontinence care. V2 stated the staff should only swipe once with each clean washcloth when using non-disposable linen during incomitance/periarea care. V2 stated the staff would not be able to meet facility incontinence care expectations if there were not enough linens available in the facility. The facility policy Incontinence Care dated 1/2025 states residents will be checked periodically for bowel and or bladder incontinence and be provided perineal and genital care to prevent infection and improve the quality of resident's care. The policy shows a resident with or without an indwelling catheter receives the appropriate care and services to prevent urinary tract infections to the extent possible.

Based on observation, interview and record review, the facility failed to provide timely incontinence care to residents who required staff assistance for ADLs (Activities of Daily Living). This applies to 2 of 4 residents (R17 and R20) observed for incontinence care in a sample of 35. The findings include: 1. On12/31/25 at 12:58 PM, R17 stated he had not had incontinence care since he got out of bed in the morning. V19 (CNA/Certified Nursing Assistant) assisted R17 back to bed for incontinence care. R17 was wearing two incontinence briefs. R17's brief had a small amount of thick feces and blood. R17's buttocks, sacrum and scrotum were excoriated, and the left abdominal fold was excoriated and bleeding. R17 stated wearing two incontinence briefs was standard procedure so he did not urinate through his clothing while waiting for assistance. V19 stated she usually placed two incontinence briefs on R17. V19 stated she is unable to get to him with so many people to care for. V19 stated she saw residents every two hours, so she puts the extra undergarment on as a liner to keep his clothes dry. On 12/31/25 at 12:22 PM, V19 stated when she was assigned sixteen residents, and did not get everything done, she informed the nurse. V19 said if she cannot provide incontinence care or lay them down, she would relay her concerns to the nurse. V19 stated R17 had some excoriation from sitting in a wet brief all day and the urine tore his skin up. V19 stated R17 does not refuse to lay down to have his brief changed. V19 stated R17 was last changed at about 7:30 AM when he got out of bed. R17's care plan showed an alteration in skin integrity with a stage 2 pressure sore on the left buttock and is at risk for additional and or worsening of skin integrity issue related to incontinence of bladder, incontinence of bowel, impaired mobility status, diabetes, comorbidities. R17's interventions included the resident being checked for incontinence as needed and peri care given. 2. On 12/30/25 at 4:12 PM, V6 (CNA/Certified Nurse Assistant) provided incontinence care to R20. V6 opened R20's brief and R20 was wearing two incontinence briefs. R20's brief was saturated with urine and stool, and his scrotum was large and reddened. On 12/30/25 at 4:30 PM, V6 stated the two briefs were placed on R20 by the previous shift staff. V6 stated residents should not have two disposable briefs on at the same time because it was bad for the resident's skin. R20's Care Plan shows R20 was incontinent of bowel and bladder and R20's interventions included cleaning R20's peri area with each incontinence episode. 3. Facility Resident Council Meeting Minutes, dated 10/21/25, 11/18/25 and 12/30/25, show residents expressed concerns about call light response times and follow up from staff to residents varies. The minutes also show residents expressed concern the staff were turning off call lights prior to being requested. On 01/02/26 at 4:15 PM, V2 (DON/Director of Nursing) stated none of the residents should have two incontinence briefs on unless they were educated and care planned for resident preference. V2 said using double briefs may lead to skin break down and UTIs if they were not changed. V2 said incontinent residents should be checked every two hours and as needed for the need of incontinence care. The facility policy Incontinence Care dated 1/2025 states residents were to be checked periodically for bowel and or bladder incontinence and be provided perineal and genital care to prevent infection and improve the quality of resident's care. The policy shows any resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible.

Based on observation, interview and record review, the facility failed to provide cold foods to meet acceptable palatable temperatures requirements for the residents. This applies to 5 of 5 residents (R1, R2, R3, R6, R8) reviewed for poor prep and quality of foods. The findings include: On September 29, 2025, at 9:37 AM, R6 had received a breakfast room tray that was set on a bedside table while he was still in dialysis. The breakfast meal included an 8-ounce carton of whole milk and 4-ounce disposable cup of orange juice. R6 returned to room at around 11:30 AM to eat his breakfast. On September 29, 2025, at 9:44 AM, 10:18 AM and R3 and R1 respectively stated that the food that is supposed to be cold is hot. R3 and R1 added that the orange juice is served warm. On September 29, 2025, at 9:56 AM, R2 stated that cold foods are served warm and that the quality is poor.On September 29, 2025, at 11:33 AM, during tray line service, deli sandwiches wrapped in clear wrap with condiments were seen placed directly on the tray line counter next to the steam table. V10 (Dietary Aide) stated that the ham sandwiches were made fresh, and the turkey sandwiches were made the day before. The turkey sandwich contained wilted lettuce and cheese that appeared to be melting. On testing the temperature of the ham sandwich, it showed 70 degrees Fahrenheit. R2 had ordered turkey sandwich and R8 had ordered the ham sandwich. Both these residents received room trays around 12:00 PM with ordered deli sandwiches. On September 29, 2025, at 12:06 PM, the food temperature in degrees Fahrenheit of drinks from a test tray was taken by V1(Administrator) and showed that orange juice was 49.8 and milk was 46.7. On September 30, 2025, at 9:07 AM, V11 (Interim Dietary Manager) on request tested a cup of orange juice after it was dispensed from the dispenser and it showed 50.7 degrees Fahrenheit. V11 stated that the juice dispenser does not keep juices cold. On September 30, 2025, at 2:22 PM, V14 (Dietitian) stated that the orange juice should come out cold from the dispenser. V14 stated that cold items should be 40 degrees Fahrenheit at the serving station and should at least be 45 degrees Fahrenheit at point of service, Facility policy titled Serving/Tray Line-Safety and Palatability included: Policy: The temperatures of all food on the serving line will be measured and recorded at every meal. Procedure: 2. Cold foods are maintained at 41-degree Fahrenheit. 3. Temperatures are taken prior to service to ensure hot foods and cold foods are maintained at the appropriate temperatures. 4. If items are not at the correct temperatures, action will be taken so that the temperatures are restored to correct the temperature. Protocol:10. Cold foods will be prepared, dipped into individual serving dishes and chilled prior to service. Cold beverages will be added at the end of tray line to maintain the temperature. 11.Cold foods will be at 40-45 degrees at the time of service for palatability.

Based on observation, interview and record review, the facility failed to serve protein portion sizes as shown for the lunch meal.This applies to 8 of 10 residents (R1, R2, R3, R4, R5, R6, R7, R9) reviewed for insufficient foods in the sample of insufficient foods in the sample of 10.The findings include:Facility menu spreadsheet for Monday (Week 4) included 6 ounces of Vitamin C juice for breakfast and 3 ounces of Baked Ham as the main entree for lunch.Facility also provided deli sandwiches as a substitute item for baked ham. Nutrition facts on Turkey Deli meat packaging label showed that 4 slices of turkey meat=10 grams of protein.On September 29, 2025, at 9:37 AM, R6 had received a breakfast room tray, and it included a half (disposable) cup of orange juice. R5 was still at dialysis. On September 29, 2025, at 9:44 AM and 10:18 AM, R3 and R1 respectively stated that the drinks served are only half or less than half filled in the cup and watered down. On September 29, 2025, at 9:56 AM, R2 stated that the portion sizes are much smaller and that the resident families have to bring extra food as the residents are still hungry. R2 added that the juices are watered down. On September 29, 2025, at 11:33 AM, during tray line service R2 ordered a turkey deli sandwich. On checking the contents of the sandwich, it contained 2 slices of deli turkey with one slice cheese and a piece of lettuce. V10 (Dietary Aide) stated that the turkey sandwiches were made the day before. On September 29, 2025, at 11:33 AM, V11(Interim Dietary Manager) was platting the food at the tray line service, and the ham slices were noted sliced into varying thickness. V11 served R3, R4, R5, R6 and R7 one slice of ham along with the other side items consisting of scalloped potatoes and carrots. V12 (Cook) who was in the vicinity was requested to weigh one slice of the ham on a weighing scale. V12 took one of the thicker sliced pieces from the steam table and when weighed the same and it showed 2.3 ounces. On September 29,2025, at 12:19 PM, R4 stated There is more vegetables than meat on the plate. On September 29, 2025, at 3:18 PM, R9 stated There is not enough food at all. We have big people here. My whole life I have never gone to bed hungry, but now I am going hungry. On September 30, 2025, at 9:07 AM and 9:29 AM, V11 stated that the juices are supposed to be served in a 7 oz plastic cup for breakfast. V11 stated that the juice from the dispenser is put in a container and that the facility adds ice to the container prior to taking it to the unit. V11 added that the ham was already pre-sliced when he had come in to assist to serve at tray line. On September 30, 2025, at 2:33 PM, V14 (Dietitian) stated that the residents should have received 3 ounces of ham and 6 ounces of orange juice as shown on the menu spreadsheet to meet the dietary requirements. V14 stated that the facility should not add ice as it waters down the juice. V14 stated that the substitute menu item should be comparable to the main menu entree. V14 stated that 1 oz of meat=7 grams of protein. V14 added that by serving 2 slices of deli turkey meat with one slice of cheese, the facility is not giving adequate amount of nutrition (protein) as main menu entree. Facility policy and procedure titled Food Preferences included: Policy: The facility will attempt to accommodate the residents' requests as available. Procedure: 1 The facility will ensure that menus are developed and prepared according to national guidelines. 3. The facility's dietitian or other qualified nutrition professional will review the resident's nutrition status to ensure the nutrition provided meets the needs of residents.

Based on observations, interviews and record reviews, the facility failed to serve palatable meals at temperatures per facility policy. This applies to all 83 residents residing in the facility receiving oral diets. The findings include:Facility Daily Census, dated 9/9/25, shows the facility census was 84 residents. POS (Physician Order Sheet) dated 9/11/25, shows one resident in the facility had a physician order for NPO (Nothing by Mouth).1. On 9/9/25 at 11:17 AM during lunch service, the facility was plating lunch foods which included sweet and sour pork, green beans, white rice and apple sauce. The plate warmer had hot plates in only one of the two sides of the equipment. The warmer had hot plates stacked in one side of the machine and the plates on the cooler side were only slightly warm but not hot. During lunch service, staff transferred some of the cooler plates into the hotter side of the warmer as they served food. At 12:10 PM a test tray was tasted. The pork and rice tasted only slightly warm, and the green beans tasted minimally warm. The temperatures of the pork measured 115 degrees F (Fahrenheit), the rice measured 118 degrees F, and the green beans measured 110 degrees F. The applesauce tasted room temperature, and the temperature of the applesauce measured 70 degrees F. On 9/9/25 during lunch service, R7 had her lunch in front of her and stated the food was served cold and was unappetizing. R7 stated she only had two warm meals in the last week. On 9/9/25 at 12:26 PM during lunch service, R1 had her lunch tray sitting in front of her uneaten and R1 was eating a chicken tender. R1 stated her lunch food did not taste appetizing and R1 was eating chicken tenders she received from her roommate. R1 stated the facility hot meals were sometimes served hot but not always.On 9/9/25 at 1:55 PM, R4 stated, The food is impossible! R4 stated she ordered out for food for lunch because she did not want to eat the facility-served lunch that day. R4 stated the hot sandwiches were prepared poorly and carelessly. On 9/9/25 at 2:50 PM, R3 stated Breakfast was so cold. It felt like they just took it out of an icebox! R3 stated she threw out her sandwich she was served the night prior because it was unappetizing. R3 stated the grilled cheese sandwiches were served with edges like rocks, one side was burnt, and the other side looked like untoasted bread. On 9/9/25 at 10:40 AM, R2 (Resident Council [NAME] President) stated the facility food service stopped using warming pellets under meal plates approximately a week prior and food that was supposed to be served hot was served cold to residents at times. R2 stated the meat was served tough and dry and vegetables are sometimes not cooked and were served tough and hard to chew. On 9/9/25 at 11:25 AM, V3 (Food Service Manager) stated she was not aware the facility had warming pellets and was made aware of the warming pellets were available for use in the kitchen only that morning. On 9/9/25, V4 (Food Service Worker) stated the facility stopped using warming pellets the prior week and one side of the plate warmer was less warm, so staff transferred plates to the other side during service to warm the meal plates.Facility Policy/Procedure Serving/Tray Line- Safety and Palatability, dated 10/25/23, shows, .For a palatable food temperature range for residents, hot foods can be slightly under 135 degrees Fahrenheit, between 120-130 degrees Fahrenheit, but should not be under 120 degrees Fahrenheit. Cold food should be served between 40-45 degrees Fahrenheit but should not be over 45 degrees Fahrenheit. 6. Small batch cooking will be utilized, when possible, to minimize hot holding or to retain food quality. 10. Cold foods will be prepared, dipped into individual serving dishes and chilled prior to service.2. On 9/10/25 during lunch service in the kitchen, staff were plating servings of macaroni and cheese with beef and broccoli/cauliflower on resident lunch plates. The macaroni and cheese with beef was pale white with light brown ground beef mixed with the macaroni. The mixture tasted bland, had no flavor or seasoning, and lacked any cheese sauce. The noodles appeared oily and there were small amounts of chewy cheese throughout the mixture. The broccoli/cauliflower appeared to have white cauliflower mixed with pale green/gray broccoli. There was an approximately four inches by four inches by four inches block of margarine sitting on top of the broccoli/cauliflower mixture in the steamtable pan located in the steamtable. The vegetables tasted mushy in texture and could be swallowed after mashing the product with a tongue. On 9/10/25 during lunch service, the following residents commented on the facility food: R19 stated It doesn't taste like there was cheese in it! R11 stated, The mac and beef sucked! R12 stated, It's bad. I can't touch it. I can't eat it! R12 had all of his portion of macaroni and cheese with beef left on his plate except a few bites. R13 stated the macaroni and cheese with beef was bland and the broccoli was overcooked. R14 stated, I ate a few bites, and I am done. It doesn't taste good. R13 and R14 stated the facility food was not served hot at times. R14 stated the food was a problem at the facility. R20 stated Lunch was horrible. The mac and beef had no flavor, no seasoning. It was horrible. The food quality is horrible. R16 stated, The food is bland - no seasoning and no flavor. R18 stated The food is not good, not seasoned. R18 stated the hot foods were not served hot at the facility. R15 stated the hot food was served cold at times. R7 stated her breakfast was served cold that morning and the eggs were ice cold. R9 stated the food quality had gotten worse at the facility. R6 (Resident Council President) stated breakfast was cold that morning and lately the food had been served cold. Facility Macaroni and Cheese with Beef recipe, undated, shows the recipe ingredients included macaroni, ground beef, salt, margarine, flour, milk, cheddar cheese, and breadcrumbs. Facility recipe Broccoli and Cauliflower, undated, shows, Do not overcook. 3. On 9/11/25 at 12:15 PM, R1 had her lunch in front of her which had spaghetti noodles and very little red sauce on the noodles. At 12:25 while in R1's room , R2 stated her spaghetti at lunch was very weak and dry and had no spaghetti sauce when served.

Based on interview and record review, the facility failed to accommodate a resident's food allergies and preferences. This applies to 1 of 3 residents (R1) reviewed for food allergies in a sample of 4. The findings include: On 5/20/25 at 12:05 pm, R1 said that she is allergic to shellfish, squash, all melons in the melon family, bananas, and cucumbers. R1 said that she made the facility aware of her allergies, but she continues to be served food she is allergic to. R1 said that on 5/18/25, she was served a salad with a cucumber on it, and she told the staff, and on 5/17/25 she was served melons on her lunch tray, and she told the CNA (Certified Nurse's Assistant). R1 then showed a picture on her phone of a meal tray with a bowl of melons on the tray. On 5/22/25 at 10:45 AM, R1 said that she is still being served food that she is allergic to. R1 said that on the previous Monday (5/19/25) she was served a salad with a cucumber in it again. R1 reiterated that she is allergic to cucumbers, and she has told the facility. On 5/20/25 at 12:59 PM, V4 (CNA) said that R1 has gotten food on her tray that she is allergic to. V4 said 1-2 weeks ago, she had served R1 her meal tray during the day and the tray had melons on it. V4 verified that R1 told her that she was allergic to melons. On 5/20/25 at 2:01 PM, V6 (Dietary Manager) said that he had no knowledge of R1's allergies and he was aware R1 had gotten cucumbers. V6 pulled R1's 5/20/25 lunch meal ticket out of his pocket which showed R1's food allergies included melons and cucumbers, but the word cucumber was lined out in ink and in handwriting above the word cucumber, was the word cantaloupe, and above the list of food allergies was handwritten in ink, Dislikes: cucumber:. On 5/20/25 at 1:46 PM, V5 RD (Registered Dietitian) said that she did not ask R1 if she was allergic to cucumbers and her daughter told her that R1 dislikes cucumbers. V5 said that R1 should not be served any food that she is allergic to. V5 said that if someone has a food that they are allergic to, an array of things could happen including having a GI reaction, respiratory reaction, skin hives, swelling, edema, and even as far as an anaphylactic reaction. On 5/22/25 at 2:30 pm, V1 (Administrator) said that he was made aware of over a month ago that R1 was served a cucumber in her salad. V1 said that in the middle of April the facility held a care conference for R1 and R1's food allergies and food preferences including cucumbers were addressed in the conference. V1 said that the facility is aware that R1 is allergic to melons but thought that R1 only had a dislike for cucumbers; not that she was allergic to them. V1 said that his expectations are that residents are served food in accordance with their dietary orders, including dietary food restrictions and preferences. On 5/22/25 at 12:28 pm, V2 DON (Director of Nursing) said that she was aware that R1 was served a house salad with a cucumber on it. V2 said that she was also made aware of R1 being served melons as well by the CNA who served it to R1. V2 said that V4 (CNA) told her that she served R1 melons, but she did not know that a honeydew was a melon. V2 said that it is important that residents don't get served food that they are allergic to because it can lead to anaphylactic shock or even death. V2 said that her expectations are that the staff do a double check to ensure they are following any food allergies. R1's face sheet showed 4/4/25 allergen: Melon family, Squash, Raw Bell Pepper, Cantaloupe. R1's 4/22/25 Order Summary Report showed 4/22/25 General diet Allergic to melon family, raw bell peppers, squash, fish, shellfish, banana, and cantaloupe. R1's 4/8/25 care plan showed, R1 will benefit from liberalized diet with supplementation. Has various nutritional allergies and preferences concerning her diet as indicated in her record. The care plan showed interventions including encourage resident to indicate further preferences with dietary management. Offer substitutions for food she's allergic to or intolerance of. Provide, serve diet as ordered. Resident provided with dietary menu slip to complete her preferences. On 4/29/24 the facility resident Grievance/Complaint form showed R1's daughter called to go over her mom's preferences because her mom gets nauseous and has a poor appetite and has dislikes. The Actions or Recommendations showed that the menus are done with R1 on a weekly basis, R1's tray is double checked for lunch and breakfast by dietary director and for dinner by PM supervisor. The Resolution showed, R1 will be served exactly what she is asking for. There will not be unwanted items on her tray. The facility's food Allergies and Intolerances policy dated June 2023 showed that the residents with food allergies or intolerances will be identified and steps will be taken to prevent residents' exposure to allergens. In accordance with a resident's care plan the culinary service department will be informed of residents with food allergies and intolerances meals will be specially prepared for residents with severe food allergies so that cross contamination with allergens does not occur. Residents with food intolerance and allergies will be offered appropriate substitutions for foods that they cannot eat .

