Every finding on record at Pavilion on Main Street, The

Based on interview and record review the facility failed to ensure resident safety during transportation to an outside appointment for 1 of 3 residents (R1) reviewed for safety in the sample of 4. The findings include:R1's face sheet printed on 10/9/25 showed diagnoses including but not limited to compression fracture of fifth vertebra (at admission), rheumatoid arthritis, spondylosis of the cervical region and lumbar region, and spinal stenosis. R1's facility assessment dated [DATE] showed no cognitive impairment and total staff assisted needed for transfers. The same assessment showed R1 needed staff supervision or touch assistance with wheelchair use. R1's progress note dated 5/19/25 at 1:30 PM, stated the resident returned to the facility following an orthopedic appointment. Nurse on duty was notified that resident fell from her wheelchair outside of the physician's office. A full assessment was done, and a hematoma (collection of blood trapped under the skin/bruise) was observed on the right side of her forehead. An order to send R1 to the local emergency room was received. On 10/9/25 at 10:56 AM, V4 (Receptionist/Transport Driver) stated she was responsible for R1's transport appointment at a neighboring hospital on 5/19/25. V4 said she went into the exam room with R1, per the resident's request. R1 was fitted with a back brace at that appointment. V4 stated she was wheeling R1 out of the building and pushing the wheelchair in a normal fashion. V4 said R1 suddenly said, I am slipping out, and firmly set her feet down on the ground. R1 fell forward out of the wheelchair and hit her head on the concrete sidewalk. V4 said she tried to hold R1 upright in the chair but just could not do it. V4 stated the wheelchair did not have footrests on it. V4 said hospital staff did respond to the situation and R1 refused any medical care from them. V4 said she called the subject facility and asked what to do. V4 was told to transport R1 back to the facility. V4 said R1 was alert, was not bleeding, but had a reddened area on her forehead. V4 said R1 was assessed by the nurse on duty when she returned to the facility and eventually sent to the local emergency room. V4 said R1 needed footrests for sure! R1 was complaining about the back brace making her sit abnormally in the wheelchair. R1 was trying to hold her feet upright but it was too hard for her. V4 said there was no facility policy regarding footrest use at that time. V4 said now the rule is nobody gets moved to the transport van unless they have wheelchair footrests. The nurse on duty when R1 returned to the facility on 5/19/25 was attempted to be reached for interview but did not respond during the survey. On 10/9/25 at 12:45 PM, V7 (Certified Nurse Aide) stated she did care for R1 frequently and was familiar with R1's needs. V7 said R1 had back issues at admission and used a wheelchair. V7 said R1 did not always sit in the wheelchair the right way. R1 would sit on the edge of the seat a lot. V7 said she had heard R1 fell out of the wheelchair while out of the facility at a doctor's appointment. On 10/9/25 at 1:25 PM, V1 (Administrator) stated resident wheelchairs should always have footrests, unless the resident refuses which is their right. Footrests are needed to elevate legs and keep them off the ground, so they don't drag. Footrests help keep the resident properly positioned in the wheelchair while being pushed. On 10/9/25 at 2:01 PM, V2 (Director of Nurses) stated residents need wheelchair footrests when being pushed by staff. V2 said, It is important to ensure the feet don't get tangled up underneath them. Residents could tip forward in the chair without them. It is tiring for a resident to hold their feet up, off the ground. All residents need footrests when staff are pushing them, unless it is care planned that the resident prefers not to have them. R1's care plan showed a focus area initiated 4/22/25 for a high risk for falls related to deconditioning, gait, and balance problems. The care plan did not show any indication R1 preferred not to have wheelchair footrests. R1's local emergency room discharge summary report dated 5/19/25 showed diagnoses of a head injury, scalp abrasion, and scalp hematoma. The facility's undated Wheelchair Use and Positioning policy states: If the resident uses their feet to self-propel keep the footrests up otherwise lower the footrests and assist the resident to place their feet on the footrest placing legs and feet in proper alignment if possible.

Based on observation, interview, and record review, the facility failed to ensure a bed rail was maintained in a safe manner for 1 of 3 residents (R1) reviewed for resident injury in the sample of 9. This failure resulted in R1 receiving an injury to her right lateral leg, being sent to a local hospital where she received stitches for her injury.The findings include:R1's admission Record, printed by the facility on 9/16/2025, showed she had diagnoses including, but not limited to, displaced comminuted fracture of shaft of humerus left arm (5/6/25), moderate protein-calorie malnutrition, difficulty in walking, reduced mobility, lack of coordination, pain in left should and left elbow, disorders of muscle, dysphagia, unsteadiness on feet, need for assist with personal care, age-related osteoporosis , repeated falls, hypertension, muscle spasm, history of healed stress fracture, dementia, glaucoma, weakness, abnormal gait and mobility, and malignant neoplasm of skin. R1's facility assessment dated [DATE] showed she had severe cognitive impairment. The assessment showed R1 had no verbal behaviors or physical behaviors (i.e., hitting, kicking, pushing, or grabbing others) towards others during the look back period of the assessment. The assessment also showed R1 required substantial to maximal assist for toileting, bathing, upper and lower body dressing, putting shoes on/off, personal hygiene, rolling side to side in bed, going from lying to sitting position, and sitting to lying position. The assessment showed R1 was dependent on staff for all transfers.On 9/16/2025 at 8:55 AM, R1 was sitting at a table with three other females after the breakfast meal. R1 was alert and smiling at staff. On 9/16/2025 at 9:20 AM, V4 (Registered Nurse-RN) said he was working the day R1 was sent out to the hospital (9/2/2025). V4 said the 9/2/2025 incident was the second time R1 went out recently to the hospital for stitches on her legs. V4 said the first incident happened in August 2025. V4 said R1 had a wound on her left leg time, was sent to the hospital and got 11 stitches to her left leg. V4 said he does not know what caused the injury to R1's left leg. He said interventions were to reinforce 2 staff assist with care and transfers and put protective sleeves on her to protect her arms. V4 said the most recent incident on 9/2/2025, R1 got a wound to her right leg. The CNA was V5 and the nurse on duty when it occurred was V6 (LPN-agency nurse). V4 said he was just starting his shift. He went down to see R1's leg on 9/2/25 before the ambulance arrived. V4 said V6 had already wrapped it, so he removed the bandage to see the wound. On 9/16/2025 at 9:31 AM, V5 (CNA) said she had just come back from a long medical leave and had only worked a few days since returning to work. V5 said it was her first time taking care of R1. V5 said R1 is fearful. V5 said, She is afraid she is going to fall. She was holding onto the side rail real tight. I was going to get her up and clean her up while she was on the toilet. I took her boots off. I came around to the right side of R1. I put the 1/2 side rail up. I was putting her gait belt on her, and she waved her hand and said, Leave me alone. She was scared. I put one arm behind her and one under her legs. I turned her to sit her up on the side of her bed. When I got her sat up on the side of the bed, she stopped, looked at me and said, My leg hurts. I looked down and there was a lot of blood. I informed the agency nurse (V6). The nurse wrapped R1's wound and called an ambulance to have R1 sent out. V5 said after they looked at the side rail it did not have the little stoppers on the ends. V5 said, They had to pad the rails. Without the stoppers it is sharp. She was a little combative and did not want to get up, but I don't recall saying she was kicking. She moved one arm to say leave me alone and the other hand was holding onto the railing. It was literally only a couple minutes. At 9:48 AM, this surveyor went with V5 to look at R1's bed. V5 demonstrated how after she put a gait belt on R1, she put one hand behind her and put the other hand under her legs to turn R1. V5 said as soon as she brought R1's legs around to the side of the bed, R1 stopped talking, looked at V5 and said, My leg hurts. V5 said she looked down and saw a puddle of blood on the floor, so she laid R1 back down, placed her leg on a pillow, grabbed something to wipe the floor really quick so no one slipped on it, and then hurried to get the nurse. V5 said maintenance padded the rail and the bed frame after the incident. On 9/16/2025 at 9:51 AM, V8 (Maintenance Director) was on the hall R1 resides looking down at a sheet of paper. V8 said he was looking at the list showing rooms had side rails with no end caps on them when they did a building wide sweep to check all the side rails. V8 said there were several siderails didn't have the caps on. Eight on the 2nd floor and 15 on the 1st floor were missing the end caps on the side rails. V8 said he was double- checking all of them and would provide the list when done. V8 was asked to come to R1's room to remove the tape and pool noodle so this surveyor could see the end of side rail. Observed the end cap on the side rail at time. The metal bars on the end of the side rail were rough where the caps met the metal. V8 said he put end caps on after R1's incident and padded the rail and bed frame.On 9/16/2025 at 10:28 AM, V7 (Licensed Practical Nurse-LPN) said R1 can be very verbal at times with staff. Her skin is like paper. V7 said R1 had a history of skin tears.On 9/16/2025 at 11:06 AM, R1 was taken to her room for wound care. R1 said she does not remember how her injury happened. R1 said she thinks it is getting better. R1 was transferred from her wheelchair to her bed by V22 (certified occupational therapist-COTA) and V23 (Certified Nursing Assistant-CNA). R1 complained of back pain after sitting down on the side of the bed. Staff said they would let the nurse know. R1's right leg was right by the end of the railing where it was now padded and covered with black tape. V9 (Wound Nurse) did the dressing changes for R1. V9 said R1's staples were removed last week. V9 said we steri-stripped it, and it looks really good. R1 had an area on her right lateral leg was secured with multiple steri-strips. The area was curved (u-shaped). After completing the right leg dressing change. V9 removed the dressing from the left lower leg (shin area). R1 had a large, reddened area on the left leg with an opened area inside the red area. V9 said R1 had a laceration on area prior to getting the laceration on the right leg. V9 said the day before R1 got the laceration to her right leg, she was started on an antibiotic due to an infection in the left leg wound. During the wound care resident was alert and pleasant. No resistance to care observed. After wound care, resident was transferred back to her wheelchair and taken back to the dining room/activity area. On 9/16/2025 4:02 PM, V6 (Agency staff-LPN) said she worked 9/1/2025 on the overnight shift. V6 said at the end of her shift, the morning of 9/2/2025 an aide came to her and said she needed me to come with to R1's room. The aide said R1 had fluid coming from her leg. V6 said, I asked the aide what kind of fluid. She said blood. V6 said R1 was in her bed when she got to her room. Blood was on the sheet and a pillow. V6 said, The laceration was deep. I asked what happened and the aide said she did not know. It was a big gash. V6 said she told V4 (RN) oncoming nurse R1 needs to be sent out. He said call the doctor, family, and 911. R1 was sent to the hospital. V6 said V5 (CNA) did not say anything about R1 kicking or being resistant. V6 said, When I went in the resident did not seem upset or resistive. V6 said V5 said she was getting R1 up and noticed fluid coming out of leg. On 9/17/2025 at 2:10 PM, V5 CNA said V1 (Administrator) and V3 (Regional VP of Clinical Operations) met with her right after she talked with this surveyor the previous day. V5 said they asked her what this surveyor was talking with her about, then they handed her a paper and said we forgot to have you sign the statement about what happened with R1's incident. V5 said she started reading it and was told to just sign it. V5 said she told them she was going to read it first. V5 said she told them she did not recall saying anything about R1 kicking. V5 said V1 and V3 said You did, just sign it. V5 said she told them R1 was not kicking, she just waved her hand and told me to go away because she did not want to get up. V5 said she felt pressured into signing the form and just signed it. V5 said as soon as she did, she regretted it, and wished she had not signed the statement.On 9/17/2025 at 2:57 PM, V2 (Director of Nursing-DON) said they determined something happened with the metal on the bed caused R1's injury. V2 said that is why her bed got padded. V2 said she expects staff to report any equipment might cause a safety issue for residents, and to take the equipment out of service until it can be repaired.On 9/18/2025 at 12:56 PM, V19 (R1's Physician/facility's Medical Director) said R1 is a very fragile individual. V19 said, She (R1) doesn't just get skin tears; she has skin explosions. V19 said there were not many days between the 9/2/2025 incident, and the one before. V19 said he would expect the facility staff to make sure the equipment used is smooth with no rough edges.The facility's investigation and QAPI plan for R1's 9/2/2025 incident showed R1 was sent to the hospital for a laceration to her right leg occurred while sitting the resident up on the side of her bed. R1 returned to the facility with 20 sutures. The list V8 had been going over showing side rails in which there were no end caps, or the end caps needed to be replaced showed over 20 side rails either did not have end caps, or they needed to be replaced. The facility's investigation file had staff interviews in it. V5's interview statement showed V5 said R1 was resistant and kicking her legs. V5's statement had a date up at the top of the form dated 9/2/2025. (These interviews were not provided to this surveyor until after V5 was interviewed by this surveyor). The facility's list of residents with wounds, provided on 9/16/2025 showed R1 has had 7 skin tears in the last three months. The facility's 9/16/2025 Wound Report for non-pressure wounds showed R1 had two active wounds as of 9/16/2025. One to her left lower leg in the front, from a previous incident on 8/25/2025 (facility was cited for this on annual survey), and one to her right lateral lower extremity measured 4.5 centimeters (cm) in length x 6.5 cm width. R1's Wound Assessment Details Report dated 9/11/2025 showed R1 sustained a laceration and was sent to the emergency room (ER). Staples dry and intact to site Resident with mild episodic pain to site. R1's 9/2/2025 notes from a local hospital showed New laceration of right lower extremity status post suture repair today. The facility's undated policy and procedure titled Supplies and Equipment, Environmental Services showed Equipment shall be monitored for good working condition or any needed repairs.