Based on observation, interview, and record review, the facility failed to ensure a resident was free from verbal and physical abuse. This applies to 1 of 3 residents (R73) reviewed for abuse allegations in the sample of 18. This failure resulted in R73 feeling traumatized, unsafe, being afraid to sleep, and developing insomnia. The findings include: R73's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE], with diagnoses that include Necrotizing Fasciitis, Severe sepsis, Pneumonia, Acute respiratory failure, Alcohol Abuse, and Long Term use of antibiotic. R73's Minimum Data Set (MDS) dated [DATE], showed R73 to be cognitively intact. The initial facility reportable dated November 21, 2024, showed the following: While in the hallway a miscommunication occurred between R73 and V12 (CNA/Certified Nursing Assistant), after which R73 began using his cell phone to video V12. Upon noticing this, V12 moved the phone out of view, which led to R73 becoming upset. The facility's final reportable dated November 29, 2024, showed the following: On November 29, 2024, the facility completed a thorough investigation into an incident involving R73 and V12. The investigation was initiated after R73 became upset during an interaction with V12 in the hallway, where V12 moved R73's cell phone out of view after noticing R73 was recording her. R73 reported feeling upset about the interaction but did not express feeling of fear or alleged physical harm. V12 stated that the phone was moved to avoid being recorded, which was perceived as intrusive or unwanted, and emphasized that there was no intent to escalate the situation. Witness interview and resident interviews revealed no concerns about V12's behavior. V12 was suspended pending the outcome of the investigation. The review concluded that V12's actions, while upsetting toward R73, did not constitute abusive behavior. The interaction appears to have resulted from a misunderstanding rather than intentional harm. The facility's investigation report showed no documentation of V14's interview. V14 was the nurse at the nurse's station during the altercation. On December 9, 2024, at 1:57 PM, R73 stated he was verbally abused and physically assaulted by V12 (Certified Nursing Assistant/CNA). R73 stated that he put his call light on and V33 (CNA) answered the light, and he told her he needed his urinal emptied. R73 stated that V33 said she was going to tell his CNA (V12) to empty the urinal. R73 stated that after a few minutes he wheeled himself to the nurse's station and he saw V14 (Registered Nurse), and he asked V14 who his CNA was. R73 stated that V14 stated his CNA was V12 (CNA) and she was in the internet/ room across from the nurse's station. R73 stated he went and asked V12 to empty his urinal and she (V12) told him to do it himself and started cursing at him. R73 stated he was on the phone with someone, and they could hear what was going on and they told him to record it. R73 stated he started recording. R73 stated V14 was sitting at the nurse's station during the altercation. R73 stated he asked V12 again if she was going to empty his urinal and she started screaming and cursing at him and then walked towards him and as she was passing him, she (V12) hit his right hand and arm, and his phone went flying out of his hand. R73 showed the video to the surveyor at 2:00 PM on December 9, 2024. On December 10, 2024, at 10:43 AM, R73 stated when he asked V12 to empty his urinal and she started yelling and cursing at him, he was shocked that she was acting like that. R73 said at the nurse's station he just asked her, if she could please empty his urinal. R73 became teary eyed, and said he is seeing a therapist because, now he has trust issues. R73 stated that V14 was there and did not say anything or do anything. R73 stated he was thinking of how to escape. R73 stated he went into his room and started thinking about what had just happened and he came back out to speak to the supervisor. It was around shift change and V16 (RN) was at the nurse's station and the girl that assaulted him was still at the nurse's station with V33, and V14. R73 stated they were all talking to each other. R73 stated he then asked to speak to the supervisor and V16 said if you decide to report this, she will have to document what he (R73) did. R73 stated he didn't do anything. R73 stated he never yelled at V12 or anyone. R73 stated then V16 asked if he was sure he wanted to call the police and he said yes. They were all talking at the nurse's station, so he went back to his room. R73 stated then V15 (Nursing Supervisor) and V16 came to his room. V16 asked what happened. R73 stated he told them what happened and V15 stated the administrator would talk to him tomorrow and they left. R73 stated they didn't ask him if he was okay or anything. R73 stated he was thinking that the person that assaulted him is still here and I'm defenseless. R73 stated he felt like there was an intent to keep him from reporting it to the police. R73 stated, he then went back to the nurse's station and asked them to call the police and V16 told him that it would be better if he called from his phone. R73 stated he went back to his room and called the police. R73 stated the police came and interviewed him and the first thing the officer said was that the V12 told the police that R73 singled her out. R73 then started crying with lots of tears rolling down his face at this point and surveyor got him some tissue. R73 stated that V12 told the police that he cornered her in his wheelchair so she swung at him because that was the only way she could get away from him. R73 stated he showed the officer the video and the officer went and got V15 and told V15 what V12 said and what the video showed. R73 said the officer then asked him if he wanted to file Battery charges and he said yes. R73 stated that the officer told V15 it was R73's right to file charges. R73 stated if he had not recorded it, no one would have believed him. R73 stated no one asked him if he was okay that night, they didn't examine him or anything. R73 stated his right hand was stinging after the CNA knocked the phone out of his right hand. R73 stated that he thought it was a little swollen, so he requested an x-ray. R73 stated the next morning the social worker, the administrator and a couple other people came and asked if he was okay. R73 stated he showed V1 (Abuse Coordinator/Administrator) the video of the altercation and V1 asked for a copy of it, but R73 did not give him one. R73 stated he does not feel safe in the facility, and he put in a request to be transferred. R73 stated after the altercation he called around to see what facilities took his insurance. R73 stated he is afraid at night and is watching closely who is here because no one helped him, and they tried to cook up a story about him. R73 was teary eyed and said they could have had me arrested. R73 stated he is suffering from sleep deprivation since this happened, he is sad, and afraid of retribution. R73 was still visibly shaken and stated that it was so abrupt and shocking. On December 10, 2024, at 1:34 PM surveyor went to go review video footage again with another surveyor. R73 stated he fears retribution. R73 stated he felt defenseless when the altercation with V12 happened because I couldn't even run away if I needed to. R73 stated again he doesn't feel safe and started to cry with tears rolling down his face. R73 again stated he started calling numbers that the hospital gave him that accepted his insurance. R73 started crying again and said had he known he needed to involve the facility to help him with the transfer, he would have contacted them sooner. As R73 continued crying he said no one ever asked how he was doing that night. On December 9, 2024, at 1:57 PM and on December 10, 2024, at 1:34 PM, the video footage of the altercation was reviewed and showed the following: R73 asked V12 if she would empty his urinal. V12 gets very upset and starts yelling at R73 and stated he pissed her off, she is going to leave the urinal and walk the hell out of the facility. V12 continues screaming while leaning in towards the resident that she is not meant to do what he can do for himself. V12 then stated so go do it yourself, whatever the F*** happens let it happen. I'm not going to do it, whatever the F*** happens let it happen as she walks past the resident and enters the nurse's station. The nurse's station has two exits on either side of V12. V12 chooses the one closest to R73 and she walks about 8-10 feet towards the resident and the video continues to show V12's hand coming towards R73's phone, the screen then becomes obscure and V12 continues to scream in the background. Immediately afterwards R73 can be heard saying to someone, you are my witness she just put her hands on me. On December 10, 2024, at 12:05 PM, V1 stated the facility does not have a video of the incident because the video recycles every week. V1 stated he did not view his facility's video footage of the incident that took place at the nurse's station where there is a video camera. V1 stated he did not request a police report of the incident. The Police report dated November 20, 2024, at 11:50 PM, showed that the responding officer interviewed V12, and she stated that she got into an altercation with R73 regarding him demanding services, cornering her in a room, and rudely asked if she was on break. The report goes on to say that V12 stated R73 then started following her in his wheelchair and recording her. V12 said she tried to get away from R73 and hit his phone out of his hand in the process. The report also shows R73 stated he was upset that V12 was not doing her job and V12 started yelling and cursing, when R73 asked her to assist him, so he started recording her (V12). R73 claimed V12 walked up to him and smacked that phone out of his hand. The responding officer incident report also stated that before the physical altercation with R73, V12 nurse had a different exit where she could have avoided R73 altogether. The police report also showed that V12 was arrested on scene on November 21, 2024, at 12:32 AM and was issued a citation to appear in court for battery. On December 10, 2024, at 4:02 PM, V13 (Police Officer) stated he interviewed the alleged CNA perpetrator (V12). The staff was on the CNA's side and stated that R73 and V12 had a verbal altercation the day before. V13 stated that R73 stated that he rang his call light, and another CNA came and said she would get his CNA to dump his urinal. V13 stated that after no one showed, R73 went looking for his CNA and found her in the room across from the nurse's station. V13 stated that R73 said he asked the CNA if she was on her break, then the CNA and got aggressive and said his call light was not illuminated and she started screaming and cursing at him. V13 stated then R73 said he started recording her. The officer stated that the V12 stated R73 was following her around in the wheelchair. V13 stated that the CNA was about 12 feet away according to the video and she initiated and approached R73 and smacked the phone out of his hand. V13 stated V12 hit R73 hard enough to knock the phone from his hand. V13 stated V12 did not have a professional demeanor. V13 stated he found her aggressive in the video. V13 stated V12 was cited for battery. V13 stated that the definition of Battery is making contact however slight with another subject. V13 stated that V12 originally said R73 cornered her and as she was trying to get pass him is when she knocked the phone out of his hand. V13 stated that was not the truth based on the video he viewed. R73's Psychiatry follow up note by V9 (Psychiatric Nurse Practitioner) dated December 2, 2024, showed the following: Patient's mood appears to be up and down, asked to assess resident by staff due to episodes of agitation. Resident guarded on exam and stated he was physically attacked by a staff member and doesn't feel too safe. He thinks he will benefit from talk therapy. Denies prior Psychiatric history and reports insomnia and agrees to start melatonin. On December 10, 2024, at 3:48 PM, V9 stated he went to assess R73 for difficultly sleeping and was surprised that R73 talked about being assaulted. V9 stated that the resident said to him. Wouldn't you be agitated if this happened to you. V9 stated R73 told him he wasn't sleeping deeply at night because he was afraid that he will be attacked by staff. V9 stated he can understand not being able to sleep if he had that concern. V9 stated he recommended V9 be seen by psychologist for therapy. V12's employee statement dated November 20, 2024, stated that she told R73 that he walked all the way from his room just to yell at her over a urinal he could have emptied himself or the last shift should have emptied for him. V12 stated that R73 immediately took out his camera and started recording her and she repeated the same thing to him and pushed the camera away from her face and walked away. V16's nursing note dated November 2, 2024, at 11:55 PM showed the following: while walking up the hall, resident was observed wheeling around the nurse's station screaming at the CNA, He pointed at the nurse on duty and said, Didn't she smack my phone out my hand? the nurse on duty said, I did not see. The resident looked at writer and said. She smacked the phone out of my [hand] and that is assault. The writer asked the CNA to leave the area and she stated, He recorded me! and resident to return to his room so that supervisor could be notified. Immediately all resident's needs were reassigned to the alternate CNA on duty, Resident informed writer and supervisor that he wanted to press charges and called 911. The police arrived and spoke to R73, writer, and all other staff. On December 11, 2024 at 11:59 AM, V14 stated she remembers the altercation with R73 and V12 on 11/20/2024. V14 stated it happened at the nursing station. V14 stated she was at the nurse's station, she heard loud screaming and got up saw them going back and forth. V14 stated she told V12 to lower her voice because people were sleeping. V14 stated R73 was looking around and then found V12 and started talking at the Cybercafe (across from the nurse's station). V14 stated she heard them screaming and told them to calm down. V14 stated that R73 said immediately after it happened that V12 knocked the phone out of his hand. V14 said she did not see it happen. On December 12, 2024, at 12:47 PM, V14 stated that at no point during the altercation with R73 and V12 did she try to remove R73 from the situation. V14 stated they were not close together. V14 stated she did tell V12 to stop screaming at the R73, but V12 was so angry and told V14 that she was not her boss and couldn't tell her what to do. V14 stated she should have documented it but wasn't aware of the facility's protocols because she is agency staff. Progress note dated November 11, 2024, showed that R73 complained of pain to his right hand at a level of 7/10 pain level. Pain medication was given and an x-ray of his right hand and wrist was ordered. Employee Discipline Form dated November 27, 2024, showed V12 was terminated for violating rule 6 of the SEIU agreement as outlined in the appendix. The violation occurred when the employee knocked the phone out of the hand of a resident, an action that constitutes inappropriate conduct. In addition, resident stated that his phone screen was cracked due to it being knocked out to the floor which violates Service Employee International Union (SEIU) rule #6- Willful destruction or damage of property belonging to facility or persons. This behavior is considered a breach of workplace standards and rules, leading to the employee's termination. The facility's Abuse Prevention Policy showed the following: 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. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal abuse is the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability.

Based on observation, interview, and record review the facility failed to monitor refrigerator temperatures, failed to label and date potentially hazardous food items, and failed to store food to prevent cross contamination of food items. The facility also failed to ensure dietary staff use facial hair covers while in the kitchen. This failure affects all residents receiving food from the kitchen. The findings include: The facility roster dated December 9, 2024, showed census of 74 residents in the facility. The diet type report dated December 9, 2024, showed 71 residents receive food from the facility's kitchen. On December 9, 2024, at 9:27 AM during the initial tour of the kitchen with V20 (Dietary Manager) the reach in refrigerator #1 had milk and cheeses in it and no thermometer in the refrigerator. The thermometer that is a part of the refrigerator was not functional. V20 stated that staff checks temperatures and records these temperatures in a logbook. The logbook of the refrigerator temperatures for December 5 through December 9, 2024, were reviewed and noted to be blank. V20 stated he did not check the temperature of the refrigerator today. V20 was also observed with a mustache and beard and V20 was not wearing a beard covering during this tour. In the walk-in refrigerator, a tray of partially covered shredded pork was in the walk-in refrigerator, with a date of 12/13/2024. The label did not identify the food item. V20 confirmed that the food item should be completely covered to prevent contamination. In the walk-in freezer there was a large aluminum pan of what V20 described as pork chops. The pork chops had cellophane plastic on top of them that was not completely sealed all around. The pork chops had frost around them, and a thick layer of ice on the top of about half of the pork chops. The ice was about 1.5 inches thick in some places. There was no date on the pork chops. V20 stated that the fan is dripping on the pork chops and stated that the facility is in the process of fixing the fan. V20 stated he will throw the pork chops away today. On December 11, 2024, at 9:20 AM with V20, observed the pork chops that were not labeled and almost completely covered in a thick layer of ice still in the freezer, in the same spot they were on 12/9/2024 and 12/10/24 (below the leaking fan.) V20 then took them and threw them in the garbage. V20 was not wearing a beard covering. On December 9, 2024, at 10:34 AM, V20 was not wearing a beard covering while preparing the pureed diet. On December 9, 2024, at 12:06 PM, V20 was not wearing a beard covering while slicing a pork loin. On December 9, 2024, at 12:35 PM, V20 started plating the resident's food without wearing a beard covering. On December 12, 2024, at 3:08 PM, V21 (Cook) and V22 (Dietary Aide) were in the kitchen and stated that staff should cover the hair on their head and face when in the kitchen. The facility's Culinary Services Inventory, Purchasing and Storage Policies stated the following: Check meat, fish, and poultry for signs of freezer-burn and refreezing. Assure that all packaging of food is clean and unbroken. All food products must be stored in their original container, except when opened or processed; then, they may be stored in a covered container. n. all products should be clearly dated as they are removed from the original container to maintain First-in-First out (FIFO) rotation. 4b. Dairy Products: check temperature, it should be 40 degrees Fahrenheit or below. All opened foods should be kept in containers that prevent contamination. Such containers should be clearly labeled with the common name of the food. Frozen storage 3. Frozen foods should be wrapped or otherwise containerized in a manner that prevents oxidation (freezer-burn). The facility's Team Member Health and Personal Hygiene policy dated June 2024 showed the following: all mustaches and beards must have a beard covering.

Based on interview and record review the facility failed to file and respond to resident grievances in accordance with their policy. This applies to 8 of 8 residents (R9, R10, R14, R15, R23, R49, R56, R61) reviewed for grievances in the sample of 18. The findings include: During the resident interview meeting on December 10, 2024, at 10:05 AM, the consensus of the attendees (R49, R61, R9, R56, R23) was that they were not aware of the facility's grievance process and did not receive feedback from the facility in response to their concerns. V17 (Ombudsman) provided a copy of the facility's grievance form to the resident attendees at the meeting, and the resident attendees stated they had not seen the grievance form before. R61 (Resident Council President) and R49 (Resident Council [NAME] President) both looked closely at the form and stated they had not seen the grievance form before. During the resident meeting, R56 stated she reported to V28 (Social Services/Medical records) during her care plan meeting over the summer, that she was missing clothing items and a phone charger and cord. Review of the grievance forms from February 1 through December 10, 2024, showed there was no grievance for R56's concern regarding missing clothing and a phone charger and cord missing. R56 stated she has not gotten a response from the facility regarding her missing items. During the resident meeting, R49 stated she reported a missing razor, and phone charger to V23 (Social Services) and V1 (Administrator) about 3 months ago. R49 stated she also reported R15's (R49's father) missing coat to V23 and V1 at the same time. Review of the grievance forms from February 1 through December 10, 2024, showed there was no grievance for R49 or R15 filed. R49 stated she has not gotten a response regarding her missing items. Review of the resident council meeting minutes showed concerns were raised, but no grievance form completed, or response provided to the Resident Council. The Resident Council Meeting Minutes dated March 19, 2024, April 16, 2024, May 21, 2024, and June 18, 2024, all showed the Resident Council identified staff using their cell phones while providing care to residents, was a distraction for staff and requested staff not use their cell phones while providing care. V1 provided a document dated September 11, 2024, titled CNA In service. V1 stated that this was the education provided to staff regarding the resident's concern. However, during the resident interview meeting on December 10, 2024, at 10:05 AM, the resident attendees (R49, R61, R9, R56, R23) all agreed staff using cell phones while providing care remains a problem and has never been resolved. On December 9, 2024, at 10:47 AM, R14 stated he does not get his clothing back from the laundry and has told the CNA and Nurses but could not recall the name of who he told, but that the missing clothing items had been going on for weeks. Review of the grievance forms from February 1 through December 10, 2024, showed there was no grievance form filed on behalf of R14. On December 10, 2024, at 5:00 PM, R49, R23, and R10 were playing cards in the dining room and asked to speak with the surveyor. R10 stated she had a concern regarding her incontinence care not being provided timely and this was an ongoing problem. R10 stated she had previously told V28, who had been working at the reception desk at the time of her concern. R10 stated V28 told her at the time she would file the grievance form on her behalf regarding incontinence care not being provided timely. Review of the grievance forms from February 1, 2024, through December 10, 2024, showed there was not a grievance form filed on R10's behalf regarding incontinence care. R10 had a grievance filed on her behalf on June 8, 2024, that showed R10 needed more boxes of tissues, and on December 2, 2024, that showed R10's phone charger was missing and replaced. R49, R23 and R10 each stated incontinence care is not being provided timely and it is not being addressed by the facility. The facility's policy titled Grievance dated October 2021, showed General: It is the policy of the facility to allow and encourage residents and their families to express grievances and concerns they may have regarding the facility, services, and staff Responsible Party: All facility staff .Guideline: .1. Posted signage required advising residents and their representatives of their right to voice a grievance. The sign must include: The Grievance Officer's contact information including name, address/phone number, email address; state QIO contact information; State Survey Agency information; State Ombudsman information .2. The resident and representative must have notification that Grievances/concerns may be filed anonymously either in writing or by postings. 3. A response in writing may be requested by the resident or representative .4. The resident or representative has the right to expect the facility to make prompt efforts to resolve grievances .5. Any staff member in the facility may receive a grievance or complaint from a resident or representative .10. The staff member will submit the grievance form to the appropriate department head/designee for resolution .13. The Administrator will be the designated Grievance Officer and will review the completed form and action taken and do any follow up necessary.

Based on observation, interview, and record review the facility failed to perform skin assessments in order to prevent pressure injuries from developing for 1 of 5 residents (R2) reviewed for pressure in the sample of 6. This failure resulted in R2 developing a facility acquired pressure injury that was not identified until it was a Stage 3. The findings include: On 9/3/24 at 11:50 AM, R2 was dressed and sitting bedside in his room. R2 had a low air loss mattress on his bed. R2 said he has a pelvic fracture in two places which causes him some pain. R2 said he is able to walk with a walker, move in bed, and takes himself to the bathroom. R2 said he got the low air loss mattress when they found a sore on his bottom. R2 said he didn't have any sores when he came in. R2's Progress Noted dated 8/6/24 shows R2 was admitted to the facility from the hospital, is alert and oriented to person, place, time, and situation, and is able to make his needs known. The same note shows No open areas, skin is intact. R2's Progress Note dated 8/8/24 shows R2's skin is intact. R2's Progress Note dated 8/9/24 shows skin intact. There are no progress notes regarding R2's skin until 8/18/24 when R2 was found with a Stage 3 pressure injury to his sacral area. R2's Wound Management Detail Report dated 8/18/24 shows R2 was found to have an in house acquired Stage 3 pressure injury sacrum area measuring 1 x 1 cm with serous drainage. R2's Wound MD Progress Note dated 8/29/24 shows R2 has a Stage 3 pressure injury to coccyx, measuring 1.5 x 0.3 x 0.1 cm with scant serous exudate. On 9/4/24 at 10:40 AM, V11 Nurse Practitioner said R2 is alert and uses a walker with minimal assistance. V11 said she was notified of R2's pressure injury on his sacrum when it was found at a stage 3. V11 said pressure injuries should be found before they are a Stage 3 and staff should be doing skin assessments during care. On 9/4/24 at 11:20 AM, V10 Wound Licensed Nurse Practitioner said R2 was admitted when she was on vacation. V10 said when she returned from vacation, she did a skin assessment on all of the new residents and found a Stage 3 pressure injury on R2's bottom. V10 said she notified V11 and got treatment orders and put pressure reducing interventions in place. V10 said Certified Nursing Assistants (CNA) look at skin daily during care and then on shower days the CNA is supposed to call the nurse into the shower room to do a full skin assessment. V10 said the nurse signs off on the shower sheet that a skin assessment was done and then if there were new openings the nurse would call the NP and get orders, let her know of the wound, and notify the Director of Nursing. V10 said R2 is alert and able to turn and reposition himself but had pain from his fractures and needed reminders to reposition. R2's Bath and Skin Report Sheet for August 2024 shows R2 received a shower on 8/8/24, refused on 8/12/24, and received a shower on 8/15/24, and then on 8/18/24. This Report has initials in the Nurse Signature column for all showers. The shower on 8/15/24 is completed in pencil and has a check mark on the open area column and an x on the sacral area on the body diagram. On 9/4/24 at 12:55 PM, V10 reviewed R2's Bath and Skin Report with this surveyor. V10 said R2's shower on 8/8/24 and 8/15/24 have an x and a check mark in the open area column but the body diagram has no marking on 8/8/24 only on 8/15/24 where there is an x on the sacral area. V10 said the nurse initialed both showers but she was unable to decipher who the initials were. V10 said if the CNA found an open area they are supposed to tell the nurse. V10 reviewed the staff schedule for 8/15/24 and could not determine who the initials were for the nurse or the CNA and said it could have been agency. V10 said the CNA probably didn't tell the nurse and the nurse didn't actually do the skin assessment and just signed off on the form. On 9/4/24 at 1:10 PM, V4 Registered Nurse said she did work on 8/15/24 but that was not her signature on the shower sheet. V4 said she was not told of R2 having a wound until V10 found it on 8/18/24. V4 said the nurse is supposed to go into the shower room and look at the resident's skin and then sign the shower form. On 9/4/24 at 1:15 PM, R2 said that no one said anything to him about an open area on his bottom during his showers and the nurses didn't come in during his showers to look at his skin. R2 said the nurse came into his room, did a skin check and found the sore on his bottom. The facility's undated Pressure Ulcer and Wound Prevention/Management Program shows Resident's skin will be inspected during daily bathing, dressing, showering, and incontinency care with special attention to bony prominences by CNA and staff nurses.

Based on observation, interview, and record review the facility failed to ensure a resident (R1) was free of physical abuse from another resident (R2) for 2 of 3 residents reviewed for abuse in the sample of 3. This failure resulted in R2 entering R1's room and hitting R1 over the volume of a TV. R1 sustained multiple facial injuries; abrasions to the left hand and ear; and required evaluation and treatment in the emergency room . The findings include: On 4/23/24 at 12:04 PM, R1's frail body was tilted to the right to watch the TV. R1's entire face was covered with bruises of various colors and stages of healing. R1 had a golf ball sized hematoma (blood filled lump) near his left cheek and eye. R1 had a dressing to the left side of his nose. R1's face was swollen, and his facial features were distorted. R1 stated, I was attacked by the guy next door because he said my TV was too loud. That's all I want to say without my lawyer present. R1 used his right arm to hold the remote control and adjust his blankets. R1 didn't use his left arm during the interview. R1 did not make eye contact during this interview and frequently looked from the TV to the floor. R1 denied pain at this time. R1's Facesheet printed 4/23/24 showed diagnoses to include, but not limited to: Stroke with left side weakness, protein-calorie malnutrition, nontraumatic subarachnoid hemorrhage (brain bleed), hyperlipidemia, hypertension, major depressive disorder, anemia, anorexia, contracture to unspecified joint, insomnia, and gout. R1's Physician Order Sheet dated 4/1/24-4/23/24 showed a new order on 4/19/24 to apply a cold back to R1's left eye/forehead for 20 minutes at a time every shift for 24-48 hours. Also, monitor bruising/swelling to left eye and neck and notify the Provider for any signs and symptoms of a complication. Monitor laceration to the left side of R1's nose, abrasion to left ear and left ring finger. This document showed R1 had new orders for treatments to the left ear, left ring finger, and left lateral nose. R1's facility assessment dated [DATE] showed he had moderate cognitive impairment; did not demonstrate physical or verbal behaviors towards others; did not reject care; had impairments on one side of his upper extremities; and impairments on both sides of his lower extremities; and was dependent on staff assistance for toilet hygiene, shower/bathing, and chair to bed transfers. R1's Care Plan initiated 4/19/24 showed R1 was at risk for abuse due to needing assistance with ADLs (Activities of Daily Living). R1's Care Plan initiated 4/19/24 showed, Resident has (lacerations, bruises, etc.) r/t (related to) trauma, laceration left side of nose, abrasion left ear, left ring finger, bruises left eye/forehead and neck . R1's Care Plan initiated 11/17/22 showed R1 had limited ability to move in bed related to left hemiplegia and hemiparesis. R1's Progress Notes showed on 4/18/24 at approximately 9:19 PM, V18 (LPN - Licensed Practical Nurse) heard resident yelling Nurse. V18 went to R1's room and found him lying in bed with a golf ball sized lesion to his left cheek, open wound to left cheek, and a small, dime-sized open wound to his left ear. There was a moderate amount of hemorrhaging (bleeding) from all sites. When asked what happened, R1 stated, the guy in the wheelchair from next door came in here and he hit me. R1's Ambulance Report dated 4/18/24 showed R1 was a victim of an assault. This report showed R1 was lying in bed with a 4 inch hematoma just distal to his left eye and another 2 inch hematoma to his left cheek. This report showed R1 stated, My neighbor attacked me because my TV volume was too loud. R1's ED (Emergency Department) Attending Note dated 4/18/24 showed, R1 is a [AGE] year old male with a past medical history of HTN (hypertension), HLD (hyperlipidemia), CVA (stroke) with residual left hemiplegia who is bed bound, who presents to the emergency department for evaluation after alleged assault. Patient reports that he was attacked by his neighbor who struck him in the face with the TV remote multiple times. Has a large hematoma to (his) face . Physical Exam: . Large hematoma over left cheek . This document showed a laceration repair was required for a 2 cm x 1 cm laceration on the left cheek. This required 4 steri-strips to close the laceration. This document showed R1's ED diagnosis was Traumatic injury of the head and assault. R1's Nursing Admission Evaluation dated 4/19/24 showed bruising and swelling to R1's left eye, forehead, and neck; a 3 x 1.5 cm laceration to his left cheek/lateral nose with 5 steri-strips; a left ear abrasion 0.5 x 0.5 cm; and an abrasion, swelling, and bruise to left ring finger. This assessment was completed by V13 (Wound Care Nurse). R1's Provider Note by V20 (NP - Nurse Practitioner) showed R1 was recently sent to the emergency roiagnom on [DATE] for facial contusions after a physical assault. This note showed R1 was assaulted by another resident and sustained wounds to his left cheek, left ear; bruising around his left eye; and steri-strips were applied to the left side of R1's nose. This note showed R1 had bruising and swelling around his left eye. The facility's abuse investigation contained a timeline that showed on 4/18/24 at 8:55 PM, R2 self-propelled his wheelchair into R1's room. At 8:56 PM, R2 self-propelled his wheelchair out of R1's room and the CNA (V6) heard R1 cry for the nurse and went into the room. At 9:25 PM, the police arrive at the building and at 9:40 PM the paramedics arrived. This timeline showed that R1 was taken to the hospital at 9:45 PM by ambulance and at 10:06 PM, R2 was removed from the building by the police, in handcuffs. R2's Facesheet printed 4/23/24 showed he had diagnoses to include, but not limited to: COPD (chronic obstructive pulmonary disease), major depressive disorder, hypertension, diabetes, and osteoarthritis. R2's facility assessment dated [DATE] showed he was cognitively intact; had no behaviors against others; and was independent for toilet hygiene, shower/bathing, personal hygiene, bed mobility, sitting, standing, and transfers. R2's Care Plan dated 4/18/24 showed R2 demonstrated behavior distress related to ineffective coping mechanisms involving an incident with a fell ow peer on 4/18/24. The interventions include but are not limited to: Explain to me the Rules of Conduct and my obligations to treat others with dignity and respect at all times. Ask me to treat others as I would like to be treated. If I become verbally or physically abusive attempt to calm me by explaining to me that this is not the way, we talk/behave and that we do not touch other people. If talking to me is not successful in stopping the behavior, try to walk with me to a quiet area, away from other individuals. R2' Progress Notes dated 4/18/24 showed R2 physically assaulted another resident, causing injuries to the other resident. V14 (Nursing Supervisor) interviewed R2 after the incident. R2 admitted to the act because the volume of the R1's TV. R2 verbalized that he did swing at R1, and this resulted in R1's injuries. V14 called 911 to report the incident to the local police and R2 was later taken to the police station. On 4/23/24 at 11:24 AM, V3 (local fire Chief) said he was not at the facility on the evening of 4/18/24, but he did receive a call that evening from the paramedics on scene. V3 said one resident had been assaulted by another resident. V3 said the victim (R1) had been taken to the emergency room and the perpetrator (R2) was charged with battery. V3 said he remembers this because it was an odd circumstance. V3 said R2 was in a wheelchair, so the fire department had to assist R2 in getting to the police station. On 4/23/24 at 1:18 PM, V2 (DON - Director of Nursing) said she was not in the building when the incident happened. V2 said V14 (Nursing Supervisor) called her and reported that R2 went into to R1's room and hit R1 because of the volume of his TV. R2 is very alert and oriented. R2 is responsible for himself and is able to move around in wheelchair without assistance. V2 said the local police took R2 to the police station and processed him. V2 said R1 is alert and oriented but can be forgetful at times. V2 said R1 is able to make his needs known and prefers to be left alone. V2 said R1 reported that R2 hit him in the face with the remote. V2 said on 4/18/24, R2 admitted to V14 (Nursing Supervisor) that he had hit R1. V2 said R1 had extensive bruising to his face and neck. V2 said R1 is refusing to talk to V1 (Administrator), V15 (Social Services Director) and V16 (LCSW - Licensed Clinical Social Worker). V2 said this incident would be classified as physical abuse and the facility had determined that the incident did happen. On 4/23/24 at 1:44 PM, V13 (Wound Care Nurse) said she was not present when R2 hit R1, but she had completed a skin assessment on R1 after he returned from the hospital. V13 said R1 had steri-strips to a laceration on the left side of his nose. There was bruising and swelling to his left eye and there was a scratch on his left ear and ring finger. V13 said R1 told her he got beat with a TV remote. V13 said she had seen R1 before the incident and he didn't have any bruises to his face. V13 stated, His face was pretty bruised. He had several traumatic injuries and I'm guessing his hand was a defensive wound. His injuries were pretty extensive. On 4/23/24 at 1:50 PM, V14 (Nursing Supervisor) said she was notified by V6 (CNA) that R1 had been hit. V14 said she went to R1's room and immediately saw the facial injuries. V14 stated, I asked [R1] what happened, and he replied, The guy in the wheelchair hit me. I wasn't sure who he was talking about then, [V18 - LPN] said it could be [R2]. I went to R2's room and he admitted to hitting [R1]. He told me that he asked [R1] to turn down his TV and [R1] said NO!' [R2] said [R1] swung at him and he swung back. [R1] had a bruise on his left check and blood coming from the crease of his nose. He also had injuries to his left ear and ring finger. [R1] told me that [R2] came in his room and demanded he turn down the TV and [R1] said No and [R2] started hitting him (R1). [R1] went to the hospital for his injuries and [R2] was placed in handcuffs and arrested by the police. The whole situation was very surprising. I hadn't known [R2] to be aggressive before. On 4/23/24 at 2:12 PM, V6 (CNA) said she was charting at the nurses' station when she heard screaming. V6 said she went to R1's room and saw him in bed and his face was bleeding. V6 said she reported it to the V14 (Nursing Supervisor) right away. V6 said R1 told her, the old man in the wheelchair hit me. V6 said the only person she saw in the room was R1's roommate and he was sleeping in bed. V6 said she didn't see R2 in R1's room, but R2 could self-propel his wheelchair independently. On 4/30/24 at 10:14 AM, V18 (LPN) said she didn't witness the incident. V18 stated, I was the nurse for [R1 and R2] that night. I'm not sure what happened. I just heard [R1] yelling for help. The CNA (V6) and I went to his room, but [V6] got there first. When I went in [R1's] room he was on his back. He was bleeding on his face, cheek and mouth. He said, the guy in the wheelchair came in and hit me. I completed a head to toe assessment and notified the Administrator. I provided first aide to [R1] and [V14 - Nursing Supervisor] came to help me. I did not interview [R2] about the incident. [V14 - Nursing Supervisor] did that interview. On 4/30/24 at 11:00 AM, V20 (NP) said she was not present when R1 was hit, but she did see R1 the next day. V20 said she was familiar with R1. V20 said when she arrived on 4/19/24 she noticed that R1 had a lot of new bruising and swelling to his face. V20 said R1 had steri-strips to the left side of his nose; bruising to his left eye and neck; and abrasions to his left ear and ring finger. V20 said all of R1's injuries were related to the physical altercation with R2. V20 said R1 would not discuss the incident with her. The facility's undated Abuse Prevention Policy showed, 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 . 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 . Definitions: .Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment .

Based on observation, interview and record review, the facility failed to provide safety measures during transfer, bed mobility and incontinence care to a resident that is at high risk for fracture. This failure resulted in R1 sustaining a displaced, spiral fracture of the left lower leg. This applies to 1 of 3 residents (R1) reviewed for ADL (Activities of Daily Living) care. The findings include: The EMR (Electronic Medical Record) shows that R1, an [AGE] year-old, was admitted to the facility on [DATE]. The POS (Physician Order Sheet) for the month of October 2022 shows R1's diagnoses that includes but not limited to [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (muscle weakness on one side of the body that affect arms, legs, and facial muscles) affecting R1's left side after R1 had suffered cerebral infarction (stroke). R1's other diagnoses were specified disorders of bone density and structure, history of Covid 19 infection, protein-calorie malnutrition, sequela of non-traumatic subarachnoid hemorrhage, dementia, psychotic disturbance, mood disturbance, and anxiety. R1 also has a gastrostomy due to dysphagia. The most recent MDS (Minimum Data Set) dated 8/26/2022 was R1's annual assessment. R1's BIMS (Brief Interview Mental Status) score was 9, moderately impaired in cognition. R1 was also assessed for Functional Status and scored 3/2 for bed mobility (extensive assistance/1 person physical assist); 3/3 for transfer (extensive assistance with 2 plus person physical assist). The Balance During Transitions shows that R1 was not steady, and only able to stabilize with staff assistance during moving from seated to standing position and surface to surface transfer between bed and chair or wheelchair. The Functional Limitation in Range of Motion shows R1 has impairment on one side of the body for both upper (shoulder, elbow, wrist and hand) and lower extremities (hip, knee, ankle and foot). The Functional Abilities and Goals for Self-Care and Mobility shows that R1's admission performance was 3 (moderate assistance and helper lifts or holds trunk or limbs) for toileting hygiene, mobility in bed and from chair to bed and vice versa. The facility's Serious Injury Incident Report dated 10/18/2022 shows that on 10/10/2022 at 5:00 P.M., R1 informed V3 (Guest Relation Staff) that she has pain on her left leg. V3 informed V4 (Nurse) and V4 immediately assessed R1. V4's assessment showed that R1 had an acute pain of the left leg, and the physician was notified. An order for an X-ray was obtained. The result of the X-ray was a distal tibial fracture of the left leg and osteopenia. R1 was sent to the hospital 10/10/2022 and returned to the facility on [DATE]. Further review of the report shows that R1 is alert, oriented to self with periods of confusion, had history of falls, requires staff assistance with ADLs and transfers. The report also shows that R1 has poor safety awareness due to cognition and is incontinent of bladder and bowel function. The report showed that V2 (Director of Nursing) investigated R1's injury. V2 reported that per interview with R1 when she returned to the facility, R1 had alleged that staff were rough to her and felt acute pain when R1 was being changed for incontinence brief, and this was after she was transferred to bed from a wheelchair on 10/10/2022. On 10/19/2022 at 11:00 A.M., R1 was observed lying in bed. R1's was semi- turned to her left side with her right hand holding unto the upper bed rail. R1's lower trunk, hips, buttocks were supine, lying flat in bed. V8 (CNA) was providing incontinence care at this time of observation. V8, with her left hand was wiping R1's buttocks while V8's right hand was pushing R1's buttocks to turn to the left side to expose for cleaning. R1's lower extremities were straight and were not turned to the left side. R1 was in an awkward position with upper body semi-turned to the left side and lower body in a flat/supine position. R1's body alignment was twisted. R1 was observed to be very particular with care and was refusing and resisting to be positioned towards her left side while V8 was pushing R1's buttocks. On 10/19/2022 at 12:30 P.M., V3 (Guest Relation staff) said that on 10/10/2022 around 5:00 P.M., R1, was lying in bed, and had complained of left leg pain. V3 said he immediately informed V4 (Nurse). On 10/20/2022 at 2:00 P.M., V4 said that she came in to work for her evening shift around 3:00 P.M. V4 said that she checked R1 around that time. V4 said that during that round, R1 was sitting in her wheelchair in her room. V4 said that R1 is alert and oriented with bouts of confusion but knows enough if someone mistreats and that R1 will report. V4 also added that during the first round, R1 did not complain of pain and was comfortable. V4 added that around 5:00 P.M., V3 informed her that R1 was complaining of left leg pain. V4 said that she immediately went to R1's room and found R1 lying in bed. V4 said that R1's left leg was not even in compared to the right leg, shortening of the left leg extremity was externally rotated. V4 said that R1 did not complain of staff being rough, though R1 was focused mainly on the pain. V4 also said that she sent R1 to the hospital after a portable left leg X-ray report obtained at the facility shows positive for left leg fracture. V4 said that she also informed V7 (Nursing Supervisor). On 10/20/2022 at 2:11 P.M., V7 said that after receiving report that R1 was injured after provision of care, she suspended both V5 and V6 (CNA's/Certified Nurse Assistant from staffing agency). V7 said that investigation was initiated by calling V2 for possible abuse/injury of unknown origin. On 10/20/2022 at 12:15 P.M., V2 said that on 10/10/2022 around 5:00 P.M., V5 had transferred R1 by herself from wheelchair to bed. V2 also said that V6 was present but did not assist during transfer. V2 said that V6 provided incontinence care to R1 after being transferred to bed by V5. V2 also said that R1 complained of acute pain of the left leg a few minutes after V6 had provided incontinence care and brief change. On 10/20/2022 at 2:15 P.M. V5 said that she had taken care of R1 prior to 10/10/2022. V5 said that she was aware of how to transfer R1 from chair to bed and vice versa. V5 also added that she had always transferred R1 by herself. V5 also said that R1 did not complain of pain when she transferred R1 to bed on 10/10/2022 at around 5:00 P.M. V5 also said that V6 was in the room during the transfer, but V5 did transfer R1 alone and then left the room when R1 was already sitting at the edge of her bed. V5 also said that R1 was transferred using a pivot transfer with V5 guiding the right leg to move, and left leg was deconditioned, flaccid, not able to bear weight was dependent with the direction of the right leg. V5 said that she left R1 with V6 after she transferred R1 to a sitting position at the edge of the bed. On 10/20/2022 at 1:36 P.M., V6 said that V5 had transferred R1 alone to bed since V5 knows R1 well. V6 said that she removed R1's left leg brace while R1 was sitting at the edge of the bed. V5 said that she then positioned R1 in bed, lying on back. V6 also said that since R1 has left sided weakness, R1 was turned to the left side, with R1 holding unto the upper bed rail with R1's right hand. V6 said that R1's lower extremities was halfway turned to the left side, so V6 had to lift R1's buttock, and pulled the brief out from R1's buttock. V6 said that 3-5 minutes later after V6 left R1's room, R1 had complained of acute pain to the left leg. On 10/20/2022 at 11:45 A.M., V10(CNA/Restorative Aide) said that R1 is transferred using a pivot transfer. V10 said that R1 was only able to bear weight on the right leg, but not the left leg. V10 added that R1's left leg was flaccid and dependent to the direction of the right leg during transfer. On 10/20/2022 at 4:00 P.M., V9 (CNA) was providing incontinence care to R1. R1's position was the same as observed on 10/19/2022 with awkward position, and twisted body alignment. V9, pushing R1's buttock with his other hand while other hand was wiping R1's buttocks. R1's brief was also pulled out underneath her buttocks while she was in the supine position. On 10/20/2022 at 3:30 P.M., V2 said that the facility had no policy for repositioning a resident while in bed. However, V2 said that it is expected that standard of care when repositioning a resident while in bed was to move/turn the resident in one piece/log roll and with good body alignment. The hospital record dated 10/11/2022 at 4:48 A.M., the ED (Emergency Department) report shows that (R1) with past medical history of [CONDITION(S)] with left sided paralysis who presents to the emergency from nursing facility for evaluation of left distal tibia fracture. (R1) reportedly was being readjusted by staff at the facility and developed acute pain .(R1) states one nurse is very mean to her and is very rough .(R1) denies falls, or head trauma. (R1) complaining of pain from her left knee down. (R1) has [CONDITION(S)] of the left side and is non-ambulatory Musculoskeletal assessment: (R1) has external rotation of the left lower extremity from knee down. There is significant tenderness to palpation over the distal tibia on the left leg with visible swelling. (R1) has pain with any attempts at passive range of motion of the left ankle or knee. Neurological assessment: (R1) is alert, and keenly responsive. Left sided upper and lower extremity paralysis. Speech is dysarthric (slurred speech) but not aphasic (a language disorder that affects how a person communicate). (R1) answers questions appropriately. Review further of hospital report shows that R1 developed an acute pain after being moved during transfer and care at the facility on 10/10/2022. The report also showed that orthopedic consultation indicated the need of posterior mold and knee immobilizer. The hospital record also shows that the R1's final diagnoses were: -1) Acute displaced spiral fracture of the left distal tibia with associated proximal fibular fracture (The Taber's Medical dictionary shows displaced spiral fracture is a fracture that pieces of bone were moved so much that a gap was formed around the fracture. A spiral fracture is a bone fracture that occurs when a long bone is broken by twisting force. The tibia and fibula are the two bones of the lower leg. It is unusual to break both bones, even in contact sports. It takes quite a bit of trauma to break both of them at the same time. A fibular fracture is a break to the fibula caused by a forceful impact that results in injury.) 2) Acute [NAME] fracture of the left lower extremity ([NAME] fracture refers to a combination of a fracture of proximal fibula together with an unstable ankle injury). 3) History concerning for possible elder abuse On 10/20/2022 at 11:05 A.M., V11 (Physical Therapist) said that a spiral fracture is a fracture when a bone was twisted. V11 also said that good body alignment and turning a resident as a whole and one-piece using log roll is the expected standard of practice. V11 explained that pivot transfer meant that good leg was guided to the direction and while the decondition leg remained flaccid and dependent to the direction of the good leg. V11 also said that the decondition leg should be handled gently and supported to prevent injury. On 10/19/2022 at 12:45 P.M., V12 (R1's Attending Physician) said the fracture that (R1) sustained was not spontaneous, it was acute, was detached and bone was twisted. This was caused from a forceful impact, and it just does not happen during routine gentle care. Like I said, the cause of the fracture was from a forceful impact, but since it was not witnessed, this cannot be determined if the force was accidental or intentional. We have different strength, so it is hard to say. The expectation of care for (R1) being a high risk for fracture due to osteopenia, decondition left leg with [CONDITION(S)] and [CONDITION(S)] should include specific measures and EDUCATION, EDUCATION, COMMON SENSE AND ALWAYS GENTLE CARE WHEN GIVING CARE. V12 also said that specific measures should be in place when handling R1 to prevent injury such as fracture. V12 added that if (R1) shows resistance of care, then give (R1) some space, explain the procedure and ensure that the decondition leg should always be supported, and body is always in good alignment and turning (R1) in one piece like log rolling. The current care plan initiated dated 5/10/2022 with goal date of 12/01/2022 shows that R1 has ADL functional limitation for transfer due to [CONDITION(S)], lack of coordination, muscle weakness, and decrease in endurance. The intervention included one staff assistance for pivot transfer. This was a conflicting intervention from the MDS assessment dated [DATE] as R1 scored 3/3 for transfer (2 person plus assistance). The care plan also was not followed that R1 be in good body alignment when in bed. Review further of care plan did not have interventions for safety measures to ensure the decondition leg (left leg) was supported, good alignment during transfer, bed mobility and incontinence care. The care plan also did not address safety measures regarding R1's high risk of fracture due to osteopenia.