Based on interview and record review, the facility failed to ensure a resident's medications were available and administered as ordered for 1 of 3 residents (R4) reviewed for medications in the sample of 10.The findings include: On 9/17/2025 at 8:39 AM, V6 (R4's wife) said R4 did not get his medications for 3 days when he was first admitted to the facility. V6 said she was not sure what medications. V6 said R4 just told her he was not getting all his medications. V6 said the facility told them the hospital did not send them. V6 said, I could not go into the facility when he was first admitted because I had the flu. I told (R4) to say something about not getting all his medications. V6 said she knows she spoke to someone about the medications. V6 said, He is on a lot of medications. I was worried he was going to have withdrawal because he is on methadone. V6 could not identify who she spoke to at the facility regarding R4's medications. V6 said when R4 was discharged from the facility back to home, they did not give him a prescription for diuretics. Bumetanide. V6 said R4 was discharged on a Tuesday (9/9/2025). The home health nurse came on Thursday (9/11/2025), so he did not start taking the diuretic until Friday. V6 said R4 missed Wednesday and Thursday's diuretic.On 9/17/25 at 11:20 AM, V24 (Registered Nurse-RN) said she was the nurse on duty when R4 was admitted to the facility on [DATE]. V24 said she did some of R4's admission. Other nurses completed some of the assessments for his admission because it was near the end of her shift. V24 said there were medications that R4 missed due to the medications not being available. V24 said she marked in R4's medication administration record (MAR) on 8/12/2025 and 8/13/2025 that the methadone and Lyrica were not available. The methadone is used for pain. The Lyrica is also for pain. V24 said when a new resident is admitted to the facility, the nurse will fax a script (prescription) to the physician. The doctor signs the script and faxes it back to the facility, the nurse will fax it to the pharmacy, and the pharmacy will dispense it for delivery. V24 said it could take 24-48 hours on admit before we receive the medications. V24 said, We must have the script to dispense the medications. V24 said as soon as we fax the signed script to the pharmacy, we can request a code if we have that medication in the C-box medications. V24 said she was not sure if those are in the C-box. V24 said there were medications that the facility did not have available and R4 did miss some medications. At 11:38 AM, V24 said she was also the nurse that discharged R4 on 9/9/2025. V24 said, He discharged home with a multivitamin that he brought in and DuoNeb treatments. I asked (R4) if he needed any medications to take home, he said no just those two. Neither him, nor his wife (V6) asked for any prescriptions. I even offered to request scripts from the doctor, and he said no. (V6) was here when he was discharged . I went over the discharge instructions and showed them which medications we were sending with them. His wife asked me to write down when all his medications were last given and when they were due next.On 9/17/25 at 1:49 PM, V2 (Director of Nursing-DON) said the hospital did not send a script for methadone and Lyrica when R4 was admitted . V2 said, We were trying to find a doctor to get the script. V19 (R4's physician while in the facility, and the facility's Medical Director) was his physician on admission. (V19) ended up signing the script. Initially (V19) told the nurse to contact the hospital. The hospital would not sign the script, so (V19) ended up signing it. Methadone is used for pain, and R4 said he had been on it for 13 years. When I found out about his methadone not being available, I went to make sure he was not in withdrawal. He said he was not having any withdrawal symptoms but was concerned that he may start having them soon. That is when he told me he had been taking it for 13 years. At 2:36 PM, V2 said R4 was admitted on [DATE]. V2 said there was an order for methadone and Lyrica, but there were no signed scripts. V2 said if there is no script, the nurse should call the doctor, and the pharmacy. If there are problems getting a script, then the nurse should call me. V2 said she was told the nurses reached out to V19, and the hospital, and was told the hospital would not send one to the facility because he was basically our problem. V2 said, Within one hour of speaking with (R4's) daughter and finding out about the medications not being available, I had the signed script sent to the pharmacy. V2 said then the facility had to wait for the pharmacy to deliver it. On 9/18/2025 at 1:56 PM, V19 (R4's physician while in facility/facility's Medical Director) he said he is familiar with R4. V19 said R4 is a challenging individual. V19 said the hospital should have sent 2-3 days' worth of the methadone with R4 on admission or sent a valid script with him. V19 said unfortunately, this is an ongoing issue with hospitals. V19 said the facility notified him to request the e-script (electronic script). V19 was not in a location where he could look it up on a computer to see when the facility first notified him of the needed e-scripts. V19 said the facility is usually pretty good at letting him know when they need one. V19 said R4 should have come to facility with the prescription, or the hospital should have let me know. V19 said they are not medications that the facility would probably have at the facility. V19 said the facility should have requested 2-3 days' worth of them from hospital.R4's August 2025 Medication Administration Record (MAR) showed an order for Pregabalin (Lyrica) 150 mg. Give 1 capsule two times a day for pain. The MAR showed four doses were not administered (8/11/25 at 8 PM, 8/12/25 at 8:00 AM, 8/12/25at 8:00 PM, and 8/13/25 at 8:00 AM). The MAR showed an order for Methadone Hydrochloride 5 mg. Give 1 tablet three times a day for pain. The MAR showed six doses were not administered as ordered. (8/11/25 at 9:00 PM, 8/12/25 at 8:00 AM, 12:00 PM, and 9:00 PM, and on 8/13/25 at 8:00 AM and 12:00 PM). R4's progress notes showed on 8/11/25, 8/12/25, and 8/13/25 the facility was awaiting delivery from pharmacy for the methadone. The 8/13/25 notes showed the facility was waiting on R1's Lyrica to be delivered from pharmacy. The 8/13/25 notes showed V2 (DON) documented at 3:38 PM that she received a call from R4's family regarding his missing medications. The notes showed the pharmacy informed her they had not received prescriptions from the doctor. 8/13/25 at 4:34 PM, V2 documented the pharmacy called and verified they received the prescriptions, and the medications would be delivered within four hours.R4's referral notes from the local hospital dated 8/10/2025 showed he was receiving methadone 5 mg three times daily and Lyrica 75 mg nightly in the hospital.The facility provided the pharmacy's packing slip showing the methadone and Lyrica were delivered to the facility on 8/13/2025 at 11:47 PM.The facility's policy and procedure titled Reconciliation of Medications, with a revision date of October 2018, showed, Gather the information needed to reconcile the medication list: a. Approved mediation reconciliation form. b. Discharge summary from referring facility. c. admission order sheet. d. All prescription and supplement information obtained from the resident/family during the medication history. e. Most recent electronic medication administration record, if this is a readmission. The policy showed, General Guidelines: 1. Medication reconciliation is the process of generating a master list of the resident's current medications. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 6. If there is a discrepancy or conflict in medications, dose, route, or frequency, determine the most appropriate action to resolve the discrepancy. For example: a. Contact the nurse from the referring facility; b. Contact the physician from the referring facility; c. Discuss with the resident or family; d. Contact the resident's primary physician in the community.Contact the admitting and/or attending physician . 7. Document findings and actions in the resident's electronic medical record. Documentation.If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift.

Based on observation, interview and record review the facility failed to safely handle a resident to prevent multiple skin tears. This failure resulted in R92 being transferred to the emergency room (ER) after a transfer which contributed to R92 sustaining a large skin tear requiring 11 stitches/sutures. This applies to 1 of 23 residents (R92) reviewed for safety in the sample of 23. Findings include:R92's progress notes dated 8/23/25 shows, Resident noted with a skin injury to the left lower leg. The incident occurred during transfer from the wheelchair to the bed, the CNA (certified nursing assistant) reported. MD (V21 R92's medical doctor (MD)) is informed with order to transfer resident to ER. R92's skin tear report dated 8/23/25 shows, Informed by the CNA (V20) that while providing care noted blood stain on sock and when sock was removed noted wound to left lower leg. Blood was new.R92's progress note dated 8/24/25 shows, Resident returned from ER at approximately 00:15 (12:15 AM) with daughter (V19) and EMS (emergency medical system). Resident received 11 sutures (stitches) to left lower leg. Bandage clean, dry and intact. Resident leg elevated on pillow. Vitals stable upon return, no pain upon arrival, but will give Tylenol as scheduled. New order for Clindamycin (antibiotic) 300mg (milligram) capsule 3 times per day for 7 days. Bacitracin (antibiotic) twice a day to left leg laceration. 10-14 days for suture (stitches) removal.R92's emergency room after visit summary dated 8/23/25 shows, Reason for visit: wound check, Diagnosis: laceration of shin. On 8/26/25 at 3/16 PM, V19 R92's daughter stated, V21 Registered Nurse (RN) called her over the weekend and said, V20 CNA was putting her to bed and bumped her leg. V19 said, Looked like more than a bump to me. It required 11 stitches. They called it a skin tear. She has had a lot of skin tears since she has been at the facility but this one required stitches. V19 said she rode with her to the ER. V19 was worried about her mom and what the facility was going to do to prevent these skin tears from happening. V19 said, They need to be more gentle with her (R92). On 8/26/25 at 2:18 PM, V18 RN stated, he told V20 CNA to put R92 to bed and then V20 CNA came back and told V18 that R92 had a skin tear. V18 said he went to the room and saw the wound on R92's leg. V18 asked V20 CNA what happened. V20 CNA told V18 RN that V20 transferred R92 to bed and tried to undress her when he noticed the wound. The blood was fresh, and he believed it happened during the transfer. V18 called V21, R92's medical doctor (MD) and reported what happened. V21 R92's MD sent R92 to the hospital for stitches/sutures. On 8/26/25 at 3:07 PM, V20 CNA stated, V20 transferred R92 to bed on 8/23/25. V20 noticed her socks had a red splotch on it. V20 pulled the sock down and saw the wound. V20 said, once he saw the wound he got the nurse. V20 said he didn't know what happened. On 8/27/25 at 10:48 AM, V21 R92's MD stated R92 sustained an injury during transfer. V21 felt it was a pretty significant skin tear and sent R92 to the ER. On 8/26/25 at 2:17 PM, V3 wound care nurse was changing R92's dressing to her left shin/leg. There was a red/purple baseball (approximately) size wound that had approximately 10 (some appeared to be double) stitches. V3 stated she received the wound during a transfer over the weekend. R92's wound assessment details report dated 8/25/25 shows, active skin tear type 2: partial flap loss, facility acquired, measuring 5.00 cm (centimeters) X 1.50 cm X 0.10 cm. R92's skin tear report dated 6/18/25 shows, This writer was notified by CNA that the resident had obtained a skin tear to the right elbow while assisting the resident with a boost in her wheelchair. R92's skin tear report dated 6/24/25 shows, During transfer from the w/c (wheelchair) to the bed, CNAs noted a blood on the pad. Resident is noted with skin tear to the left elbow. R92's skin tear report dated 7/17/25 shows, At the time of the incident, resident was being repositioned in her wheelchair. Resident stated she hit her leg. Notes: . Resident observed sliding while sitting in her chair. During repositioning, resident stated, I hit my leg on my wheelchair. Skin tear noted to the posterior (back) left leg. R92's care plan date initiated 6/3/25 shows, The resident has an actual impairment to skin integrity: 6/3/25-laceration to left elbow, 6/4/25- left lateral elbow, 6/11/25- abrasion to left mid-upper back, 6/18/25- rt (right) elbow skin tear, 6/24/25- left elbow skin tear, 6/25/25- right elbow skin tear, 7/17/25- left posterior skin tear, 8/1/25- bruise to right forearm, wrist ad hand, 8/12/25- skin tear right elbow.R92's care plan date initiated 8/25/25 shows, R92 has a laceration to her left lower leg. She is taking Clindamycin and bacitracin to prevent infection. Interventions: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. R92's care plan date initiated 5/7/25 shows, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) activity intolerance, dementia. Interventions: Sit to stand: dependent, 2 assist. The facility's resident transfers and safety devices policy dated 10/2017 shows, Policy: All residents are assessed at time of admission for transfer ability. Residents who are unable to transfer themselves independently or with minimum assistance shall be transferred following the principles of this policy to allow for maximum safety during resident transfer. Transfers shall always be conducted following the principles of proper body mechanics, and safety.

Based on observation, interview and record review the facility failed to ensure dietary recommendations were implemented for residents with a history of significant weight loss. This failure resulted in R43 and R93 not receiving their therapeutic diets as ordered for their severe weight loss. This applies to 2 of 9 residents (R43, R93) reviewed for weight loss in the sample of 23. Findings include:On 8/25/25 at 10:32 AM, V5 Dietary Manager added 21 cooked, individual chicken nuggets into the facility's food processor. V5 stated, she was making puree for 11 residents. V5 stated, regular diets will get 5 chicken nuggets per person. (There should have been 55 nuggets pureed for 11 pureed diets but only pureed half of the amount she should have). The spreadsheet for the noon meal on 8/25/25 shows, regular diets should get 5 chicken nuggets to equal 2 ounces of protein per person. 1. R43's face sheet lists his diagnoses to include: toxic encephalopathy, dysphagia and dementia. R43's meal ticket shows, pureed diet with double portions on every tray. On 8/25/25 at 11:51 AM, R43 was eating the lunch. He was eating a regular pureed diet. He did not have double portions.On 8/26/25 at 8:28 AM, R43 was eating breakfast. He had a regular pureed diet. He did not have double portions. On 8/26/25 at 11:49 AM, R43 was eating lunch. He had a regular pureed diet. He did not have double portions. On 8/26/25 at 1:26 PM, V8 Registered Dietitian (RD) stated, R43 had a significant weight loss in one week when he went out to the hospital. R43 has continued to lose weight. V8 saw R43 last week and recommended larger portions. V8 clarified that meant double portions. V8 stated she put that on R43's meal ticket. V8 stated, They should be following the meal ticket and providing double portions. R43's progress notes from V8 RD dated 8/4/25 state, Nutrition note due to significant weight loss: Observed R43 during meal service this morning- he was feeding himself and appeared to be eating well. Noticed some coughing. He continues to receive a general/pureed diet with thin liq's (liquids). He feeds himself with set-up or requires assistance with meals. Supplements: House supplements- 120 ml (milliliters) TID (three times per day). PO (by mouth) intake has been 50-100% at meals since readmission per nsg (nursing) documentation. Weight 146.4 # (pounds)- decreased from 148# upon readmission from hospital and significantly by 9.6% in the past month from 162# on 7/1 (7/1/25). His weight has decreased by 11.8% in 3 months form 166# on 5/16 (5/16/25) and by 10.6% in 4 months from 163.8# on 4/23 (4/23/25). Current BMI (body mass index): 21.0- low for his age. He is not currently taking diuretics. Labs do not suggest hydration imbalance. Will arrange for him to receive larger portions to prevent further weight loss and monitor via nutrition at risk team. R43's care plan date initiated 8/5/25 shows, Focus: R43 has had a significant weight loss. Weight: 146.4# on 8/1-decreased from 148# upon readmission from hospital and significantly by 9.6% in the past month from 162# on 7/1. His weight has decreased by 11.8% in 3 months from 166# on 5/16 and by 10.6% in 4 months from 163.8# on 4/23. He continues to receive a general/pureed diet with thin liq's. He feeds himself with set-up or requires assistance with meals. Interventions: 8/4/25 Increase portions for him at meals to prevent further weight loss. 2. R93's face sheet lists his diagnoses to include: major depressive disorder, complete loss of teeth, alcohol use & gastro-esophageal reflux disease. R93's meal ticket shows, pureed diet with super cereal X2 in the morning, double portions of all food and ice cream for lunch and dinner. On 8/25/25 at 11:51 AM, R93 was eating lunch. He had a general pureed diet. He did not have double portions or ice cream. On 8/26/25 at 9:29 AM, R93 was eating breakfast. He did not have 2 bowls of super cereal or double portions. On 8/26/25 at 11:49 AM, R93 was eating lunch. He did not have double portions or ice cream. On 8/26/25 at 1:15 PM, V8 RD stated, interventions they have in place for R93's weight loss is double portions at every meal, 2 bowls of super cereal at breakfast and ice cream. V8 stated, They need to be following the recommendations to meet the nutritional needs of the residents. R93's progress notes from V8 RD dated 8/4/25 shows, Nutrition noted due to significant weight loss: Saw R93 this morning during meal rounds and he had eaten 100% of this meal (double portions). R93's weight decreased significantly by 11.2% in 6 mo from 114# on 2/3 to 101.2# on 8/2. Current BMI: 14.9- severely underweight. He continued to receive a general/pureed diet with double portions and thin liquids. He feeds himself with supervision and set-up. Supplements: super cereal with breakfast and 120 ml supplements with every meal. PO intake has been 76-100% at most meals recently per nsg documentation. Family has been notified of significant weight loss and have decline when TF (tube feeding) was discussed. Will continue to monitor nutritional parameters follow up as needed. R93's care plan date initiated 3/18/2024 shows, Focus: R93's weight decreased significantly by 11.2% in 6 mo. from 114# on 2/3 to 101.2# on 8/2. He continues to receive a general/pureed diet with double portions and thin liquids. He feeds himself with supervision and set-up. Supplements: super cereal with breakfast and 120 ml supplements with every meal. Interventions: Give resident supplements as ordered. The facility's weight management policy dated 9/2019 shows, Policy: It is a policy of this facility that each resident will be provided with sufficient food intake to maintain proper nutrition and health. Procedure: .Significant weight changes are defined as a gain or loss of: 5% in one month, 7.5% in 3 months, 10% in 6 months, gradual or insidious unwanted weight loss/gain. These residents shall be referred to the registered dietitian/diet tech for assessment of nutritional status. Appropriate dietary recommendations shall be made as indicated.