Based on observation, interview, and record review, the facility failed to provide safety measures for a resident while being turned/repositioned during provision of care. This failure resulted in R1 sustaining a laceration to the left side of his forehead, a subdural hematoma, and intensive care monitoring. This applies to 1 of 4 (R1) residents reviewed for falls with injury in the sample of 4. The findings include: R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke) with [CONDITION(S)] and [CONDITION(S)] (paralysis) affecting the left side, diabetes, [CONDITION(S)], [CONDITION(S)], and depression. R1's MDS (Minimum Data Set) dated March 16, 2022, shows R1 had severe cognitive impairment. R1 required extensive assistance of two staff for bed mobility, extensive assistance of one staff for personal hygiene, totally dependent on one staff for toilet use, and totally dependent on two staff for transfers. R1's care plan dated March 15, 2022, shows R1 is at risk for falling related to difficulty walking, muscle weakness, [CONDITION(S)], lack of coordination and decreased endurance. Interventions dated March 15, 2022, include keep bed in lowest position with brakes locked, keep call light within reach at all times, and keep personal items and frequently used items within reach. Interventions dated March 24 include floor mats to side of bed. V3's (RN, Registered Nurse) Nursing Progress Note dated March 24, 2022, at 7:32 AM shows while CNA was changing R1's incontinence brief, R1 rolled out of bed and fell on the floor in the prone position. R1 hit his forehead and got a laceration with bleeding. 911 was called and R1 was sent to hospital for evaluation and treatment. V12's (LPN, Licensed Practical Nurse) Nursing Progress Note dated March 24, 2022, at 3:38 PM shows R1 was admitted to hospital with intracranial bleed. On March 28, 2022, at 1:15 PM, R1 was lying in bed with the top of the mattress approximately two and half to three feet off the floor. R1 had a healing laceration on his left forehead. R1's bed was not in the lowest position as possible per the fall intervention in R1's care plan. On March 29, 2022, at 9:35 AM, R1 was lying in bed with the top of the mattress approximately two and a half to three feet off the floor. R1's bed was not in lowest position as per the fall intervention in his care plan. On March 29, 2022, at 11:26 AM, V4 (CNA) stated he provides care with two staff. V4 also stated he has provided care to R1 by himself but can tell when R1 is having a bad day and he knows to have another staff help him on those days because he can get squirmy in the bed. On March 29, 2022 at 1:39 PM, V8 (Director of Rehab) stated when turning a resident to their side in the bed, the staff should first pull the resident closer to them, that means further away from the side of bed the resident will be turned towards, so if they are turning the resident to their left side, the staff needs to pull the resident over to the right side of bed before turning the resident to their left side. Furthermore, the staff should bend the top leg and place one hand on hip/waist area and the other hand on the upper back and ease them onto their side. On March 29, 2022, at 2:21 PM, V9 (CNA/Certified Nursing Assistant) stated on the morning of March 24, 2022, he was turning R1 onto R1's left side. V9 also stated R1 was positioned in the middle of the bed prior to V9 rolling R1 onto his side. R1 was rolled onto his left side and while V9 was gathering the soiled linens behind R1, R1 grabbed the side of the bed with his right hand and rolled off the bed onto the floor. V9 stated at the time of the fall there were no side rails on the bed or fall mats on the floor. V9 noted that R1 was bleeding from his face, he notified the nurse and 911 was called. R1 was sent to the local hospital and admitted . On March 29, 2022, at 3:08 PM, V10 (Physician) stated the facility made her aware of R1's fall which resulted in a new subdural hematoma. V10 also stated that when R1 was admitted to this facility, R1 refused to be placed on anticoagulants due to a previous fall which he had that resulted in a brain bleed. V10 said if R1 had been on an anticoagulant at the time of this incident, the outcome could have been much worse. R1's hospital records dated March 24, 2022, shows R1 had multiple comorbidities including left [CONDITION(S)]. R1 presented to the ED (Emergency Department) after he [R1] fell out of bed while staff was logrolling him to change his clothes. R1 had a diagnosis of subdural hematoma. The hospital records also included a CT (Computerized Tomography) scan of R1's head with results of a recent left subdural hematoma. V11's (emergency room Physician) provider note shows R1's head laceration was closed with liquid skin adhesive. V11's note also included given the high probability of imminent or life-threatening deterioration of R1's condition without intervention, R1 was assessed by V11 and a nurse. During R1's stay in the emergency room , V11 spent considerable time at R1's bedside performing serial re-evaluations of R1's vital signs and clinical status because of the recognized potential threat to life or limb in this condition. Clinical management of R1 involved high complexity decision making to assess, manipulate, and support vital organ system failure. The hospital record also shows R1 was admitted to the intensive care unit and had a neurosurgery consultation.

Based on observation, interview, and record review, the facility failed to follow their policy and care plan interventions to ensure residents at high fall risk were being monitored. This failure resulted in R1 having an unwitnessed fall, sustaining a fracture requiring hospitalization and surgical intervention. This applies to 3 of 4 residents (R1, R3, and R4) reviewed for falls in a sample of 10. The findings include: 1. According to the Electronic Health Record (EHR) R1 had diagnoses including diabetes, [CONDITION(S)], hypertension, gastroesophageal reflux disease, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], dementia, depression, [CONDITION(S)], dysphagia, weakness, reduced mobility, assistance with personal care, and history of falling. The Minimum Data Set (MDS) dated [DATE] showed R1 needed extensive assistance of one person for bed mobility, dressing, eating, and toilet use; and needed extensive assistance of two people for transfers. The MDS showed R1's cognition was moderately impaired. The admission MDS dated [DATE] showed R1 did not have any falls prior to admission. A Care Plan showed R1 had dementia and confusion; had an actual fall and is at high risk for falling related to dementia, weakness, difficulty walking, stroke, lack of coordination with interventions including being in a supervised area at all times while up (09/01/2021), toileted early morning, after each meal, before bed, and check for incontinence every two hours. The EHR event log showed R1 had a history of previous falls in the facility: a fall on 05/24/2021 at 1:50 PM, R1's roommate had called for staff. R1 was observed lying on the floor, right side of the bed with R1's head against the wall heater vent. a fall on 08/10/2021 at 2:35 PM with a laceration to forehead. R1 had stood up from the wheelchair while being wheeled back to room by V5 (RN); and a fall on 08/31/2021 at 9:00 AM R1 was found on the floor in the dining room. On 10/25/2021 at 3:29 PM, V4 (Registered Nurse/RN) said R1 was a fall risk, sometimes sitting at the nurse's station so someone was always watching . V4 had heard about R1's fall and thought V5 (RN ).the nurse taking care of R1, had been on break when R1 fell . V4 thought R1 often would lean forward when sitting in the wheelchair and that was why R1 was kept at the nurse's station. R1 was alert and oriented to person and place. V4 said she never saw R1 walk and doubted R1 was able to walk. V4 said R1 did have a low bed with fall mats on either side of the bed. A Nursing Progress Note dated 10/19/2021 at 2:20 PM showed (V5, RN) was in the dining room and heard a thud sound towards the nurse's station. When V5 responded, R1 was lying on left side, next to the wheelchair, and had a bump on the left forehead. A body check was done, ice was applied to R1's forehead, vital signs were taken and R1 was assisted back in the chair with the assistance of two people. R1 had complained of pain on forehead and the left hip. R1 had verbalized wanting to go to the bathroom and had gotten up without assistance. On 10/26/2021 at 12:07 PM, V5 (RN) said he was on a break in the dining room near the nurse's station sometime after 2:00 PM. It was around shift change for the Certified Nursing Assistants (CNAs). R1 had been sitting in a wheelchair near the nurse's station. V5 had heard a noise and when he came out of the dining room, R1 was lying on left side on the floor. V5 said R1 did not call out for help and there was no staff in the vicinity. V5 said since it was near the end of the shift, possibly the CNAs were making rounds on other residents. V5 said the CNAs who had been working the day shift were V6 (Restorative CNA) and another CNA. V5 said he had to go find V6 to help get R1 up off the floor. V5 said when he was on break, there wasn't another nurse to cover the residents for him. V5 said R1's fall was unwitnessed. R1 initially was grimacing, had a large bump on the left forehead, and said wants to go. V5 said R1 was always saying that R1 wanted to go home. R1 was alert but very forgetful. At 3:00 PM when asked about the care plan showing R1 should be in a supervised area due to being a high fall risk, V5 said R1 was placed at the nurse's station to be supervised to the best of our ability. V5 said sometimes, if the CNA would need to answer a call light, it would take them away from the nurse's station. V5 (RN) thought V6 (CNA) knew he was on break. The CNAs change shifts at 2:00 PM and V5 couldn't recall seeing the evening shift CNAs coming on duty yet, at the time. On 10/26/2021 at 12:32 PM, V6 (Restorative CNA) said R1 was a fall risk because R1 tried to get up a lot. R1 would try to stand and take steps but R1 did not meet the requirements to be walked. V6 said R1 had been taken to the toilet approximately 1:30 PM with V6 and another CNA. When R1 had fallen, it was toward the end of V6's shift and V6 was down at the other end of the hallway, getting ready to leave. V6 said she was walking down the hallway when V5 (RN) came to get V6 (CNA) because R1 had fallen. V6 (CNA) did not know where any other CNAs were. V6 said R1 way lying on the ground, near the nurse's station, on the left side. V6 (CNA) said sometimes the CNAs give report to the oncoming CNAs sometimes they don't. V6 said sometimes there are CNAs who may come to work 15 minutes late. On 10/26/2021 at 3:48 PM, V2 (Director of Nursing/DON) said if a resident was a high fall risk, they should be placed in a high-volume area where they can be observed. V2 said the interim nurses station area in the middle of the hallways, someone was always right there. V2 said it was near her office and the activities take place in the dining room near there. V2 said R1 fell near the nurse's station, near the end of the hallway, on another unit. V2 said the staff was monitoring her, a CNA would have been watching R1. V2 said if the CNA or nurse had to go somewhere else, they should have brought R1 to the activity area to be monitored since there was an activity going on. V2 was unsure if the evening shift CNAs were there. V2 said she had passed R1 around 2:00 PM and R1 was sitting by the nurse's station humming. On 10/27/2021 at 9:52 AM, V8 (Nurse Practitioner/NP) said R1 was confused due to dementia, sometimes R1 had agitation, would try to get up out of bed or the wheelchair, and try to walk. V8 said the nursing homes have standard fall precautions which would include having a call light within the resident's reach, padding on the floor on both sides of the bed, sometimes a bed and chair alarm, and lock the wheels on the wheelchairs. V8 said the residents who were at a high fall risk should be closely monitored. V8 said the staff should have kept a close eye on her. On 10/27/2021 at 5:09 PM, V9 (Occupational Therapist) said she had passed R1 in the hallway and had exchanged brief pleasantries asking how was doing. V9 could not recall the exact time but thought it had been around 2:30 PM. V9 was not sitting at the nurse's station but was working with another resident at the time and had passed by to get something from the supply closet. Tthe encounter [MEDICATION(S)] less than 30 seconds. V9 said she had previously worked with R1 for therapy. V9 said R1 was able to stand up, needed extensive assistance with toilet use, and needed a lot of cues including safety cues for proper hand placement. According to V9, R1 was rather impulsive at times, would reach for the wrong grab bar, not push up on the wheelchair arm rests, or not lock the brakes of the wheelchair. On 10/25/2021 at 12:46 PM, this writer was looking for any nursing staff for 10 minutes to assist a resident who requested crackers, V3 (Housekeeper) said she had worked in the facility for three and a half months and often nursing staff cannot be found very easily. V3 said it takes awhile to find someone on the nursing staff to help the residents. A Magnetic Resonance Imaging (MRI) dated 10/20/2021 showed a nondisplaced proximal left femoral fracture involving the subcapital region and extending into the intertrochanteric region. A Hospital Orthopedic Consultation note dated 10/21/2021 at 9:44 AM from V11 (MD Orthopedic Surgeon) showed R1 had a nondisplaced left femoral neck fracture with a plan for left hip percutaneous screw fixation surgery the same evening. On 10/27/2021 at 1:38 PM, V11 (Orthopedic Surgeon MD) said R1's fracture was a result of the fall. V11 said R1 was admitted with altered mental status from a subarachnoid hemorrhage and was admitted to the intensive care unit for observation. A MRI scan showed R1 had a fracture. V11 said R1 had surgery on 10/21/2021, three screws were placed in the fracture location. V11 said Without knowing what the layout or feasibility of the nursing home staffing, more aggressive monitoring probably could have prevented the fall and subsequent fracture from happening. The Hospital Discharge Summary dated 10/23/2021 showed R1 was admitted to the hospital after having a fall and found to have a small right frontal traumatic subarachnoid hemorrhage and a had a left hip fracture requiring a successful left hip percutaneous screw fixation surgery on 10/21/2021. 2. According to the Electronic Health Record (EHR) R3 had diagnoses including protein-calorie malnutrition, metabolic [CONDITION(S)], chronic respiratory failure with [CONDITION(S)], chronic obstructive pulmonary disease, [CONDITION(S)], asthma, respiratory failure with [CONDITION(S)], dementia, Weakness, Other reduced mobility, need for assistance with personal care, altered mental status, hallucinations, pain, dyspnea, hypoxemia, depressive disorder, history of (healed) traumatic fracture, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], constipation, dysphagia, hypertension, and history of falling The Minimum Data Set (MDS) dated [DATE] showed R3 needed extensive assistance of one person for bed mobility, transfers, locomotion, dressing, eating, and toilet use. R3 was always incontinent of bowel and bladder. The MDS showed R3's cognition was moderately impaired. R3 has had one fall since prior assessment. A Care Plan showed R3 was at risk for falls with interventions including scoop mattress (09/27/2021), bolsters 12/09/2020, transfer with gait belt and one staff assistance. The EHR event log showed R3 had an unwitnessed fall from bed on 07/22/2021 at 10:24 PM and an unwitnessed fall from bed on 09/27/2021 at 5:00 AM with a laceration noted on forehead. On 10/25/2021 at 3:23 PM, R3 was awake, lying in a low bed with a fall mat on the right side of the bed only. R3's touch call light pad cord was lying on the floor near the bedside table. R5 was also awake, lying in a low bed with the call light cord lying on the floor. On 10/26/2021 at 4:25 PM, R3 and R5 were each sitting in their low beds with their legs hanging over the right side of the bed. Neither call light cord was accessible to the residents as the call light cords were laying on the floor. 3. According to the EHR R4 had diagnoses including chronic obstructive pulmonary disease, respiratory failure with [CONDITION(S)], diabetes, [CONDITION(S)] heart disease, difficulty in walking, need for assistance with personal care, congestive heart failure, dementia with behavioral disturbance, delusional disorders, [CONDITION(S)] [CONDITION(S)], presence of left artificial elbow joint, chronic kidney disease, anxiety disorder, seizures, [CONDITION(S)], [CONDITION(S)], hypertension, gastroesophageal reflux disease, and dysphagia. The MDS dated [DATE] showed R4 needed extensive assistance of one person for bed mobility, transfers, locomotion, dressing and toilet use; and needed supervision set up help for eating. The MDS showed R4 had impaired range of motion on one side of her upper extremities and no impairment of the lower extremities. R4's cognition was severely impaired. The Care Plan showed R4 was at risk for falling with an intervention to keep the call light accessible and had a [CONDITION(S)] disorder. On 10/25/2021 at 12:17 PM, R4 was asleep, lying in bed with head leaning to the right side. One fall mat was on the left side of the bed only. The head of the bed was elevated and the top of the mattress of the bed was elevated approximately 32 inches from the floor, not in a low bed position. A wheelchair was next to the left side of bed, on the fall mat. R4's call light cord was draped on the oxygen bubbler of R4's oxygen concentrator, not accessible to R4. On 10/25/2021 at 2:00 PM, R4's bed remains in elevated position, the call light cord remained draped on the oxygen concentrator bubbler and was not accessible. On 10/26/2021 at 4:23 PM, R4 was awake in bed. One fall mat was on the left side of the bed only. The head of the bed was elevated and the top of mattress about 32 inches from floor as it was the previous day. R4's call light cord was draped on the oxygen concentrator bubbler, same location as yesterday, not accessible to R4. On 10/26/2021 at 4:47 PM, V2 (DON) said R4's bed should be in a low position and should not be left that high. V2 lowered R4's bed using controls on the bed footboard, which R4 would not have been able to operate. V2 said all residents should have the call light cord accessible to them. The facility's Falls Clinical Protocol dated August 2008 included the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions until falling reduces or stops. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. On 10/27/2021 at 11:29 AM, V2 said this policy was the only policy the facility had regarding fall prevention.