Based on observation, interview and record review the facility failed to prepare pureed foods in a manner to maintain its nutritive value. The facility failed to serve mechanical soft foods to residents that required a mechanical soft diet. The facility failed to serve foods according to their daily menu.These failures apply to all 97 residents in the facility. Findings include:1. A facility list dated 8/25/25 showed 11 residents required a pureed diet.Chicken nuggets, cooked carrots, potatoes, bread, and melon were the food items listed on the facility's lunch menu/spreadsheet dated 8/25/25. The menu/spreadsheet showed each resident was to receive a total of 5 chicken nuggets, for a total of 2 ounces of protein, at lunch. The facility's pureed chicken nugget recipe printed 8/25/25 showed each resident on a pureed diet was to be served the pureed equivalent of 5 chicken nuggets for lunch. The recipe showed facility kitchen staff were to add 3 tablespoons of chicken broth to each 2 ounce portion of chicken nuggets to make the puree. Staff were to add thickener as needed to make the puree. On 8/25/25 at 10:32 AM, V5 Dietary Manager added 21 cooked, individual chicken nuggets into the facility's food processor. V5 stated she was making puree for 11 residents. V5 then added an unmeasured amount of hot water and bread crumbs into the food processor with the chicken and began to puree the mixture. V5 stopped the processor and again added an unknown amount of hot water and bread crumbs to the pureed chicken nugget mixture. V5 pureed the mixture. At 10:41 AM, V5 poured the chicken nugget puree into a tin pan and placed it in a warmer. At no time during the puree prep, did V5 Dietary Manager refer to or follow a puree recipe for chicken nuggets. V5 Dietary Manager did not puree any bread for lunch.On 8/25/25 at 11:40 AM-12:10 PM, V5 Dietary Manager plated lunch for residents, from the steam table, which included the pureed chicken nuggets. No pureed bread or slices of bread were served to any residents. On 8/25/25 at 2:00 PM, V5 stated, Each puree was supposed to have gotten 5 pureed nuggets. I don't puree enough. I only pureed 21 nuggets for 11 people. I should have used 55 nuggets. They only got 2-3 nuggets a piece. V5 stated she added water to the chicken instead of broth because broth can be too salty. When asked why she used bread crumbs instead of thickener to make the lunch puree, V5 stated, The residents don't like the thickener. V5 stated she did not refer to the facility's pureed chicken nugget recipe prior to or while making the puree. V5 stated residents did not receive a slice of bread or pureed bread for lunch because she forgot it was on the menu. On 8/26/25 at 1:15 PM, V8 Dietician stated the facility cooks are to follow the facility's recipes when making pureed foods to ensure residents on pureed diets are receiving adequate nutrition and accurate serving sizes. V8 stated water should not be added to purees unless the recipe calls for it to ensure the nutritive and calorie content are preserved. V8 stated bread crumbs are not to be used in purees to thicken the mixture unless the puree recipe calls for it. 2. A facility list dated 8/25/25 showed R81 and R92 each required a mechanical soft diet.Chicken nuggets, cooked carrots, potatoes, bread, and melon were the food items listed on the facility's lunch menu/spreadsheet dated 8/25/25. The facility's mechanical soft chicken nugget recipe printed 8/25/25 showed chicken nuggets where to be ground, with gravy added to the ground nuggets. to achieve a mechanical soft texture. On 8/25/25 at 11:40 AM-12:10 PM, V5 Dietary Manager served and plated lunch to residents on the second floor. No mechanical soft chicken nuggets were noted on the steam table to serve to residents. On 8/25/25 at 11:45 AM, R81 was served 5 individual chicken nuggets, carrots and potatoes for lunch. On 8/25/25 at 11:51 AM, R92 was served 5 individual chicken nuggets, carrots and potatoes for lunch. On 8/26/25 at 1:15 PM, V8 Dietician state kitchen staff should follow the facility's recipes/spreadsheets when preparing mechanical soft foods. V8 stated if the recipe/spreadsheet shows the food/meat should be ground, it should be ground. The facility's Cycle Menu Food and Nutrition Services policy (undated) showed, Cycle menus are planned to meet the nutritional needs of the clients in accordance with the Dietary Reference Intakes of the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences and with additional guidance from My Plate for Older Adults and the USDA Dietary Guidelines for Americans Key Recommendations.