Based on interview and record review, the facility failed to ensure that ordered medications were administered to a resident who is on insulin and antianxiety medications. The facility also failed to administer pain medication as scheduled for a resident. This applies to 2 of 6 (R16 and R17) reviewed for medication administration in the sample of 21. This failure resulted in R17 not receiving ordered Insulin for blood sugar control and anti anxiety medication as prescribed. This resulted in R17 suffering from increased anxiety while at the facility and promoting R17 to leave the facility AMA (Against Medical Advice). This failure also resulted in R16 having discomfort during [CONDITION(S)] session because prescribed medications were not provided prior to [CONDITION(S)]. The findings include: 1. Review of R17's EHR (Electronic Health Record) showed R17 was admitted to the facility 6/3/21 at 6:45 P.M. R17's progress dated 6/4/21 showed R17 signed out (AMA) against medical advice on 6/4/21 at 4:00 P.M. R17's face sheet showed the resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R17's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R17's observation detail list report dated 6/4/21 showed R 17 was alert on admission to the facility. The observation detail list showed R17 with blood pressure 127/72mm/Hg, temperature 97.3 degrees, blood sugar 164mg/dl on 6/3/21 at 7:15 P.M. Review of R17's hospital transfer and medication form dated 6/3/21 showed the next time her medications were due to be administered: (1). [MEDICATION(S)] 20mg oral tablet 1 tablet 4 times a day due 6/3/21 at 9PM. (2). [MEDICATION(S)] 10mg oral tablet 2 tablets oral daily due 6/3/21. (3). Sevelamer 800mg 3 tablets oral three times a day. Next dose 6/4/21 at 8AM. (4). [MEDICATION(S)] 40mg oral delayed release tablet 1 tablet oral two times a day. Next dose 6/3/21. (5). [MEDICATION(S)] 10mg oral tablet 1 tablet oral daily. Next dose 6/4/21. (6). [MEDICATION(S)] 40mg 1 tablet oral daily next dose due 6/4/21. (7). Insulin [MEDICATION(S)] ([MEDICATION(S)] kwikpen 100units/ml subcutenous solution) 15units subcutaneous every morning. Take once or twice daily in various doses from 4-10units depending on how much she eats and her blood sugar. Next dose 6/4/21. (8). Insulin [MEDICATION(S)] (Insulin [MEDICATION(S)] kwikpen 100units/ml injectable solution). 1 unit subcutaneous three times a day before meals as needed blood sugar. Next dose 6/4/21. (9). [MEDICATION(S)] 2mg 1 tablet oral two times a day as needed for anxiety. Next dose as needed. R17's remaining medications on the transfer form showed medication that should be given as needed. Review of R17's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] (1). [MEDICATION(S)] 2mg 1 tablet oral twice a day as needed. (2). [MEDICATION(S)] 10gram 1 packet once a day due at 09:00 (3). [MEDICATION(S)] 40mg 1 tablet oral once a day due at 09:00 (4). [MEDICATION(S)] Kwikpen U-100 insulin, 15units subcutaneous three times a day before meals due 06:00 A.M., 11:00 A.M., 04:00 P.M. (5). Ducosate sodium 100mg 1 capsule oral once a day as needed. (6). Insulin [MEDICATION(S)] 100 unit/ml, 1 unit subcutaneous three times a day before meals at 06:00 A.M., 11:00 A.M., 04:00 P.M. (7). [MEDICATION(S)] 3mg 1 tablet oral at bedtime as needed. (8). [MEDICATION(S)] Hcl 10mg 1 tablet oral once a day at 09:00 A.M. (9). [MEDICATION(S)] 5mg 2 tablets oral. special instructions: Give for SBP less than 90 three times a day at 06:00 A.M., 02:00 P.M., 10:00 P.M. (10). [MEDICATION(S)] 40mg 1 tablet oral twice a day at 09:00 A.M. and 05:00 P.M. (11). Polyethylene [MEDICATION(S)] 3350 powder 17 grams oral once a day at 09:00 A.M. (12). Sevelamer [MEDICATION(S)] 800mg 3 tablets oral, special instruction: Give with meals three times a day; 06:00 A.M., 12:00 A.M., 04:00 P.M. (13). [MEDICATION(S)] 10mg 2 tablets oral once a day at 09:00 A.M. (14). [MEDICATION(S)] 8mg/0.4ml; give 0.3ml subcutaneous once a day every other day due at 09:00 A.M. (15). [MEDICATION(S)]-acetaminophen 10-325mg 1 tablet oral every four hours as needed. Review of facility's convenience box medication list titled Westmont Manor CAPSA contents showed three of R17's prescribed medications were available and they include: (1). Insulin [MEDICATION(S)] (Humalog) 100units/ml is available in the convenience box cassette D, bin B6 and cell C4. (2). [MEDICATION(S)] 0.25mg ([MEDICATION(S)]) tab 0.25mg available in the convenience box cassette A, bin (controlled) and cell C1. (3). [MEDICATION(S)] 2.5mg tab available in the convenience box cassette C, bin B5 and cell C2. The [CONDITION(S)] list on the unit showed R17 was scheduled for [CONDITION(S)] on 6/4/21 6:00 A.M. Review of R17's MAR (Medication Administration Record) dated 6/01/21 through 6/10/21 showed the above listed medications were either documented as Not Administered: Drug/Item unavailable or Not Administered: Resident unavailable. Review of R17's progress note dated 6/4/21 at 2:18 P.M., showed R17 was seen by the nurse practitioner at the facility. The note also showed R17's medications were reviewed and faxed to pharmacy. On 6/14/21 at 12:43 P.M., V32 (Nurse Practitioner) stated on 6/3/21 she went over the medication reconciliation with the nurse. V32 stated she briefly had an encounter with R17 on 6/4/21. V32 stated she was never informed R17 was unable to receive any of her medications at the facility. V32 stated if she was informed, she would have ordered the medications as stat orders to be given. V32 stated it was a concern that R17 did not receive any of her prescribed medications throughout her short stay at the facility. V32 stated she expected medications to be given as ordered. On 6/10/21 at 8:20 A.M., V1 (Administrator) stated she was informed by nursing staff that R17 signed out AMA because she wanted her [MEDICATION(S)] which was not available and was not allowed to smoke. On 6/14/21 at 10:37 A.M., V27 (Agency Nurse) stated she worked evening and night shifts on 6/3/21. V27 stated she received R17 from the hospital. V27 stated she obtained the hospital transfer form from the paramedic staff. V27 stated she checked R17's vital signs, did a skin assessment and performed blood glucose check because R17 had an order to check the blood glucose four times a day. V27 stated she called the nurse practitioner for R17's medication reconciliation over the phone. V27 stated she is an agency nurse and was not familiar with the facility's EHS (Electronic Health System) and how to enter R17 into the facility's EHR as a new admission. V27 stated on 6/3/21 when R17 was admitted , she could not add R17 into the system, so she was unable to send R17's medications to the pharmacy for processing. V27 stated that was her first admission at the facility and she did not have access to the convenience box otherwise she could have given R17 some of her medications. V27 stated she should have notified the DON (Director of Nursing) of the issues. V27 stated she later informed the DON the following morning. V27 stated she did not give R27 any medications throughout her shift including coverage for the blood glucose test she obtained from R17. On 6/14/21 at 11:20 A.M., V29 (Nurse) stated on 6/4/21, she worked on the evening shift and cared for R17. V29 stated when she first approached R17, the resident was crying, anxious and very agitated. V29 stated R17 wanted to speak with V28 (Former Social Service). V29 stated V28 came upstairs to talk with R17. V29 stated she was not aware R17 was yet to receive any medications at the facility. V29 stated she would have gotten R17 medications from the convenience box. V29 stated she did not give R17 any medications because R17 was ready to leave the facility. On 6/10/21 at 9:32 A.M., V2 (Director of Nursing) stated she was made aware R17 left the facility AMA on 6/5/21. V2 stated she was informed R17's name could not be entered into the system which prevented nursing staff from documenting the initial assessment and faxing her orders to pharmacy. V2 stated some of R17's medications could have been retrieved from the convenience box but she believed staff could not do that because R17's name was not in the system. V2 stated she visited R17 in her room in the morning of 6/4/21. V2 stated she found R17 curled herself up in a fetal position in bed and informed her she suffers from social anxiety and wanted her medication. V2 further stated R17 was seen by V32 (Nurse Practitioner) and her medications was faxed to pharmacy. V2 stated she was not aware R17 did not receive any of her ordered medications before signing out AMA on 6/4/21. On 6/10/21 at 3:23 P.M., V3 ADON (Assistant Director of Nursing) stated she notified V32 that R17 complained she needed her anxiety medication and she was a new admit. V3 stated V32 saw R17 that morning after R17 had received [CONDITION(S)]. V3 stated she faxed the orders to pharmacy but was not aware R17 did not receive any of her ordered medications. 2. On 6/9/21 at 10:10 A.M., R16 stated she attends [CONDITION(S)] Monday, Tuesday, Thursday and Friday from 6:30 A.M., through 10:30 A.M. R16 stated depending on the nurse on duty, she does not receive her medication before been taken down for [CONDITION(S)]. R16 stated on 6/8/21 for instance, she did not receive her early morning medications for pain and her stomach issues. Review of R16's MDS (Minimum Data Sets) dated 3/16/21 showed R16 with BIMS (Brief Interview for Mental Status) of 15 which indicated an intact cognition. Review of R16's POS showed an order dated 5/25/21 for: Acetaminophen 500mg 2 tablets oral, special instructions: for pain , resident requests first dose to be at 05:00 because she leaves early for HD (Hemodialysis). Review of R16's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Acetaminophen 500mg 2 tablets. Special instructions: For pain, resident requests first dose to be at 05:00 A.M., because she leaves early for [CONDITION(S)]. (2). [MEDICATION(S)] capsule delayed release 20mg once every morning at 06:00 A.M. R16's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to verify and obtain a physician's treatment order regarding oxygen administration and [CONDITION(S)] care. This applies to 1 of 1 resident (R1) reviewed for oxygen and [CONDITION(S)] care.This failure resulted in R1 being found with [CONDITION(S)]-lke activities and having a hypoxic event with pulse oximeter reading of 77% ,which required a transfer to to the emergency room . The findings include: R1, was a [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital record ED (Emergency Department) dated 2/6/2021 showed that R1 had a [CONDITION(S)] like activity, altered mental status change, acute respiratory failure and was unresponsive when brought to the ED (Emergency department) on 2/6/2021. R1 was then intubated. R1 was admitted to the intensive care unit. R1 had undergone [CONDITION(S)] insertion on 2/19/2021. The most recent hospital notes regarding R1's [CONDITION(S)] was dated 2/26 and 2/28/2021 which showed that R1 was on an oxygen mask over her [CONDITION(S)] tube opening. These multiple pages of hospital records, approximately 60 pages were sent to V3 (Business Development/Admission Director) for screening and referral for R1's admission to the facility. This hospital record included R'1s H&P (History & Physical), [CONDITION(S)] insertion, and oxygen mask administration. The record also showed that R1 has a gastrostomy tube, [MEDICATION(S)] catheter and a peritoneal [CONDITION(S)] catheter that was clamped. The records confirm R1 was receiving hemodialysis via the [MEDICATION(S)] catheter. The hospital record showed no documentation that R1's [CONDITION(S)] was capped. Instead, the record had showed the use of an oxygen mask over the [CONDITION(S)] tube opening. R1 was admitted to the hospital on 2/6/2021 and stayed until 3/3/2021. R1 was transferred to the facility on [DATE]. On 6/2/2021 at 1:00 P.M., V3 (Admission Director) stated that the facility cannot accept a resident with active and uncapped [CONDITION(S)] because the facility cannot provide the needed services for these kind of residents. On 6/2/2021 at 1:15 P.M., V4 (Assistant Director of Nursing) stated that Hospital records for incoming residents need to be evaluated by me or the DON (Director of Nursing) .The former Director of Nursing from R1's admitted is no longer working at the facility. I did not screened (R1). The facility has to make sure that we can accommodate resident's assessed needs. We have to make sure it was properly set up for the oxygen and emergency [CONDITION(S)] kit tray in case of unexpected dislodgement of the [CONDITION(S)] tube. The nurse's admission progress notes dated 3/3/2021 which was documented by V6 (Licensed Practical Nurse , Staffing Agency) showed that (R1), a [AGE] year old female was admitted from (acute hospital medical center). (R1) arrived in facility aprox 7:15 PM via ambulance accompanied by two paramedics. (R1) is alert, does not appear to be in any pain at this time. Heart rate is regular, l/S clear bilaterally upon auscultation, abdomen soft non tender. Resident is nonverbal at this time. Resident is a [CONDITION(S)] pt., unsure of scheduled days at this point. Resident also has a [CONDITION(S)]. MD has been notified, Director of Nursing aware. Order obtained to continue with discharge orders. Noted and carried out. The nurse' admission progress notes showed that there was no nursing admission assessment regarding the type of R1's [CONDITION(S)], whether the [CONDITION(S)] was capped or uncapped, cuffed or [MEDICATION(S)] and the size of the tube, There was also no follow up with the attending physician to verify and to obtain order whether to continue oxygen administration with humidifier and how many liter per minute for administration. No physician order was obtained during R1's admission to the facility regarding management and care services of the [CONDITION(S)] so that the airway patency would be maintained, the tube would not be plugged and to prevent [CONDITION(S)] (a condition in which oxygen supply was insufficient). There was no documentation that there was an emergency [CONDITION(S)] kit with a correct size of extra and unused [CONDITION(S)] tube. A kit would be deemed essential in an event that R1's [CONDITION(S)] be dislodged. The POS (Physician Order Sheet) for the month of March 2021 showed that there were no physician orders that was obtained regarding oxygen administration and [CONDITION(S)] care when R1 was admitted on [DATE]. On 6/2/2021 at 3:41 P.M., V6 (Licensed Practical Nurse from staffing agency) stated that she does not remember admitting R1. V6 also added that the standard of practice was to verify orders from the admitting physician and verify any questionable transfer orders ,such as in this case, R1's oxygen administration and [CONDITION(S)] care. V6 also added that since she does not remember R1's admission V6 stated whatever I wrote on the admission progress notes that was what had happened. When asked regarding [CONDITION(S)] care and oxygen administration that was not verified based on the documentation ,(V6's progress notes and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 further stated that she will review R1's record and will call back the surveyor if there would be an additional information. V6 did not call back the surveyor throughout the survey time. On 6/2/2021 at 2:53 P.M., V7 (Licensed Practical Nurse from staffing agency) stated that she came to work on 3/3/2021-3/4/2021 from 11:00 P.M. through 7:00 A.M. V7 added that she remembered very well what happened that night, because she left the facility at 11::00 A.M. versus the scheduled 7:00 A.M. because it was madness and extra busy working and spending 3-4 hours for a patient that was not even at the facility because of the unprepared, disorganized admission of a patient that did not belong at the facility. V7 stated there was no [CONDITION(S)] care kit at bedside, no respiratory therapist and the physician order was incomplete and it did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V7 stated I had to call the hospital where (R1) came from to determine what I was dealing with here, what kind of [CONDITION(S)] and how many liters of oxygen that was administered to her at the hospital. I saw (R1) sitting at the edge of her bed in her room around 11:00 P.M. I saw she had a [CONDITION(S)] tube but there was no oxygen administered to her. I then received a shift report from (V6). I was surprised that (V6) did not give me any report about (R1). I only found out about (R1) being a newly admitted resident when the pharmacist had called me regarding (R1's) medications. I checked (R1) at 12:30 A.M. (3/4/2021) and found her lying in bed and her lower extremities having a [CONDITION(S)]-like activity, She was barely responsive to commands and tactile stimuli. I asked her if she was okay, she replied slowly, with a gesture, indicating that she was not okay. I then immediately checked her pulse oximeter to see if she was having enough oxygen supply. I was surprised because the reading of her oxygen saturation level was very low and it was only 77% and the normal reading was 92% and above. I rechecked the pulse oximeter again, using the facility's oximeter, and the reading was the same 77%. I administered 5 liters of oxygen via mask over her [CONDITION(S)] tube opening, but the oxygen saturation level remained the same. I suctioned her, and still the reading was the same. I found out that her [CONDITION(S)] tube was plugged with her mucous. It must have been because there was no oxygen administration, with humidifying solution. No humidity had dried her [MEDICATION(S)] and had plugged her [CONDITION(S)] tube, and without the oxygen (R1) got low saturation level of oxygen and was hypoxic. I called 911 immediately, and R1 was sent to the hospital at 12:35 P.M. (R1) had returned to the facility around 4:30 A.M., and I received a report from the ED nurse that they had given (R1) a medication for restlessness and oxygen administration was bumped up to 15 liters. When (R1) had stabilized with the oxygen saturation level that went up, the oxygen administration was given at 5 liters per minute. I informed (R1's) spouse regarding R1 being sent to the hospital. As I was leaving that morning around 11:00 A.M. on 3/4/2021, I saw (R1's spouse and (R1's daughter?) coming into the facility. But (R1) was on her way to another facility that would accommodate her care and services for her uncapped [CONDITION(S)]. On 6/3/2021 at 10:40 A.M., V8 (Registered Nurse) stated he took care of R1 on 3/4/2021 before R1 was discharged to another facility that could provide care and services regarding her uncapped [CONDITION(S)]. R1 also said that management arranged for (R1's) transfer, and I don't know if family was made aware of the transfer. V8 also added that R1 left the facility via paramedics at 11:28 A.M. on 3/4/2021. On 6/3/2021 at 11:00 A.M., V1 (Administrator) stated that during the morning meeting with the facility's IDT (Interdisciplinary Team) on 3/4/2021, it was discussed that R1's care for her uncapped [CONDITION(S)] could not be addressed at the facility. Therefore, R1 was transferred to another sister facility that handled uncapped tracheostomies. V1 also added that R1's family was made aware of the transfer. On 6/3/2021 at 9:00 A.M., V9 (Nurse Practitioner ) stated that it is an expectation that the facility should have reviewed and screened R1's discharged documentation and hospital medical records to determine continuity of care. V9 also added that if it was indicated on the hospital record regarding oxygen mask over the [CONDITION(S)] tube, then a verified order must have been done upon admission and an oxygen administration order obtained. V9 also added that if the order of oxygen administration was not clear, then a verification should have been made by the admitting nurse to determine proper care. V9 added that oxygen saturation level of 77% was very low and indicate [CONDITION(S)], the normal was 92% and above. V9 expressed hope that the facility had sent her to the hospital via 911. On 6/3/2021 at 10:00 A.M., V10 (Medical Director) stated she did not see R1 because she was only in the facility 3/3/2021-3/4/2021. V10 did not see R1 because R1 was transferred to another facility. V10 stated she specializes in geriatric populations in nursing homes and because of lack of resources , such as lack of staffing, there are mistakes that happens. What matters was that (R1) was sent out to the hospital when she had [CONDITION(S)]. The facility should have followed-up with the physician regarding oxygen administration and [CONDITION(S)] care when (R1) was admitted to the facility. The main thing was that the facility should have not have accepted her (R1) at the facility because (R1's) [CONDITION(S)] was uncapped. (R1's) uncapped thracheostomy status should had been determined upon R1's admission assessment. If this would had been determined upon admission, then (R1) would have been placed to another nursing home placement so care and management of her uncapped [CONDITION(S)] would have been provided. That facility where R1 was admitted to originally, does not cater to residents with active, uncapped [CONDITION(S)] because these residents are considered very high risk for respiratory failure /arrest and that the facility does not have a respiratory therapist to correctly manage [CONDITION(S)] care and monitor adequate oxygenation.

Based on observation, interview and record review the facility failed to ensure safe transfer. The facility also failed to follow their policy for injury prevention. This applies to 1 of 3 residents (R3) reviewed for incident/accidents in a sample of 7. This failure led to R3 sustaining a fractured left tibia. Findings include: The Medical Record documents the following [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) 8/12/17 for R3 documents R3 requires extensive staff assistance with transfers; R3 has impairment to both lower extremities; and has a BIMs (Brief Interview for Mental Status score) of 15/15 indicating no cognitive impairment. R3 was listed as an interviewable resident by the facility. The facility's incident report to the State Surveying Agency (9/30/17) documents that R3 was noted with swelling to left knee. MD (Medical Doctor) and family notified with new orders for x-ray which revealed fracture of left tibia/fibula. On 10/6/17 at approximately 10:00 am, R3 was awake in bed. R3 had a brace to R3's left leg. R3 stated I had a cast on my leg last week. I had the most things happen here than ever before. R3 stated I fell last Friday, they tried to do a one man transfer, one girl held the back of the shower chair and tried to undo my pants while E8 (Certified Nursing Assistant/CNA) held me up. My leg went under the bed. You could hear it crack like a dull pencil. On 10/6/17, R7 (Roommate of R3) stated They were trying to pull R3's pants off and R3 was dropped a bit and the leg snapped. I could hear it. Instead of using a lift, the big guy picked R3 off the shower chair. R7's MDS documents BIMs of 15/15 indicating no cognitive impairment. R7 was listed as an interviewable resident by the facility. On 10/6/17 at 11:06 am, E9 (CNA) stated E8 lifted R3 to the chair by holding R3 under the arms. He asked me to pull down R3's pants and E8 was holding R3 by the arms. E8 put R3 down on the shower chair by the arms. On 10/6/17 at 2:47 PM, E8 (CNA) stated I stood R3 up so E9 could take off R3's pants and switch the chair to the shower chair. I was holding R3 under the arms. R3 can't stand by R3's self. Then when I got done with the shower and transferred R3 to bed, I held R3 up and turned R3 (unassisted). I stood R3 out of the chair and had R3 hold the trapeze above the bed and I just swung R3's legs to bed. E9 added I didn't need a gait belt. I don't normally use gait belt. The policy is to use gait belt, R3 can't pivot. R3 can't move R3's lower body at all. We always use 2 person transfers. That day E8 and I transferred R3, I just lifted R3 up and I can do that while she switches the chair. On 10/6/17 at 3:10 PM, E7 (Therapy Director) stated after completion of therapy, we recommended the use of a mechanical lift or 2 person slide board for R3. R3's Physical Therapy discharge summary documents: 8/21/17 Due to inability to roll the lower body due to T9 [DIAGNOSES REDACTED]. Nursing is advised to have 2 person assist for safe slide board transfers or use the mechanical lift for safety of patient and for the safety of staff. On 10/10/17 at 9:58 am, Z2 (Nurse Practitioner/Provider) stated R3 could not move R3's lower extremities. R3 has no feelings from the waist down. R3 is paraplegic. So as far as the waist down, R3 is totally dependent on staff. R3 is not able to bare weight. On 10/10/17 at 10:21 am, E3 (Assistant Director of Nursing) stated R3 is T9 paraplegic with no sensation to the lower extremities. R3 is paralyzed from the waist down and totally dependent on staff, waist down. R3 requires 2 person transfer assist. Therapy said to use either the sliding board or mechanical lift. They should've had the slide board or mechanical lift for transfers. E8 and E9 did not use recommended transfer and did not follow policy. E3 added that R3 has a left tibia/fibula fracture. On 10/10/17 at 11:23 am E1 stated We realized regardless of when the fracture occurred, an improper transfer had taken place. E8 did not follow facility policy. Review of the investigation file revealed a documented statement by E8. E1 stated statements given by staff are allowed to be read by surveyor but not copied. E1 refused to provide a copy of statement. E1 verified what was written in the statement: E8 documented he was holding R3 under the arms and R3 asked, did my foot pop? He said this at the side of the bed and that was when I pivoted R3 to the bed. The pop happened after the shower. When asked when the actual incident happened and when the x-ray was obtained. E1 stated E8 failed to notify the nurse that R3 heard a pop on 9/29/17. E1 stated the shower happened Friday 9/29/17 and the x-ray was not obtained until Saturday 9/30/17 when R3 noticed the left leg/knee was bigger than the right. So R3 asked E15 (CNA) and E15 confirmed the left leg was bigger. The Care Plan for R3 documents: ADL (Activities of Daily Living) self care deficit as evidenced by weakness related to physical limitations, [DIAGNOSES REDACTED]. Intervention- ADL assist: Transfer 2 person assist with fully dependent mechanical lift (Date created and initiated 10/4/17, 4 days after the diagnosed fracture). The facility's policy titled Injury Prevention, Lifts and Injury-Reducing Devices Manual, Safety First documents: All patients classified as extensive assist are lifted and transferred between beds, chairs, toilets, and bathing and weighing facilities with the aid of a mechanical lift device. The determination of which lift to use is noted in the patient's Care Plan. Department Responsibility checklists: -Administrative Director of Nursing Services-Supports the program and ensures compliance -Nurse Supervisor- Ensure employee compliance with this program -Patient Care Employees- use the appropriate lift and friction-reduction devices for each patient assessed. Immediately notify supervisor of any injuries sustained while performing patient-handling tasks. The radiology report for R3 dated 9/30/17 reads: Knee, left- Acute fracture of the proximal tibia.