Based on observation, interview and record review the facility failed to ensure kitchen utensils were stored in a sanitary manner. The facility failed to ensure food was prepared in a manner to prevent cross contamination. The facility failed to ensure kitchen staff covered facial hair to prevent cross contamination. The facility failed to maintain the kitchen in a sanitary manner. These failures have the potential to affect all 97 residents in the facility. Findings include:The facility's Long-Term Application for Medicare and Medicaid form date 8/25/25 showed a resident census of 97. On 8/25/25 from 9:11 AM-9:25 AM, the following observations were noted during the initial tour of the facility's basement kitchen: The garbage container located under the handwashing sink was overflowing with garbage. The kitchen floor, by the oven and the food prep table, was sticky. Food and liquid debris were noted on the floor in these areas. Dried liquid and food debris were noted on the sides and front of the oven. A sticky substance was noted to the sides and front of a food processor. Multiple large spoons and metal scoops were noted on a black, plastic drainage mat located on top of a prep table. Food debris and a sticky white liquid were noted scattered across the black mat, under the spoons and scoops. V5 Dietary Manager pointed to the scoops and spoons and stated, That's where we store our clean scoops. It looks like they need to be cleaned again. That mat is dirty. When asked when the kitchen floor was last mopped or cleaned, V5 stated, Probably the last time I worked, which was over a week ago. Scattered frozen green beans, a bag of flour tortillas, and a bag of potatoes wedges were noted on the floor of the walk-in freezer. Packets of sugar, crackers, and salt were scattered across the floor of the dry storage room. Food debris and multiple opened cardboard boxes were noted on the floor of the room. At 9:23 AM, V6 and V7 Dietary Aides were noted in the kitchen performing different tasks. V6 and V7 each had full beards. Neither V6 nor V7 wore facial coverings over their beards.On 8/25/25 at 9:27 AM, during the initial tour of the facility's first floor kitchenette, the following observations were noted: The coffee machine appeared dirty with dried coffee and food debris noted on the sides of the machine. A soiled spoon, wet washcloth, a cup and an empty pitcher sat in the sink of the kitchenette. Food debris, including scrambled eggs, were noted on the bottom of the sink. Flies were noted crawling in the sink. The floor of the kitchenette was sticky to walk on. Multiple areas of food debris were noted across the floor. The steam table was empty however areas of spilled oatmeal and eggs were noted on the table. Flies were noted crawling on the food on the table. On 8/25/25 at 10:32 AM, V5 Dietary Manager removed a metal tin, containing cooked chicken nuggets, from a warmer and placed the tin on a prep table. Behind the prep table, a large black garbage bag was noted sitting on the floor, 3/4 full of garbage. At 10:34 AM, V5 removed the foil covering off the tin, with her bare hands. V5 turned and grabbed the garbage bag with her bare hands and threw away the foil. Without washing her hands, V5 immediately began preparing the pureed chicken to be served for lunch. On 8/25/25 at 10:42 AM, V5 Dietary Manager stated beards and facial hair are to be covered when in the kitchen and/or when serving food to prevent hair from falling into the food. V5 stated she was unsure when the kitchen had last been cleaned. V5 stated, They are supposed to clean it daily, but I have been off for over a week, so I don't know if it was ever done. It needs to be cleaned. If I am not here, I am not sure it gets done.The facility's Food and Nutrition Services Hair Restraints/Jewelry/Nail Polish policy dated 2017 showed, Food and nutrition services employees shall wear hair restraints and beard guards. Hairnets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated.The facility's Food and Nutrition Services Cleaning Schedule policy dated 2018 showed, The healthcare community stores, prepares, distributes and serves food in a sanitary manner to prevent foodborne illness. A daily cleaning schedule will be posted in the kitchen with specific cleaning assignments to include both routine cleaning/sanitizing tasks along with deep cleaning tasks. Director of food and nutrition services or someone designated as person in charge will review the cleaning schedule each day to assure the tasks have been completed in a satisfactory manner.

Based on observation, interview and record review the facility failed to ensure residents receiving pureed diets were served appetizing and flavorful meals for 4 of 4 residents (R73, R43, R93 & R6) reviewed for palatability in the sample of 23. Findings include:On 8/25/25 at 9:13 AM, R73 was in his room eating his morning breakfast tray. R73 said he must have his food pureed and the food here just sucks, and I can't eat most of it. R73's tray was noted to still have a full bowl of hot breakfast cereal, and what he reported to be pureed pancakes. R73 said he was not sure what the other meal item on the tray was, but he was done and could not eat it. R73's morning meal ticket shows he should have pureed pancakes, cream of rice, and pureed scrambled eggs.On 8/25/25 at 12:33 AM, R73 was in his room eating his lunch. R73's meal ticket showed he should have on his meal tray pureed chicken nuggets, carrots, fruit and bread. R73 said the chicken nuggets were terrible and he could not eat them. The chicken nuggets were in a ball on the tray and looked like a big ball of stuffing. On 8/25/25 at 12:50 AM, after the lunch service was finished, a test tray of the pureed meal was sampled by this surveyor and 2 additional surveyors. The chicken nuggets and carrots were very thick and would stick to the roof of your mouth as you tried to swallow them.On 8/26/25 at 8:35 AM, during the morning breakfast service the pureed eggs were sampled by this surveyor and one additional surveyor. The eggs were a milky white color with the consistency of a thin pudding. The taste of the eggs were a mixture of water and powder and very unpleasant to eat. On 8/26/25 at 8:40 AM, V1 (Administrator) sampled the pureed eggs in front of the surveyors and said to him it tasted like a pudding with no sugar.On 8/26/25 at 9:20 AM, R73 was again in his room eating the morning meal tray. R73 pointed to the eggs which were still on his tray and said, I can't even tell you what that tasted like. R73 pointed to a ball of food and said, and I am not sure what that is but it's awful I think it maybe bread.On 8/26/25 at 2:03 PM, V8 (Dietician) said the staff cooking the food should follow the recipes in the kitchen. When it was described by this surveyor to V8 how the pureed eggs looked and tasted V8 replied, Oh my. The facility provided pureed diet list shows in total 11 residents receive a pureed diet including: R73, R93, R43, and R6. R93, R43 and R6 Electronic Medical Records show they all have cognitive impairments and were not able to be interviewed. The facility provided Food Palatability-Hot Food Temperature Guidelines dated 2018 shows that food should be prepared and served that are both safe and appetizing.

Based on observation, interview, and record review the facility failed to provide a homelike environment. This applies to 2 of 23 (R8, R85) reviewed for homelike environment in the sample of 23. Findings include:On 8/25/2025 at 9:44AM, R8 and R85 room was observed to have heavy gouging behind both residents' headboards and behind R85's recliner. The area with heavy drywall gouging and missing paint is approximately 2-3 feet by 2-3 feet tall behind the headboards and recliner.On 8/26/2025 at 12:00PM, V16 Director of Maintenance said work orders are put in the [app] by staff or by him when issues are reported to him. V16 said there is not a work order for that room. V16 said resident rooms should have no wall damage or holes.The facility provided Quality of Life - Homelike Environment dated 4/2014 states, . residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on interview and record review the facility failed to ensure baths were provided as scheduled for 2 of 23 residents (R56 & R91) reviewed for Activities of Daily Living (ADL's) in the sample of 23. Findings include:1. R56's ADL care plan initiated on 1/12/24 shows she has an ADL self-care deficit and requires assistance from staff for bathing/showering.The first-floor shower schedule shows R56 should receive showers on Tuesday morning shift and Friday evening shift. R56's Bath and Shower Report Sheet shows she had showers on 8/8/25 and not again until 8/19/25. R56's Electronic Medical Record (EMR) tasks/shower documentation conflicts with R56's shower sheets and has checkmarks indicating that R56 had both a shower and a bed bath on 8/12/25 (Tuesday). On 8/27/25 at 9:40 AM, R56 said, A couple weeks ago it did happen it was on a Tuesday that I did not get my shower. I was told by staff there was too much going on and they would try to come back and do one, but no one ever did.A Concern/Compliment Form shows V22 (R56's) son filed a grievance on 8/17/25 that R56 did not receive her shower the week of 8/10/2025. The concern form is documented that it is substantiated and that showers were not given that evening due to it being an agency CNA (Certified Nursing Assistant). On 8/27/25 at 10:08 AM, V2 (Director of Nursing) said it was verified that R56 did miss her shower that day as indicated in the substantiated grievance. 2.) On 8/25/25 at 10:06 AM, R91 said, Actually I do have a concern here, last Saturday no one ever came to give me my bath.R91's ADL care plan initiated on 7/16/25 shows he has an ADL self- care deficit and requires assistance from staff for his ADL's.The first-floor shower schedule shows R91 should receive showers on Wednesday morning and Saturday evening.R91's Bath and Skin Report Sheet has documented on Saturday 8/23/25 that R91 Refused his shower. There is no documented reason or name of who documented that refusal, why the shower was refused and there was no nurse signature on that shower documentation. On 8/26/25 at 11:16 AM, V14 (CNA) said residents should receive showers twice a week and document it on shower sheets, and if anyone refuses, they let the nurse know and she should sign off on the sheet. V14 said they should also re attempt to get the resident a shower later that day or the next day. On 8/27/25 at 9:35 AM, R91 was asked again when he missed his shower and if he refused to take one. R91 smirked and stated, I definitely did not refuse any shower. I wait for my showers. The facility provided Showers policy revised on 6/22 shows showers should be given a minimum of twice a week and if a resident does refuse a shower a nurse should be informed and document that refusal after speaking with the resident.