Based on observation, interview and record review, the facility failed to prevent an avoidable accident by ensuring that metal food cart was safely transported to residents unit. This applies to one of three residents (R1) reviewed for injury. This failure resulted in R1 sustaining multiple toe fractures and a toe amputation after being run over by the food cart while being pushed by the dietary staff. The findings include: R1, a [AGE] year old with [DIAGNOSES REDACTED]. On March 6, 2017 at 12:15 P.M., R1 was sitting in her wheelchair. R1 was in the dining room. R1 has bilateral leg rests attached to the wheelchair. R1 was wearing a pair of socks and a post-operative pair of shoes. R1 was pleasant and responds coherently. R1 stated I was sitting in my wheelchair, either in the hallway or dining room, when the cart run over my toes. Whoever was pushing the cart was not looking. On March 6, 2017 at 3:50 P.M., with R1's permission, and together with E4 (Registered Nurse/Unit Manager), R1's feet was checked. R1's left 3rd toe was amputated. There was a scant amount of dark brownish substance around the incision site of the amputated toe. E4 stated that the amputation was a part of the injury that R1 sustained when the metal food cart hit her toes while the cart was being pushed by E8 (Food Service Director). E4 added that this incident happened on February 13, 2017. E4 also added that R1 also had sustained fractures of the 3rd and 2nd toes of the left foot and the 5th toe of the right foot. The nurse's notes dated February 13, 2017 at 10:20 A.M. showed that the dietary cart was being pushed while R1 was sitting in her wheelchair in the hallway by the nursing station. The nurse's notes also showed that after the cart reached the nursing station, the nurse (E3) was summoned to check R1's feet. The nurse's assessment showed that R1 had sustained a deep cut of just below the nail and beyond the 3rd toe of the left foot. The notes also showed that Z1 (Nurse Practitioner) was asked to see R1. R1 was then sent to hospital. Z1's progress notes dated February 13, 2017 showed that (R1) was sitting in the hallway when the food cart ran over her left 3rd toe. (R1) is in moderate to severe pain, left 3rd toe has a deep laceration with the toe nail totally removable. The facility's incident investigation dated February 13, 2017 showed that E8 (Food Service Director) was pushing the food cart and when he took a turn, it was a blind spot corner where R1 was sitting. The investigation also showed that E9 (Respiratory Therapist) made a statement that E8 was pushing the cart slightly faster than he should but not racing. On March 6, 2017 at 2:00 P.M., E3 (Licensed Practical Nurse) stated that on February 13, 2017 around 10:00 A.M., R1 was sitting in her wheelchair. R1 was in the hallway next to the wall and was facing the nursing station (Intermediate station). E3 also stated that at the time of incident, E3 was of the same vicinity with R1. E3 was facing the Intermediate nursing station and was at hallway (west side). During this time, E3 added that she saw a heavy metal food cart being pushed by someone from behind. E3 added that the food cart was being pushed too fast. Further added by E3 that she cannot see the person pushing the cart because it was being pushed from behind and the person was not looking the pathway. The food cart came from the north dining room coming towards the intermediate nursing station hallway. As E3 added, it was only when the cart had passed her that she saw the person pushing it and it was E8 (Food Service Director). E3 also stated that there was a short turn at the nurse's station hallway and where R1 was at. E3 also added that the hallway was narrow and the food cart was big. As E3 further stated, it was a blind spot for E8 when he turned the food cart to the left around the nurse's station and R1 was at the right side of the cart. E3 also added that it did not help either because E8 had continued to push the cart too fast when he made the turn. E3 also added that after E8 turned the cart to the front of the nursing station, E3 was summoned to check R1's foot. E3 stated that R1 had non-skid socks on and feet were on the floor. Once the socks were removed, E3 saw R1's left 3rd toe was deeply cut and barely attached to a piece of skin. E3 further stated that this incident could have been avoided, if E8 was not careless, way too fast of pushing the food cart in a narrow hallway and was not cautious of a clear pathway. During the interview, E3 showed the place of the incident. At the time of incident, R1 was next to the wall facing the intermediate nursing station. There was a short turn/corner from the west hallway towards the front hallway of the nurse's station where R1 was located at. E8 had to make a left turn, leaving R1 on the right side of the cart during the turn. On March 6, 2017 at 2:30 P.M., E2 (Director of Nursing) provided dimension of the metal food cart and the distance of R1's location in a wheelchair to the nurse's station. The distance of the wheelchair to the nursing station counter was 47 inches. The food metal cart was 52 and 1/2 inches in width, height was 62 inches and the depth was 34 inches. This makes an approximate 5 and 1/2 inches space between R1 and the food cart for E8 to maneuver. The metal food cart also weighs 362 pounds. On March 7, 2017 at 10:15 P.M., E5 (Certified Nurse Assistant) stated that on February 13, 2017, R1 had breakfast, was assisted to the toilet and then placed on her usual spot which was next to the wall, hallway and front of the intermediate nursing station. E5 also added that R1 wears the non-skid socks all the time as R1's preference, no wheelchair leg rests since R1 was able to propel her wheelchair. E5 also added that after the food cart incident, R1 was assisted with propelling wheelchair due to the foot injury. On March 7, 2017 at 10:30 A.M., E6 (Certified Nurse Assistant) stated that on February 13, 2017 around 10:00 A.M., R1 was heard screaming of pain. E6 added that he immediately came out of the resident room 223 (which was a nearby room to the place of incident location). E6 further stated that he saw E8 holding R1's foot and E6 was asked to call the nurse. E6 also stated that he saw blood coming from R1's left foot. E6 further stated that few seconds prior to the incident, E6 saw E8 in the hallway pushing the food cart from behind. E6 also added that while E8 was pushing the cart, (E8) was moving so quick like he was in a hurry. E6 further added that he had seen in the past how E8 pushed the cart which was in the same manner that he did when the incident happened. E6 also added that the food cart was safer to pull than push because the person who is handling the cart has more control of the cart and can visualize if the pathway was clear. E6 further added that R1 is alert and oriented times three but forgetful at times. As E6 added, R1 can propel her wheelchair, however due to the foot injury, staff helps R1 with locomotion. On March 6, 2017 at 3:05 P.M., Z1 (Nurse Practitioner) stated that she assessed R1 immediately after R1's feet was ran over by the food cart. Z1 stated that R1's left 3rd toe was flayed, deeply cut and barely attached to a piece of skin. Z1 also stated that the amputation of the third toe could not be avoided because the bone of the left 3rd toe was already severed. Z1 further stated that R1 was sent to the hospital precipitated by this incident. The hospital report dated February 13, 2017 showed that R1 had an avulsion fracture of the distal phalanx of the left 3rd toe. There was also a fracture of at the distal phalanx of the 2nd left toe. The hospital surgical report dated February 14, 2017 showed that R1's pre-operative [DIAGNOSES REDACTED]. The report further showed that R1 had traumatic amputation of the left third toe extending from the distal toe at the level of DIP (distal interphalangeal) to the plantar toe at the level of the PIP (proximal interphalangeal) joint medially, with exposed tendon. R1 had undergone surgery of the left 3rd toe due to the traumatic amputation related to the incident. On March 6, 2016 at 4:00 P.M., E1 (Administrator) stated that E8 was terminated from work related to the incident that occurred with R1's foot. E1 also stated that the facility has no policy regarding safe transfer of the food cart. However, as E1 added, the staff should be aware of surroundings making sure the pathway was clear when transporting the food cart. E8's personnel file showed that he was terminated due to the incident that occurred on February 13, 2017 that resulted to serious injury to a patient requiring a surgery. The file also showed that E8 had violated work rules that included but not limited to . 2. Comply with all health and safety rules, including rules prohibiting unsafe conduct or unsafe acts that jeopardize the health and safety of self or others or result in serious injury. On March 7, 2017 at 12:50 P.M., E7 (Registered Dietician/Interim Food Service Director) stated that the facility has no policy regarding safe transport of the food cart. E7 also stated that the appropriate way to transport the food cart should be pull the cart versus pushing, to be aware of surroundings and to pull slowly. Pulling gives the individual more visual field and has more control of the cart which was much needed when making turns. When pulling the food cart, the person pulling it should be facing and looking toward the direction they are heading or going. The safe practice should be pull not push. This incident could have been avoided if the food cart was transported appropriately as described. The nurse's note showed R1 returned to the facility on [DATE]. On February 20, 2017, R1 complaint of right foot pain. On February 24, 2017, R1 went for a follow up orthopedic appointment. The progress notes for the follow up appointment showed that R1 had the following Diagnoses: [REDACTED]. Right 5th metatarsal fracture 2. Left 3rd toe amputation 3. Left 2nd distal phalanx fracture. On March 7, 2017 at 11:35 A.M., E4 stated that she had verified with the orthopedic clinic and had confirmed that the 5th metatarsal fracture of the right foot was an acute fracture that was sustained from the food cart incident.

Based on interview and record review, the facility failed to follow physician orders [REDACTED]. This failure resulted in R1 receiving [MEDICATION NAME] 2 MG (milligrams) for 12 days without a physician order [REDACTED]. This applied to 2 of 3 residents (R1 and R2) reviewed for anticoagulation medication errors in the sample of 22. The findings include: 1). R1's face sheet showed [AGE] year old R1 was admitted with [DIAGNOSES REDACTED]. R1's order summary report on the date of admission did not include an order for [REDACTED].>R1's progress note dated January 12, 2017 showed upon admission, R1 was alert, oriented to person place and time and was verbally responsive. On January 14, 2017, an order was transcribed into the medication profile of R1 for [MEDICATION NAME] 2 MG to be given at bedtime for anticoagulation and an order to draw labs for PT ([MEDICATION NAME] time) and INR (international normalized ratio) testing in the morning for monitoring lab until January 16, 2017. R1's January 1-31, 2017 Medication Administration Record [REDACTED]. R1's Order Recap Report from January 26 through January 27, 2016 showed the [MEDICATION NAME] medication was discontinued on January 27, 2017 at 6:19 PM as R1 was transferred out of the facility. R1's progress notes dated January 26, 2017 at 2:37 PM showed this morning pt (patient) seemed not like herself. She is awake and alert but not talking much. Not always responding when asking direct questions .spoke with doctor .do stat labs .will come to see pt. R1's progress notes dated January 27, 2017 at 12:02 AM showed patient was alert, nonverbal, and slow responds .was seen by doctor .in evening .6:15 PM noted bleeding on diaper. When assessed it was rectal bleed .called doctor .send to hospital .admitted the patient and [DIAGNOSES REDACTED]. R1's physician progress notes [REDACTED]. Yes and no answers since morning. The document titled State Report of Patient Incident which was reported by the facility to Illinois Department of Public Health (IDPH) on January 27, 2017 described the incident as [MEDICATION NAME] given in error, resident sent to hospital. On January 31, 2017, at 12:14 PM, E1 (Administrator) stated she was looking into re-hospitalization of resident and was informed Z1 (Attending physician) had called and questioned when R1 was on [MEDICATION NAME], because it wasn't something the provider would have ordered based on the resident's comorbidities. E1 added the medication was given from January 14-25, 2016 in error and the resident it was intended for was R3. On January 31, 2017 at 12:48 PM, E2 (Director of Nursing) stated Z1 (Attending physician) called from the hospital, reported R1 had an elevated INR and asked if R1 was on [MEDICATION NAME], which prompted an investigation. E2 stated R1 received [MEDICATION NAME] from January 14 through January 24, 2017. E2 added the error occurred because E4 (nurse) transcribed the order late. On January 31, 2017 at 2:55 PM, E4 stated she inadvertently wrote the orders too close to R1's name on E4's report sheet, did not go back to verify if R1 was on [MEDICATION NAME] and therefore created the error. On February 1, 2017 at 2:11 PM, R1 stated that Z1 (Attending physician) stated the medication was not ordered for R1. R1 remembered taking it but not knowing why, added that when asked if R1 was on medication at home, R1 responded no. R1 continued to state that at the hospital, R1 had no knowledge how she got there, was told that R1 wasn't herself and expressed the experience was very scary. R1's final report from the hospital stay dated January 27, 2017 showed R1 presented with loose stools looked dark in color and her INR was 9.5. R1 was positive for fecal occult test. The diagnostic impression showed [MEDICAL CONDITION], likely lower [MEDICAL CONDITION]; [MEDICAL CONDITION], likely secondary to [MEDICAL CONDITION] and R1 was on anticoagulation for unknown reason. On February 8, 2017 at 11:25 AM, Z1 (Attending physician) stated when R1 was admitted to the facility, R1's transfer paperwork did not include orders for [MEDICATION NAME]. Z1 went on to say that Z1 did not provide R1 an order for [REDACTED]. On February 8, 2017 at 11:35 AM, Z5 (pharmacist) stated the biggest fear of someone receiving anti-coagulation medication in error would be internal bleeding, diarrhea and fatigue. Lexi-Comp's drug Reference handbooks, 12th Edition shows [MEDICATION NAME] ([MEDICATION NAME]) is an Anticoagulant. It is a High alert medication. The Institute for Safe Medication Practice (ISMP) includes this medication among its list of drugs which has a heightened risk of causing significant patient harm when used in error. It further states as with all anticoagulants, bleeding is the major adverse effect of [MEDICATION NAME]. Hemorrhage may occur at virtually at any site. 2). R2's face sheet showed R2 was admitted on [DATE] with [DIAGNOSES REDACTED]. R2's medication review report sheet displayed physician orders [REDACTED]. R2 was ordered [MEDICATION NAME] in varying doses related to [MEDICAL CONDITION]. On January 9, 2017, review of physician written orders showed to discontinue R2's [MEDICATION NAME] and decrease [MEDICATION NAME] to 11 MG at bedtime. R2's MAR indicated [REDACTED]. R2's progress note dated January 9, 2017 at 3:22 PM showed: [DIAGNOSES REDACTED]. R2's progress note dated January 10, 2017 at 8:04 PM showed orders written on January 9, 2017 to discontinue [MEDICATION NAME] and decrease [MEDICATION NAME] was not carried out on January 9, 2017; physician was informed. On February 8, 2017 at 1:03 PM, Z4 (nurse practitioner) stated she was unable to recall if she had been informed the orders for R2 had not been carried out. Z4 stated the failure to reduce the [MEDICATION NAME] and discontinue of the [MEDICATION NAME], could cause Z4 to make decisions to further decrease the [MEDICATION NAME] based on the lab results. On February 8, 2017 at 11:35 AM, Z5 (pharmacist) stated the biggest concern of someone receiving anti-coagulation medication in error, would result in internal bleeding, diarrhea and fatigue. The facility provided guidelines for oral anticoagulation therapy dated 2015, which showed the following: Anticoagulation effect can be expected within 36-72 hours with peak effect occurring within 5-7 days; INR is monitored daily until stable and therapeutic level is achieved; and resident education is important in anticoagulation therapy. Lexi-Comp's drug Reference handbooks, 12th Edition shows [MEDICATION NAME] is an Anticoagulant. It is a High alert medication. The Institute for Safe Medication Practice (ISMP) includes this medication among its list of drugs which has a heightened risk of causing significant patient harm when used in error. It further states use with caution as hemorrhage may occur.

Based on interview and record review facility failed to thoroughly assess and evaluate one resident's (R13), complaints of persistent, recurring, relentless, excruciating severe pain in a timely manner as a means to determine location, origin, etiology and root cause of the pain. This failure resulted in 10 days of prolong, relentless pain and suffering due to delayed timely medical evaluation and intervention. This failure applies to 1 of 9 residents (R13), reviewed for pain related to ill fitting medical devices. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 02/06/2014. The Immediate Jeopardy began 01/21/2014. While the immediacy was removed on 02/06/2014, the facility remains out of compliance at a severity level 2 to evaluate staff compliance with facility protocols, response to inservices and changes in facility pain management procedures. The findings include: R13 was admitted to facility 01/21/2014 with a [DIAGNOSES REDACTED]. R13 was admitted with a long leg posterior mold brace attached to the right leg, secured with adhesive closure straps across the anterior portion of leg. The brace encompass the upper thigh down to, under and around the right foot. R13's 01/28/2014 minimum data set assessment (MDS), includes assessment: always able to understand and be understood, alert, with independent cognitive skills and no behavior or mood problems. This MDS also includes presence of constant pain at a level 10 on a scale of 0-10 (10 being the worst pain imaginable), that interferes with ability to function, including ability to sleep at night. During a 01/30/14, 12:20PM interview, R13 stated, "I wish they could stop my pain, it's horrible. The staff know about it and tell me they can not do anything about it." R13 also said the pain medication provided only works for a little while without much relief. During a 02/04/14, 9:45AM interview, R13 stated, "I had horrible pain in my ankle, inner ankle, heel and inner upper thigh area. The pain was a level 12 on a scale of 1 - 10. The pain was so horrible I could not sleep at night, I'd scream all night and I know I was keeping my room mate up. The nursing staff knew about my pain and they said they couldn't do anything about it, I'd have to wait for the orthopedic to fix it. I did not get relief from the pain until the orthopedic doctor fixed my brace on 01/31/14. The brace was too tight, causing severe pressure and hurting me. I had horrible pain from the time I was admitted (01/21/14), until the orthopedic doctor fixed my brace last Friday, (01/31/14 = 10 days). Now that the brace is adjusted, my pain is much better." During a 02/04/2014, 2:30PM interview, E18 (nurse aide), said, (R13) complained of pain to his right leg from the day he was admitted and frequently there after. On 01/25/2014, (R13), was holding the sides of his face and rocking back and forth complaining of severe pain to the right leg. E18 attempted to reposition the leg but R13 continued to voice severe pain so E18 notified E19 (the nurse). E19 contacting R13's doctor and then removed R13's right leg brace. R13's right heel and area above the heel (pointing to Achilles area), was the color "Black." During a 02/04/14, 4:00PM interview, Z5 (physiatrist), said R13 was admitted with a right tibia / fibula fracture and was first assessed by Z5 on 01/24/2014 (4 days after admission). Z5 said, R13 complained of severe uncontrollable right lower extremity pain and was very agitated about it. Z5 said she is involved with R13's pain management and stated, "I believe we all (facility staff), thought (R13's) complaints of pain was due to his fractures. We should have done a more thorough pain assessment to evaluate exact location and possible etiology of the pain." Z5 also stated, "I did not do a comprehensive pain assessment to determine the root cause of (R13's) pain." Z5 said, R13 was placed on a long acting [MEDICATION NAME] twice a day due to ineffective pain relief from the [MEDICATION NAME]. R13 continued to voice complaint severe right leg pain, so more [MEDICATION NAME] was ordered for break through pain, as needed (PRN). Z5 finished her interview saying, "I don't think (R13's) pain got worst, because it was always severe." On 01/24/14 Z5 ordered [MEDICATION NAME] 10 mg every 12 hours for 7 days, then on 01/28/14, Z5 ordered to discontinue [MEDICATION NAME] and administer [MEDICATION NAME] 5 mg every 4 hours PRN for pain, please administer one one hour before therapy. R13's 01/21/2014 admission physician orders [REDACTED]. There were no parameters ordered or obtained to define when to administer one pain medication verses the other. R13's medication administration records ( MAR's) and nurses progress notes document 14 separate times PRN [MEDICATION NAME] or PRN [MEDICATION NAME] was administered for pain at levels 4 - 8 out of 10. R13's nursing progress notes fail to include pain levels, 6 of the 14 times PRN pain medications were administered (01/24/14 at 4:31AM, 01/25/14 at 3:04PM, 01/26/14 at 2:06PM, 01/27/14 at 2:16PM and 6:42PM and 01/29/14 at 11:02AM.) Per 01/29/14 record review: R13's 01/21/14 - 01/29/14 pain assessments on MAR, nurse progress notes and pain evaluations all contain conflicting information regarding pain levels: January 2014 MAR indicated [REDACTED]. R13's nurses progress notes document his pain at 4 -8 out of 10. R13's 01/21/14 and 01/26/14 pain evaluation forms document pain level at a 2 on a scale of 1 - 10. No comprehensive pain assessment was performed to evaluate location and possible causes, even with the need to increase his pain medication to a long acting [MEDICATION NAME] on 01/24/14. R13's physician progress notes [REDACTED]. 01/24/14 = "Up the past several nights due to pain in right lower extremity (RLE)." "Per therapist reports, R13's therapy was limited by pain yesterday (01/23/14)." 01/28/14 = "OT (occupational therapy), requires maximum encouragement because of pain." "Irritable." 01/30/14 = "Anxious about pain." "Very nervous anticipating pain." presence of right foot pain. 01/31/14 = "Poor sleep at night due to pain in leg. Brace had been fitting poorly but now better. Leg pain pretty good today after brace adjusted." R13's 01/30/14 physician progress notes [REDACTED]. The wounds included open areas on the inner right thigh. Z9 documented recommendation for R13 to be seen by Orthopod and needs brace evaluated. R13's 01/31/14 orthopedic physician progress notes [REDACTED]." "He (R13), is having excessive pressure from this brace. The brace has recently been modified by the brace shop to relieve pressure with additional padding. We will also have him (R13), wear it loosely." Facility pain management policy and procedure includes: Initial evaluation : "Whenever possible the underlying cause of pain is identified and addressed through review of relevant medical history and completion of comprehensive pain evaluation." R13 had 2 pain evaluations conducted 01/21/14 and 01/26/14. Neither of these 2 assessments included sufficient information to assist in identifying the underlying cause of R13's pain. Facility failed to develop and implement an individual plan of care for R13 to address the need to evaluate for pressure, skin alterations and circulation impairments that can result from use of a long leg brace. R13's care plan also failed to include the need assess, monitor and evaluate recurrent, unrelieved complaints of pain as a means of analyzing possible cause / etiology of the pain. R13 sustained prolonged (10 days), severe, unrelieved pain and suffering to right lower extremity as the result of untimely pain evaluation and intervention to relieve constant severe pressure from the leg brace. E1 (Administrator), was informed of the Immediate Jeopardy on 02/06/2014 related to the facility failure to thoroughly assess and evaluate one resident (R13), complaints of persistent, recurring, relentless, excruciating severe pain as a means to determine location, origin, etiology and root cause of the pain in a timely manner. This failure resulted in 10 days of prolong, relentless pain and suffering due to delayed timely medical evaluation and intervention. The surveyor confirmed that the facility took the following steps to remove the immediacy of the situation: 1. R13 was evaluated by the orthopedic surgeon and his right long leg brace was modified to reduce pressure and reducing pain on 01/31/2014. 2. All residents in house were assessed to identify residents at risk (residents with splints / braces and residents with recurrent complaints of pain), on 02/06/2014. 3. Head to toe body audit and comprehensive pain assessment completed for all residents with splints / braces on 02/06/2014. 4. A comprehensive pain assessment has been completed for all residents with pain on 02/06/2014. 5. Plans of care have been updated accordingly per results of the body audits and pain assessments on 02/06/14. 6. All licensed staff inserviced by administrative staff or designee on facilities pain management policy, comprehensive pain assessments and policy on splints / braces. Education completed by 02/06/2014. Those employees not on duty 02/06/2014 will be inserviced prior to their next shift on 02/07/2014. 7. New and current residents who are experiencing pain greater than a 4 (on a scale of 1 -10), or with new pain will be monitored through daily QA IDT process to ensure risk factors are identified, pain management regimen reviewed and complaints of pain are appropriately addressed. 8. An ad-hoc QA meeting with the medical director, was conducted on 02/06/14. 9. Administrative staff will conduct reviews 5 days a week for 4 weeks to ensure facility protocols are followed for patients with splints / braces and residents with pain. The findings of these reviews will be reported to the Administrator weekly and reviewed by QA committee including the medical director monthly for further recommendation as needed. 10. QA committee shall monitor for trends and issues or concerns weekly for 4 weeks and develop action for follow-up and resolution. There after QA will continue to review for compliance on a monthly basis.