Based on observation, interview and record review the facility failed to follow physician's orders for a dermatology consult for a resident with a persistent body rash, ongoing since July 2025. This applies to 1 of 23 residents reviewed for quality of care in a sample of 23. Findings include: On 8/25/2025 at 12:30 PM R64 was in his room sitting in his wheelchair. R64 had a red, scabby rash covering his arms and abdomen. R64 stated it has been going on for a while and the facility recently tried a new cream on him. R64 stated, They used the whole tube. R64 stated he was treated for scabies in July, which he thinks it is, but the rash still continues. R64 stated he continues to be very itchy. R64 stated the rash is also on his inner thighs. R64 stated his son was supposed to be taking him to the dermatologist soon. On 8/26/25, during the Resident Meeting, R64 was observed scratching and picking at scabs on his arms. R64's Physician's Order Sheet shows he was treated with Permethrin Cream on 7/9/25 for the same rash. R64's Progress Notes dated 8/7/25 state, Refer to dermatology for rash. and This writer spoke with POA about referral and is in agreement. On 8/26/2025 at 11:15 AM V17 (Scheduler) stated, I was not aware of the need for the appointment. I have not made him an appointment yet. At the end of the day on 8/26/25 a document was presented to this Surveyor showing an appointment had been made with dermatology on 12/3/25 for R64.

Based on observation interview and record review the facility failed to administer medication as ordered. There were 30 opportunities with 2 errors resulting in a 6.67% error rate. This applies to 2 of 4 residents (R51, R35) reviewed for medication administration in a sample of 23. Findings include:1. On 8/26/2025 at 8:45AM V15(RN) took a new needle from the medication cart drawer and applied it to the Insulin Degludec (Long-Acting Insulin) pen. V15 then dialed the pen to 20 units and administered the medication to R51. V15 did not prime the needle prior to administration of the insulin. When questioned, V15 stated, We only have to prime the needle with the first dose from the pen. The Manufacturer's Guidelines for the administration of the insulin state, Instructions for use Priming your (Insulin) pen: Turn the dose selector to select 2 units, Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top, Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer, A drop of insulin should be seen at the needle tip. 2. On 8/26/25 at 8:19, V18 Registered Nurse (RN) was passing R35's morning medications. He gave 1 tablet of Bumex (water pill) instead of 2 tablets. Before giving the medications to R35, V18 verified a total of 6 pills in the cup. (Should have been 7). R35's medication administration record (MAR) for August 2025 shows, bumetanide (Bumex) oral tablet 1 mg, give 2 tablets by mouth one time a day related to essential primary hypertension (high blood pressure). The same MAR shows, he should have received 7 pills total for the morning medication pass. On 8/27/25 at 11:51 AM, V18 RN stated, the Bumex tablets are 2 mg (milligram) tablets, so he only gave 1 tablet. R35's Bumex card was verified and shows, they are 1 mg tablets and to give 2 tablets in morning as prescribed by the physician. The facility's administering medications dated 11/2020 shows, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: .4. Medications are administered according to physician's orders unless otherwise specified (for example, before and after meals orders) .

Based on observation, interview and record review the facility failed to ensure the glucose monitoring machine was cleaned after each resident use. This applies to 2 of 23 residents (R21 and R23) reviewed for infection control in the sample of 23. Findings include:On 8/26/2025 at 8:30 AM V15 (RN) used the blood glucose monitoring machine to check R21's blood sugar. After getting the result V15 returned to the medication cart, took a new test strip from the bottle and a new lancet from the drawer and without cleaning the machine proceeded to go to R23's room and checked her blood sugar. V15 then returned to the medication cart in the hallway again and put the blood glucose machine into the top drawer of the cart. V15 was asked if/when the facility cleans the blood glucose monitoring machines. V15 stated, We clean the machine after each shift with the purple wipes. R21's Physician's Order Sheet dated 8/26/25 shows R21 has an order for Insulin Aspart (Fast acting insulin) per sliding scale before meals and at bedtime. Within this order there is a place to enter R21's blood sugar results. R23's Physician's Order Sheet dated 8/26/25 shows R23 has and order for Blood Glucose Monitoring before meals and at bedtime. The facility policy entitled Cleaning and Disinfecting Blood Glucose Meters dated 6/2022 states, Patient-care devices (e.g. electronic thermometers, glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared between patients without cleaning and disinfecting between patients.