Based on interview and record review the facility neglected to follow it's pain management policy and procedure by not performing thorough comprehensive pain assessments as a means of identifying and addressing location and possible causes of the pain for 1 sampled resident (R13). This failure resulted in 10 days of prolong, relentless pain and suffering due to delayed timely medical evaluation and intervention. This failure applies to 1 of 9 residents (R13), reviewed for pain related to ill fitting medical devices (splints, braces or casts). The findings include: R13 was admitted to facility 01/21/2014 with a [DIAGNOSES REDACTED]. R13 was admitted with a long leg posterior mold brace attached to the right leg, secured with adhesive closure straps across the anterior portion of leg. The brace encompasses the upper thigh down to, under and around the right foot. R13's 01/28/2014 minimum data set assessment (MDS), includes assessment: always able to understand and be understood, alert, with independent cognitive skills and no behavior or mood problems. This MDS also includes, presence of constant pain at a level 10 on a scale of 0-10 (10 being the worst pain imaginable), that interfere with ability to function, including ability to sleep at night. During a 01/30/14, 12:20PM interview, R13 stated, "I wish they could stop my pain, it's horrible. The staff know about it and tell me they can not do anything about it." R13 also said the pain medication provided only works for a little while without much relief. During a 02/04/14, 9:45AM interview, R13 stated, "I had horrible pain in my ankle, inner ankle, heel and inner upper thigh area. The pain was a level 12 on a scale of 1 - 10. The pain was so horrible I could not sleep at night, I'd scream all night and I know I was keeping my room mate up. The nursing staff knew about my pain and they said they couldn't do anything about it. I'd have to wait for the orthopedic to fix it. I did not get relief from the pain until the orthopedic doctor fixed my brace on 01/31/14. The brace was too tight, causing severe pressure and hurting me. I had horrible pain from the time I was admitted (01/21/14), until the orthopedic doctor fixed my brace last Friday, (01/31/14 = 10 days). Now that the brace is adjusted, my pain is much better." During a 02/04/2014, 2:30PM interview, E18 (nurse aide), said, (R13) complained of pain to his right leg from the day he was admitted and frequently there after. On 01/25/2014, (R13), was holding the sides of his face and rocking back and forth complaining of severe pain to the right leg. E18 attempted to reposition the leg but R13 continued to voice severe pain so E18 notified E19 (the nurse). During a 02/04/14, 4:00PM interview, Z5 (physiatrist), said R13 was admitted with a right tibia / fibula fracture and was first assessed by Z5 on 01/24/2014 (4 days after admission). Z5 said, R13 complained of severe uncontrollable right lower extremity pain and was very agitated about it. Z5 said she is involved with R13's pain management and stated, "I believe we all (facility staff), thought (R13's) complaints of pain was due to his fractures. We should have done a more thorough pain assessment to evaluate exact location and possible etiology of the pain." Z5 also stated, "I did not do a comprehensive pain assessment to determine the root cause of (R13's) pain." Z5 said, R13 was placed on a long acting [MEDICATION NAME] twice a day due to ineffective pain relief from the [MEDICATION NAME]. R13 continued to voice complaint severe right leg pain, so more [MEDICATION NAME] was ordered for break through pain, as needed (PRN). Z5 finished her interview saying, "I don't think (R13's) pain got worst, because it was always severe." Facility pain management policy and procedure includes: Initial evaluation : "Whenever possible the underlying cause of pain is identified and addressed through review of relevant medical history and completion of comprehensive pain evaluation." R13 had 2 pain evaluations conducted 01/21/14 and 01/26/14. Neither of these 2 assessments included sufficient information to assist in identifying the underlying cause of R13's pain. The pain policy also includes nursing should conduct on-going subjective pain evaluations, that include description and location of the pain, when and why the pain is occurring. R13's medication administration records ( MAR's) and nurses progress notes document 14 separate times PRN [MEDICATION NAME] or PRN [MEDICATION NAME] was administered for pain at levels 4 - 8 out of 10. R13's nursing progress notes fail to include pain levels, 6 of the 14 times PRN pain medications were administered (01/24/14 at 4:31AM, 01/25/14 at 3:04PM, 01/26/14 at 2:06PM, 01/27/14 at 2:16PM and 6:42PM and 01/29/14 at 11:02AM. Per 01/29/14 record review; R13's 01/21/14 - 01/29/14 pain assessments on MAR, nurse progress notes and pain evaluations all contain conflicting information regarding pain levels: January 2014 MAR indicated [REDACTED]. R13's nurses progress notes document his pain at 4 -8 out of 10. R13's 01/21/14 and 01/26/14 pain evaluation forms document pain level at a 2 on a scale of 1 - 10. No comprehensive pain assessment was performed to evaluate location and possible causes, even with the need to increase his pain medication to a long acting scheduled [MEDICATION NAME] on 01/24/14 and [MEDICATION NAME] every 4 hours PRN (as needed), for break through pain on 01/28/14. R13's physician progress notes [REDACTED]. 01/24/14 = "Up the past several nights due to pain in right lower extremity (RLE)." "Per therapist reports, R13's therapy was limited by pain yesterday (01/23/14)." 01/28/14 = "OT (occupational therapy), requires maximum encouragement because of pain." "Irritable." 01/30/14 = "Anxious about pain." "Very nervous anticipating pain." presence of right foot pain. 01/31/14 = "Poor sleep at night due to pain in leg. Brace had been fitting poorly but now better. Leg pain pretty good today after brace adjusted." R13's 01/30/14 initial evaluation by Z9 (wound physician), included recommendation for R13 to be seen by Orthopod and needs brace evaluated. R13's 01/31/14 orthopedic physician progress notes [REDACTED]. The brace has recently been modified by the brace shop to relieve pressure with additional padding. We will also have him (R13), wear it loosely." Facilities pain management policy also includes nursing should conduct on-going subjective pain evaluations, that include where, when and why. This pain protocol describes the need to develop / revise an individual pain management care plan. The facility failed to develop and implement an individual plan of care for R13 to address the need to evaluate for pressure, skin alterations and circulation impairments that can result from use of a long leg brace. R13's care plan also failed to include the need to assess, monitor and evaluate recurrent, unrelieved complaints of pain as a means of analyzing possible cause / etiology of the pain. R13 sustained prolonged (10 days), severe, unrelieved pain and suffering to right lower extremity as the result of untimely pain evaluation and intervention to relieve constant severe pressure from the leg brace.

Based on observation, record review and interview the facility failed to conduct thorough fall risk evaluations for one resident (R7), failed to evaluate the circumstances and analyze the root cause of R7's falls, failed to assess the effectiveness of current interventions and failed to monitor and supervise R7 to prevent him from from falling and sustaining injury. This is for one of six residents reviewed for falls in the sample of 24. This failure contributed to R7 falling and sustaining a laceration to the forehead and receiving 7 sutures. The findings include: Review of R7's most recent MDS (minimum Data Set) dated 12/1/13 shows R7 has [DIAGNOSES REDACTED]. muscle weakness. It shows R7 requires physical assistance with all activities of daily living except eating and is not capable of any type of weight bearing mobility without staff assistance to stabilize him. This MDS shows R7 is [AGE] years old, 5'10" and 278 pounds and indicates the same mobility information as the annual MDS of 3/1/13. Review of R7's incident reports show the following: 2/8/13 2:45am Found on floor next to bed. Cut to left leg. 5/10/13 9:40am Transfer by nurse's aide from shower chair to bed. 5/21/13 8:50pm Found on floor. R7 was looking for his wallet. 6/12/13 4:00am Found on floor. Noted large old ecchymosis on right hip/upper buttocks. New ecchymosis on left forearm. 6/13/13 10:10pm On floor by bed. Rolled out of bed. Neurologist re-evaluated without any changes on 7/13/13. 7/25/13 10:51pm Found sitting on floor. R7 was reaching for something and fell . 8/4/13 7:50am Found on floor. R7 was trying to go to bathroom. 8/21/13 7:18am Found on floor inside room. R7 stated he had to urinate. 9/21/13 8:47pm Found on floor in hallway. Had been waiting for restorative to walk him since 2:00pm. 10/5/13 1:00am Lying next to bed on floor. 10/16/13 5:30am Rolled out of bed. 12/11/13 9:55pm Found on floor 12/23/13 1:30am Found on floor in bathroom 1/7/14 5:12am Found on floor next to bed 1/26/14 7:00am Found on floor next to bed with laceration to forehead. 7 sutures to right forehead area. R7 was observed to be sleeping in his wheelchair on 1.29.14 at 1:30pm. His right side was leaning forward with his right arm hanging down in front of his body almost touching the floor. The privacy curtain was drawn across so R7 could not be seen from the doorway. R7 responded to his name and was pleasant and cooperative. R7 stated he falls asleep off and on all day and night, for short periods. R7 knows when he has to urinate and will put the call light on but if staff don't come soon he will take himself. R7 stated he uses a urinal that is kept in the bathroom. R7's urinal was observed in his bathroom on 1/28/and 1/29/14. R7 said it would be a good idea if the urinal could be left closer to him so he didn't have to go into the bathroom all the time. R7 also stated he has been falling a lot lately and he thinks it is because he takes so many medications at one time. "I think they make me dizzy when I stand up." R7 stated it is really important to him to keep walking as long as possible. E4 (assistant director of nursing) stated on 1/29/13 at 2:10pm the reason for R7's falls is pretty clear, sometimes its impulsive behavior due to memory deficits from Parkinson's Dementia. Z1 (nurse practitioner) stated on 1/29/13 at 9:45am R7 could benefit from a re-evaluation by neuro-psych, the last one being in July 2013. Review of this evaluation dated 7/5/13 states R7 was being seen for re-evaluation after recent falls. No new recommendations were made. R7 has had at least 10 falls since then. Review of these facility Fall Investigation Reports repeatedly contribute R7's falls to the fact he is a high risk for falls, very poor impulse control and resistive to redirection. While these are risk factors which contribute to R7 being a high fall risk, the facility does not perform a comprehensive and individualized analysis of why R7 continues to fall such as not having his urinal accessible, the importance of R7 wanting to maintain some mobility as long as possible and the possibility of R7 receiving too many medications at one time (18 tablets at the 9:00 am med pass was observed on 1/29/14 which were reduced to 9 tabs at 9:00am during survey.) R7's MDS from 3/13 to 12/13 shows R7 had a decline in bladder continence from a 0 to a 2, indicating R7 has gone from being continent to being frequently incontinent yet this factor has not been evaluated as a contributing factor in R7's continued attempts to take himself to the bathroom. Review of the 9/21/13 investigation states R7 was waiting from 2:00pm until about 8:00pm for restorative personnel to walk him. They were supposed to have been there at 2:00pm per R7. The nurse's aide had to convince R7 he was not going to get walked that day because restorative staff had gone home. R7 was found in the hallway on the floor at 8:45pm, trying to walk by himself. The 12/1113 and 12/23/13 investigations both state for R7 not to be left alone in his bedroom in the wheelchair. R7 was observed alone in his room, in his wheelchair on 1/28/14 through 1/30/14 and 2/4/14. On 1/29/14 and 2/4/14 (about 1:30pm, each day), both at approximately 1:30pm, the privacy curtain was drawn and R7 was not visible from the doorway. Review of the most recent fall care plan dated 10/20/13 do not show R7's fall interventions have been evaluated for their effectiveness. The current interventions are not individualized nor based on R7's risk factors for falls. For example, there is no mention of R7's persistent attempts and desire to remain continent and to maintain his mobility and the implications of such as they relate to his falls. The fall on 1/26/14 resulted in R7 be sent to the ER and receiving 7 sutures to the forehead according to the incident report of 1/26/14.

Based on record review and interview the facility failed to provide timely treatment and services for 4 days after initial signs and symptoms of a shoulder injury on 12/8/11, with resulting fracture. This failure resulted in R4 experiencing new onset of pain to the right shoulder without evaluation or treatment for 4 days. and a decline in her ability to feed herself. This is for one resident (R4) in the sample of 24. Findings include: Review of most recent MDS dated [DATE] (significant change) shows R4 is [AGE] years old, current admission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review indicates R4 has been a total mechanical lift for transfers and has moderate confusion. Review of facility's investigation into R4's shoulder fracture of unknown origin shows that direct care staff observed R4 as having new pain to the right arm in addition to a sudden inability to feed self on Thursday, 12/8/11. There is no nursing documentation or interventions regarding this new pain and inability to feed self until 12/11/11 when an order was received to apply an ice pack to the area due to the development of a bruise. There was another 24 hour delay in diagnosing and treatment of [REDACTED]. The following are written staff statements provided to facility during their investigation into this injury, followed by interviews conducted by surveyor: E8 (cna-nurse's aide): noticed on Thursday (12/8/11) that R4 wasn't moving her arm and was complaining of a lot of pain. Informed E7. E8 stated he gave R4 a drink and she (R4) could barely move her arm. E8 stated on 12/22/11 at 1:50pm that he has taken care of R4 for 5 years. On 12/7/11, R4 had been fine, feeding herself as usual in the dining room. When E8 came in to work on 12/8/11, R4 was unable to feed herself as usual. E8 said he told E7 (nurse) that something was not right and had R4 demonstrate to E7 that she could not lift the milk carton as usual. E7 (nurse): a nurse's aide reported to her (E7) on Thursday (12/8/11) that R4 was having pain in her right arm. On Sunday (12/11/11) the area was bruised and the cna had to feed her because of the pain in the right arm. E7 stated on 12/22/at 2:00pm that E8 (cna) reported to her (E7) that R4 was complaining of pain in her right shoulder and could not move her arm. E7 stated she looked for bruising but didn't see any. E7 confirmed that she did not document or put any interventions in place on 12/8/11. E7 stated that she called the nurse practitioner several times during the day on 12/8/11 because of R4's complaints of pain and inability to lift her arm but did not hear back from the NP. When asked what interventions E7 took as a result of this change in condition, E7 said she wrote on the 24 hour report that R4 had increased complaints of pain but that was all. E7 said that on Saturday, 12/10/11, she (E7) instructed staff to keep R4 in bed and feed her because R4 could not feed herself. E7 stated that on 12/11/11, (the first day of physician notification about this injury) R4 developed bruising to the right shoulder and obtained an order for [REDACTED]. Review of nurse's notes from 12/8/11 through 12/10/11 do not document any aspects of R4's complaint of shoulder pain and decreased ability to move arm and feed self. Review of nurse's note dated 12/11/11 at 8:15am states that a cna noticed a new bruise to upper arm with increased complaints of pain upon touch and with movement. Review of POS physician order [REDACTED]." There was no physician visit or follow-up that day. There is no further documentation on R4 about her complaints of pain to the shoulder, how care was provided over the course of the course of 4 days, (12/8/11 through 12/12/11) or R4's response. A nursing entry on 12/12/11 at 6am notes continued complaints of pain to the area. At 11:00am on 12/12/11, the nurse practitioner was notified and a portable x-ray was taken at 12:15pm, confirming the [MEDICAL CONDITION] humeral neck with displacement. R4 was sent out to the ER at 2:50pm on 12/12/11 for evaluation of the right shoulder fracture. There was a delay of over 4 days between when facility staff first became aware of increased complaints of pain and decline of movement. However, E1 and E2 (administrator and director of nursing) stated on 12/22/11 at 10:40am that they consider the date of the incident to be 12/11/11 because that is the date the bruising to the shoulder became evident, even though they suspect the injury had occurred by 12/8/11.

Based on observation, record review and interview the facility failed to: (1). Initiate and complete an accurate and thorough bowel and bladder assessment of factors that may predispose six residents (R20, 21 12, 17, 16 and R19's) in the sample of 24 with incontinence (2) Obtain an accurate voiding pattern of the residents in order to implement a specific program to assist six residents (R20, 21 12, 17, 16 and R19's) in the sample of 24 with incontinence (3). Identify the type of incontinence of R20, 21 12, 17, 16 and R 19's. (4) Develop an individualized program based on the needs of R20, 21 12, 17, 16 and R 19. (5) Develop and implement a facility bowel and bladder assessment, evaluation and treatment policy and procedure. (6) Offer an alternative to an adult disposable brief. (7) Follow facility indwelling catheter policy and procedure to prevent further development of urinary tract infection R14 and R27 in the supplemental sample. These failures resulted in R20 expressing psychosocial and emotional distress from wearing a diaper. R20 who is alert and oriented stated "wearing diaper (adult disposable brief) is disgusting; it's so thick, it's bulging. I'm embarrassed, humiliated and felt like a baby wearing it!" Findings include: 1. On 12-22-11 at 2:30 PM, R20 who is alert and oriented stated, "I have been here three to three and a half weeks, I'm here for Physical Therapy for my knee then, I'll go back home. I use a diaper (adult disposable brief) here; they put a diaper on me on my first day here. They didn' t me give choices! They didn't ask me if I wanted it or not. I don't like using a diaper! It's disgusting! It's sticking out, look its bulging! That's why I stay in my room most of the time. It's embarrassing! Look! (showing her pants bulging due to the adult disposable liner.) I'm ashame people to see me like this because this is not me. I'm not here to wear a diaper. It's so thick! I never wear a diaper at home. Of course I can feel the urge to go to the bathroom. At times when I call for help by the time that they get here I'm already wet. No, they don't come at specific time to ask me if I wanted to go to the bathroom. Get use to nursing home life I guess! The feeling of wearing a diaper is emotionally draining. " On 12-23-11 at 12:15 PM, R20 said I can't understand why they will not let me use a commode. I even brought this commode from home. I would think if I can only have one person to help me transfer from bed to the commode, that would be better for me rather than putting me on a brief and changing me in bed. I was upset at the beginning and even now, I felt humiliated I felt like a baby, you can never get used to it! I think you just need to go with the flow. It was hard to walk with it. The diaper is rubbing on my groin area. At home I wear liner just in case but never a diaper." 2. On 12-21-11 at 10:45 AM, R16 stated "I've been calling for help to go to the bathroom for two hours now. I felt like I'm being ignored! I'm treated like dirt! They come in at times and they turn off my call light, they usually say they will be back by the time they come back I already pee on my diaper. They (staff) here are not crabby, it's just I wait too long for my buzzer to get answered. I really don ' t like to wear a diaper, but that's all that they give you. I asked my family to bring me underpants. At home this (soiling her adult disposable brief) never happened because I can go to the bathroom on time. Here (in the facility)I ' m wet almost all the time. It's hard to sit and wait for too long. When you want to go to the bathroom you can't wait forever! I don't want to pee on myself! That's the only complaint I have for this place. They just they don't answer the call light fast enough! They don't come in on a regular time to ask me if I wanted to use the bathroom, I need to call them. " At 10:45 AM, the C.N.A E 11 took R16 to the bathroom and observed R16's diaper saturated with urine. However R16 was able to void in toilet when the CNA took R16 to bath room. On 12-22-11 at 12:25 PM, the CNA/E 15 stated "she (R16) can verbalize her needs to go to the bathroom, she wears a diaper (adult disposable brief), I think because she dribbles. She (R16) can clean herself; needs assistance pulling her pants down, hers (incontinence) is usually wet at night. She needs assistance with transfer, she's fall risk. " 3. R21 was observed in the room sitting in her wheelchair on 12-22-11 at 2:10 PM. R 21 stated "I need to be changed (adult disposable brief). "At 2:15 PM the CNA/E12 claimed R21's "alert and oriented X 3, she can tell if she wants to pee. She (R21) wears a diaper because sometimes she can't hold it. I don't know if she's in any specific toileting program. I change her (adult disposable brief) when she ask me to. She can stand up, she's in therapy." 4. R12 stated on 12-21-11 at 10:50 AM, I take my self to the bathroom, I'm not supposed to, but rather than wetting my bed, waiting for someone to answer my call light for assistance. I just take myself. You wait for a long time for help here, so you need to help yourself. They come on their convenience. " 5. On 12-21-11 at 1:30 PM, R17 was observed in physical therapy room: At 2:00 PM, R17 was observed in the hallway asking for someone to take her back to bed. At 2:20 PM, E19 took R17 to bed and changed her adult disposable brief which was soiled with urine. E18 stated "she's (R17's) alert, with periods of confusion, remember names very well. She (R17) mumbles a lot and keeps repeating her name, but that's basically it, no other behavior that I know." Review of R12, R16, R17, R19, R20 and R21 clinical record showed a blank bladder patterning and analysis worksheets. There were no comprehensive assessments that were conducted to analyze the causes of their incontinence and no specific plan or interventions were implemented to try to maintain or improve R12, R16, R17, R19, R20 and R21 incontinence. R12, R16, R17, R19, R20, and R21's plan of care are almost the same for everyone. On 12-22-11 at 2:55 PM, the Director of Nursing /E2 stated "we currently have no Bowel & Bladder Coordinator. We lost our Restorative Nurse six months ago. I just got certified (restorative). That will be my goal; we know that (Bowel & Bladder) is a problem. E2 confirmed R12, R16, R17, R19, R20 and R21 were alert and oriented and stated "they're only here for skilled Physical and Occupational Therapy." When the surveyor requested for the Bowel & Bladder policy and procedure, none was made available. This was confirmed by the Administrator/E1 on 12-23-11 at 10:50 AM. E1 stated "we don't have a Bowel & Bladder policy and procedure, what we have is just a guideline for incontinence. " 6. R14 was an inpatient at the hospital and was diagnosed to have bilateral hydro[DIAGNOSES REDACTED]. Bilateral urethral stents were placed on 12/8/2011 and a indwelling urinary catheter was placed. R14 was readmitted to the facility on [DATE] with a urinary indwelling catheter. R14 is receiving the medication bactrim for the treatment of [REDACTED]. R14 was observed from the corridor on 12/21/2011 at 10 a.m. seated in a wheelchair in her room. The drainage bag contained dark amber urine and was not inside a catheter bag and the drainage tubing was on the floor. R14's was observed on 12/21/11 at 1:30 p.m. during a physical therapy session and on 12/22/11, in the residents room with indwelling catheter tubing on the floor. R27 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R27 was observed to be totally dependent on staff for care of activity's daily living. R27 was observed from the corridor lying in bed with the indwelling drainage tubing on the floor at 8:15 a.m. on 12/22/2011. E16 CNA (certified nursing assistant) was observed in R27's room on 12/23/11 at 8:45 a.m. . R27's indwelling catheter tubing was on the floor underneath the bed. This was brought to the attention of E16 who placed the tubing off the floor. The facility's policy and procedure for Catheter Care was reviewed with E1 administrator and E2 director of nurses. The procedure directs the staff to position the catheter tubing off the floor and place into a catheter bag. This procedure was verified by E1 on 12/21/11. Review of R19's bowel and bladder assessment and care plan was reviewed on 12/22/2011. The assessment was found to be blank and incomplete. E10 stated on 12/22/2011, that R19 is continent of bowel and bladder. E10 stated that R19 will let the staff know when she needs to use the bathroom. The care plan reviewed on 12/22/2011 and dated 5/30/11 documented R19 had Urinary and Bowel incontinence related to disease process. R19 was observed in bed wearing a disposable diaper. The diaper was moderately wet with urine. E14 (certified nursing assistant) stated R19 is continent during the day and wears pull ups. E13 (nurse) and E14 agreed that R19 may be occasionally incontinent, but mostly continent during the day hours when they work. Interview with E10 (nurse unit manager) on 12/23/11 agreed with E13 and E14 that R19 is continent and can tell the staff when needing to go to the toilet. E10 was told that the Bowel and Bladder Assessment was not done. E10 sated she would have the staff begin this tonight. E10 was queried why R19 would wear a disposable diaper at night. E10 could not explain. There was no individualized bowel or bladder care plan for R19 to wear disposable diapers and not use the toilet once in bed at night.

Based on record review and interview the facility failed to ensure one resident (R3, who had history of recent small bowel obstruction) was sent to the hospital after exhibiting signs and symptoms of GI (gastro intestinal) distress. R3 showed a decline in condition and suffered with nausea, vomiting, stomach/abdominal pains and gastro-intestinal upset from [DATE] to [DATE] (17 days) before being sent to the hospital. As a result of this failure R3 was found in respiratory distress and sent to the hospital on [DATE] where she expired in the emergency room . This is for one resident in the sample of 3, (R3). Findings include: Review of R3's closed record admission face sheet showed R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital history and physical documentation dated [DATE] and hospital progress note dated [DATE] showed R3 had history of [MEDICAL CONDITION] and highly suspicious [MEDICAL CONDITION]. Hospital history and physical examination [REDACTED]. Documentation on this report showed: The patient probably has a bowel obstruction inside probably from adhesions because she has distally collapsed small bowel. I believe the patient has a high-grade partial obstruction that has been going on for a while and probably conservative measures are not going to be well because she has been readmitted several times. Review of hospital abdominal Xray documentation showed findings of either a resolving small bowel obstruction or an ileus. Documentation by Z1 on R3's History and Physical exam at the facility dated [DATE] showed "S/P small bowel obstruction - resolved." Review of nursing documentation and interviews with E2 (Director of Nurses), E5 (RN), and E6 (Speech Pathologist) on [DATE] noted all to say R3 was alert and verbally responsive upon admission ([DATE]). E2, E5, and E6 stated R3 came to the facility to receive therapy. Review of R3's 14 day MDS dated [DATE] showed R3 had no problems with cognition or decision making skills. R3 was independent with eating after set up and was continent of bowel and bladder. R3 was assessed as only needing supervision with one person assistance with transfers and ambulation. Interviews with E2, E5, and E6 noted all to say R3 ambulated freely by walking and holding on to the back handles of her wheel chair. R3's admission weight was 97.2 lbs. Nursing documentation showed R3 started having periods of emesis. Nursing documentation on [DATE] at 11:15 a.m. showed, "To therapy then had emesis." No amount or description of the emesis was documented. On ,[DATE] and [DATE] nursing documentation showed R3 vomited clear liquid emesis. By [DATE] at 9:00 p.m. nursing documentation showed "Incontinent at times." On [DATE] R3 was exhibiting more frequent signs and symptoms of abdominal discomfort/distress. Nursing documentation showed the following: [DATE] 12:30 p.m. Complain of feeling sick to her stomach due to meds. [MEDICATION NAME] given. [DATE] - 4:25 p.m. Complain of upset stomach. Requested [MEDICATION NAME]. Bowel sounds present 4 quadrants. Refused palpation of abdomen. [DATE] - 10:15 p.m. Vomited 200 cc yellow/brown fluid. [DATE] - 4:00 p.m. Report of abdominal discomfort and bloating. KUB ordered. Refusing meds due to abdominal discomfort. [DATE] 8:00 p.m. Complain of abdominal pain, gas pain, abdomen soft with mild distention. Res stated passed lot of gas with sm. amt of diarrhea and soft stool. [MEDICATION NAME] given. Not effective. [DATE] 8:45 p.m. Still complain of pain. MD contacted. Order given for [MEDICATION NAME]. Res refused. [DATE] 9:30 p.m. Vomiting clear liquid with small amount food content. Took [MEDICATION NAME] and [MEDICATION NAME]. MD contacted. [MEDICATION NAME] (antiemetic) and [MEDICATION NAME] (for bloating and gas) ordered (stat). [DATE] - 4:00 a.m. One large vomitus (undigested [MEDICAL CONDITION] fluid) and complained of 4 episodes of small greenish/watery stool. MD contacted. Order to send res to MD office in a.m. for val of vomiting and diarrhea. [DATE] - 3:00 p.m. Returned with new order for [MEDICATION NAME] dosage. [DATE] - 9:00 p.m. Res stated had 4 loose bowel movements. [DATE] - 6:00 a.m. Had 2 loose bowel movements. Small in amt. [DATE]- 9:00 p.m. One episode loose bowel movement. Yellow/brown, moderate amount. [DATE] - 11:00 a.m. Complain of stomach discomfort. Stated had strong coffee. Made stomach upset. Ate poorly. [DATE] - Daughter concerned about res. condition. MD notified of res condition and appetite. [DATE] 11:00 a.m. New order for [MEDICATION NAME] 400 mg (appetite stimulant). [DATE] 1:45 p.m. Complain of stomach upset. Abdomen soft, non-distended. Had large bowel movement per patient. Poor appetite. One can dietary supplement taken. [DATE] 2:30 a.m. Occasionally incontinent of bladder. [DATE] 4:00 p.m. Complain of abdominal pain. [MEDICATION NAME] and [MEDICATION NAME] given. [DATE] 5:30 p.m. Was spoon fed supper by CAN. Had cup of yogurt and 60 cc dietary supplement. [DATE] 6:00 p.m. MD notified of res inadequate food/fluid intake and res looking weak and dehydrated. New order for IV fluids. [DATE] 8:30 p.m. and 11:30 p.m. Incontinent of bladder. [DATE] 5:00 a.m. Monitored almost every hour. [DATE] 6:55 a.m. Noted with audible rales/rhonchi. O2 sat at 65%. O2 mask rebreather at 10 L/min. Oropharyngeal suction. 911 called. Two staff Ambu bagged res. Transferred to hosp per paramedics. [DATE] 10:00 a.m. Informed by hospital ER res expired at emergency room . ER documentation dated [DATE] at 7:32 a.m. showed R3 was received non-responsive with shortness of breath and vomiting bile. During emergency room care of R3 an NG tube was inserted and 400 ml of bile was obtained. Nursing documentation showed on [DATE] R3's condition was declining. R3 had an admission [DIAGNOSES REDACTED]. R3 was exhibiting increased episodes of vomiting and diarrhea and increased complaints of abdominal pain and abdominal discomfort. Review of R3's plan of care showed no interventions addressing signs and symptoms of small bowel obstruction, abdominal pain, discomfort, or abdominal distress. In addition, R3 had a decrease in appetite. Review of R3's weight record showed R3's admitting weight on [DATE] was 97.2 lbs. On [DATE] R3 weighed 89.4 lbs. Documentation on [DATE] on Z1's progress note showed R3 weighed 80 lbs. This showed a 17.2 lb weight loss in less than one month. R3's plan of care for weights still showed R3 was to be weighed "monthly." On [DATE] R3 had gotten so weak that she had to be spoon fed by the CAN. Nursing and CAN documentation during this time period showed R3 was also becoming frequently incontinent. Review of hospital lab work from the transferring hospital showed R3 had elevated WBC (white blood cell) counts. R3's WBC on [DATE] was high at 18.27 (norms =4XXX,[DATE].00). On [DATE] the WBC was high at 17.91, on [DATE] WBC high at 11.38. When R3 was admitted to the facility her WBC was within normal limits. On [DATE] the facility's lab work for R3 showed R3's WBC was 8.39, but on [DATE] R3's WBC was high at 12.95. R3's WBC had started elevating again. There was no further monitoring of R3's WBC's after [DATE]. Interviews with E2 (Director of Nurses) and E5 (RN) on [DATE] noted both to say they did not know R3 had history of any kind of infection and both stated they did not know what kind of infection R3 had in the hospital before being admitted to the facility. Review of R3's plan of care showed no plan addressing monitoring R3 for infections or monitoring lab work for increased WBC's . Even though R3 had started exhibiting a decline in her condition on [DATE], she was not sent out to the hospital until she was found with labored breathing (rales and rhonchi) on [DATE]. R3 expired in the emergency room approximately 2 hours after she arrived there. R3's final [DIAGNOSES REDACTED].

Based on interviews and record review, the facility failed to provide consistent monitoring, adequate supervision, provide assistance for transfer and develop individualized interventions that were specific to a resident's current medical, physical and cognitive impairment and limitations in order to prevent further falls and or injury. This failure occurred to 1 of 3 sampled residents (R1) identified with history of multiple falls and was assessed as high risk for falls. These failures resulted in a fall incident sustained by R1 on 2/10/2011 which resulted in R1 being sent to hospital with admitting [DIAGNOSES REDACTED]. Findings include: R1 is a [AGE] year old with [DIAGNOSES REDACTED]. R1 was originally admitted to the facility on 12/ 12/2010 from hospital. R1 was at admitted from hospital due to an increasing dyspnea related to pulmonary hypertension. Prior to hospitalization , R1 came from home and live with daughter. While at the hospital, R1 had undergone a cardioversion related to her atrial fibrillation. R1 was also on Coumadin (anticoagulant) related to atrial fibrillation. R1's original stay at the nursing facility was from 12/12/2010 to 12/23/2010, discharged home with home health services. While at home, on 12/15/2011, R1 sustained a fall due to a syncopal episode while trying to get papers outside home. Record showed that R1 was found by neighbors and was taken to the hospital. R1 sustained a subarachnoid hemorrhage, right eyelid paralysis (eyelid closed with decreased intraocular movement) and with right third cranial nerve palsy. It was also indicated that R1 had sustained ecchymosis and laceration that was sutured under the right lip. R1 was readmitted back to the facility on [DATE] from the hospital for deconditioning and therapy. Review of the following nurse's notes, nutritional notes, therapy notes and discharge summary described R1's level of cognition and physical limitations: Nurse's notes of 12/13/2010 at 6:00 A.M.= "(R1) woke 2 A.M. after sleeping for 5 hours, thinking it was time for breakfast " Nurse's notes of 12/14/2010 at 3:00 A.M.= "toilet (R1) with minimal assist" Nurse's notes of 12/23/2010 at 10:30 A.M.= R1 is "alert and verbally responsive with periods of confusion and forgetfulness." Nutritional notes dated 12/13/201: "(R1) is forgetful, ie. forgetting she spoke with daughter earlier after daughter called later this morning." discharged summary from the nursing facility dated 12/23/201 indicated that R1 was identified as "(R1) has decreased memory and not fully aware of [DIAGNOSES REDACTED]. Occupational notes dated 1/12/2011 = R1 requires minimal assistance with ADL's (activities of daily living), "(R1) presents with decreased self care skills, decreased balanced and ambulation, decreased strength and endurance, decreased memory, decreased safety awareness." Occupational notes dated 1/21/2011= R1 with "decreased depth perception, double vision." R1 was also identified that cuing was required for "problem solving, safety awareness, memory." R1 on fall precaution. Physical Therapy notes dated 1/21/2011 = R1 is alert oriented x3 (person/place/time), however, at same time , R1 was also assessed with [REDACTED]." R1 was also described as "walks too fast for her impaired balance. The facility failed to 1) 12/14/2010 at 12:15 P.M., location; R1's bathroom. (R1) found in bathroom, lost balance, falling back, landing on her buttocks and bumping the back of head on the grab bar. Intervention showed that R1 was applied with a sensor alarm to be on at all times(monitoring electronic device) and a low bed with mats on the floor. 2) 1/22/2011 at 9:30 A.M., , location; R1's room. "(R1) found on the floor, stated got up and to plug in phone charger, lost balance." New interventions include for staff to continue education R1 regarding proper safety, reinforce call light for assistance , phone charger placed within R1's easy reach. 3) 2/10/2011 at 8;00 P.M. , location R1's room. " (R1) stated she stood up out of wheelchair, and lost balance and fell . (R1) also stated she did not know why she stood and as a result she lost her balance and hit head on the bedside table. (R1) got up and put herself back to wheelchair and uses her call light. Call light answered and found (R1) with a napkin held to left side of head with spots of blood . (R1) was transferred to hospital and was admitted with reopening of original area where subarachnoid hemorrhage occurred." On 3/7/2011 at 2:00 P.M., E4(physical therapist) stated that when she evaluated R1 on 1/21/2011, R1 was alert oriented times 3. E4 also stated that R1 has very poor safety awareness and poor proprioception. As E4 explained, R1's was assess with poor safety awareness because R1 has no follow through with following instructions and directions. As E4 added, R1 had demonstrated to be forgetful in using assistive device (walker) while ambulating and had failed to follow safety instructions regarding safety transfer to a wheelchair. E4 further stated that R1 had a very poor standing balance when R2 was evaluated and assessed and scored 2 seconds for 1 leg stand for both bilateral lower extremities. E4 explained that average normal standing balance for this assessment is 8 to 10 seconds endurance. E4 also stated that R1 will not follow instructions such as using a call light since she might forget to use it or just had no awareness that she needed assistance for transfer. E4 also added that R1 was too unsteady with gait and that R1 walks too fast for her impaired balance and was anxious. When surveyor asked E4 if R1 would benefit from an electronic monitoring device since R1 had used this monitoring device on the first occurrence of fall on the first admission, E4 stated "looking back I guess it would have help with monitoring her(R1), however it was not my call." On 3/7/2011 at around 3:00 P.M. E2(Director of Nursing) indicated that R1's care plan and assessments are computer charting. E2 showed to surveyor the documentation in the computer. Surveyor requested all the fall assessments and all care plans for R1 while at the facility. E2 printed the requested documentation including care plan with 7 pages. E2 confirmed that this 7 pages care plan documentation are all that R1 had. E2 also informed the surveyor that the notation"Cancelled" that was on the care plan meant that it was a closed record since R1 was discharged immediately after the fall on 2/10/2011. Review of the care plan provided by E2 on 3/7/2011 showed that the care plan for fall was initiated on 12/13/2011 (first admission). The care plan interventions were so generalized and non specific such as: administer medications per physician order assess for fall risk upon admission and as reassess as needed encourage and assist and assist as needed to wear proper non slip shoes encourage to attend supervised activity programs encourage to transfer and change position slowly evaluate effectiveness and side effects of psychotropic drugs have commonly used articles within easy reach Notify physician and family of any falls provide adequate lighting provide assist to transfer and ambulate as needed provide education related to risk /benefits to family and resident about use of adaptive device low bed with mats (initiated on 12/16/2010)-after 12/14 2011 fall On 3/8/2011 at around 10:00 A.M., E2 presented to surveyor R1's care plan that differs from the care plan provided on 3 /7/2011. Review of the care plan provided on 3/8/2011 by E2 showed that it was an 18 pages and showed no notation for "Cancelled" which meant closed record. Surveyor asked E2 verification for this care plan as it differs from what she had informed surveyor on 3/7/2011. E2 responded that she made a mistake when she had given the information. E2 was asked that since R1 was not placed on a sensor alarm (electronic monitoring device) for the second fall (1/22/2011) that happened on the second admission, then what was the specific intervention that was implemented to ensure that R1 was consistently monitored. E2 had responded "sensor alarm could be a dignity issue and the reason why (R1) fell on [DATE] was she was trying to reach her phone charger, so we make sure her charger was in her reach." The care plan has no individualized interventions to prevent further falls that were specific to R1's current medical, physical and cognitive impairments and limitations that was formulated by interdisciplinary team. The facility failed to integrate that R1 has poor safety awareness with no awareness for physical limitations.