Based on observation, interview and record review the facility failed to immediately isolate residents with a suspected infectious rash. The facility failed to ensure staff did not expose residents to a suspected infectious rash. The facility failed to ensure residents on isolation remained in their rooms to prevent the possible spread of infection. The facility failed to clean and disinfect resident rooms and linen in a manner to prevent the possible re-exposure of a skin infection. These failures have the potential to affect all 94 residents in the facility. The findings include:The Facility Data Sheet dated 7/23/25 showed a resident census of 94 residents. A facility isolation list dated 7/23/25 showed R1 was on contact isolation for a suspicious rash. R2, R3, and R7 were on contact isolation due to scabies.1. R1's resident assessment dated [DATE] showed R1 was severely cognitively impaired and dependent on staff for all cares.R1's nurses note dated 7/19/25 showed R1 was found to have a petechial rash to legs, torso, chest and back.A physician order dated 7/22/25 showed R1 was placed on contact isolation (2 days after her rash was noted). On 7/23/25 at 8:28 AM, no contact isolation signage was noted on or around R1's doorway. No isolation cart with PPE (personal protective equipment) was noted by or around the entrance to R1's room. No bins for isolation garbage or linen were noted in R1's room. On 7/23/25 at 8:58 AM, a contact isolation sign was noted on R1's door. V8 Housekeeping Director was placing isolation garbage and linen bins by the entrance to R1's room. No PPE cart was noted by or around the entrance to R1's room. V8 stated V15 Licensed Practical Nurse (LPN)/Acting Infection Preventionist (IP) had placed the contact isolation sign on R1's door a few moments ago. R1 was in bed with a red, pinpoint rash noted to her left upper and lower abdomen.On 7/23/25 at 8:51 AM, V5 Certified Nursing Assistant (CNA) stated R1 was not put on contact isolation until this morning. V5 CNA stated although she knew R1 had a rash, R1 has been brought out of her room by staff, that morning, to eat breakfast in the dining room with the other residents.On 7/23/25 at 8:51 AM, V6 CNA also confirmed R1 had eaten her breakfast in the main dining room that morning despite staff knowing about R1's rash. 2. R2's nurses note dated 7/21/25 showed R2 was found to have a petechial rash to his left upper leg. The note showed, Clothes and linens washed. Room deep cleaned. R2's physician order and July 2025 Medication Administration Record (MAR), dated 7/22/25, showed R2 was placed on contact isolation for his rash (one day after the rash was noted). R2's MAR dated 7/21/25 showed R2 received his first treatment of Permethrin Cream 5% (cream to treat scabies) topically for his rash. On 7/23/25 at 8:36 AM, a contact isolation sign hung on the door to R2's room. A PPE cart was noted by R2's doorway. This surveyor donned PPE and entered R2's room. R2 was in bed with a red, pinpoint rash to his right upper arm, right elbow, right breast area, and right upper abdomen. R2 was actively scratching his right upper arm. R2 stated to this surveyor, No one has been wearing that stuff (PPE) you have on. You are the first. R2 stated he's had his rash for a couple of days now. R2 stated he was treated with a cream and then showered but no one had changed his bed linen or cleaned his room since the application of the cream and shower. On 7/23/25 at 10:21 AM, V8 Housekeeping Director stated R2's room should have been deep cleaned and his bed linen changed after R2's first Permethrin treatment and prior to him coming back to his room from his shower, but we are working on it. We haven't done it yet.3. R3's nurses note dated 7/19/25 showed R3 was found to have a petechial rash to his right upper and lower leg. The note showed, Clothes and linens washed. Room deep cleaned. R3's MAR dated 7/21/25 showed R3 received his first treatment of Permethrin Cream 5% (cream to treat scabies) topically for his rash. R3's physician order dated 7/22/25 showed R3 was placed on contact isolation for his rash (3 days after his rash was noted). On 7/23/25 at 8:45 AM, a contact isolation sign hung on the door to R3's room. A PPE cart was noted by R3's doorway. This surveyor donned PPE and entered R3's room. R3 was seated in a wheelchair by his bed. A red, pinpoint rash was noted to R3's left breast area and left arm. R3 stated he also had the rash to his bilateral inner thigh areas. R3 stated the rash to his left breast was still itchy. R3 stated to this surveyor, This is the first time seeing anyone in that garb (PPE). R3 stated he was put on isolation that morning (7/23/25), after he had eaten breakfast in the main dining room with other residents. R3 stated he'd had his first Permethrin treatment and shower, but no one had cleaned his room or changed his bedding in the last few days. On 7/23/25 at 8:51 AM, V5 and V6 CNAs stated R3 did eat breakfast in the main dining room that morning (7/23/25) despite staff knowing about R3's rash. V5 and V6 CNA each stated R3 was not put on isolation until the morning of 7/23/25. On 7/23/25 at 10:21 AM, V8 Housekeeping Director stated R3's room had yet to be deep cleaned, and his bedding had not been changed. On 7/23/25 at 10:51 AM, V15 LPN/Acting IP stated she had been the facility's Infection Preventionist for over a year but had yet to successfully complete the test for the infection preventionist course and receive the certification. V15 stated skin scrapings had not been done on R1-R3 or R7's rashes however they were assuming the rashes were scabies based on exposure and the appearance/symptoms associated with the rashes. V15 stated R1 was the first to develop a rash, on 7/3/25, that didn't seem to ever go away. V15 stated she believed R1-R3 and R7 had been exposed to an infectious rash by V6 CNA. V15 stated she was notified on 6/15/25 by an unnamed staff member, that on 6/10/25, V6 CNA was treated for a scabies-type rash by her physician. V15 stated she gave V6 CNA a verbal reprimand on 6/15/25 for not reporting her rash to administration and because she continued to work in the facility while having the rash. V15 stated V6 CNA provided cares to R1-R3 and R7 in June 2025 and July 2025. V15 stated staff are to place residents on contact isolation immediately once a suspicious rash is identified on a resident. V15 stated residents on contact isolation are not to come out of their rooms until their treatment is completed due the potential of spreading the rash to other residents. V15 stated, per facility policy, a resident's rash is to be treated with Permethrin cream, wait eight hours, and then shower the resident. This treatment is repeated seven days later. V15 stated, While the resident is in the shower, his/her room is to be deep cleaned, and all the bedding is to be changed. If that is not done and the resident comes back to a dirty room. This could potentially re-infect the resident with scabies. V15 stated she had not reported V6 CNA's or R1-R3, R7's skin rashes to the local health department. A facility Coaching/Corrective Action for Minor Offenses form dated 6/15/25 showed V6 CNA was given a documented verbal warning/training for a failure to disclose communicable disease in a timely manner or unreported. V6 CNA's June 2025 timecard showed V6 worked in the facility 6/4/25-6/9/25 and 6/11/25-6/13/25. The facility's Policy and Procedure Scabies dated 12/22/23 showed, Purpose: To identify and treat residents that have rashes that have the potential of being contagious. Residents that have been identified with a suspicious rash may be treatment prophylactically without confirmation testing and skin scrapings with medications ordered by the resident's attending physician. Initiate contact precautions upon identification of the suspicious rash. Apply scabicide (Permethrin cream) to the skin. Allow the cream to sit on the skin following the MD orders. Re-shower the resident to wash off lotion. Terminally clean resident's room. Wash all linens, curtains, and soft items. Items that can be washed must be bagged and not used for 14 days. Repeat procedure in 7 days or according to MD order.

Based on interview and record review the facility failed to employ an Infection Preventionist that had successfully tested and completed infection preventionist training and education. This failure has the potential to affect all 94 residents in the facility. The findings include:The Facility Data Sheet dated 7/23/25 showed a resident census of 94 residents. V15's Licensed Practical Nurse (LPN)/Acting Infection Preventionist (IP) Nursing Home Infection Preventionist Training Course records printed 7/23/25 showed V15 started the course on 9/30/2023 but had yet to successfully complete the test portion of the course and receive the certification. On 7/23/25 at 10:51 AM, V15 LPN/Acting IP stated she had been the facility's Infection Preventionist for over a year but had yet to successfully complete the test for the infection preventionist course and receive the certification. V15 stated she had been acting as the IP under the IP certification the previous Director of Nursing (DON) had but that DON no longer worked at the facility. On 7/23/25 at 11:57 AM, V1 Administrator stated the facility did not currently have a certified Infection Preventionist. The facility's Infection Preventionist job description (undated) showed the Infection Preventionist education and experience requirements included a certification in Infection Prevention.

Based on observation, interview, and record review the facility failed to ensure staff wore beard coverings when serving food. This applies to 4 of 4 residents (R52, R70, R43, R80) reviewed for food sanitation in the sample of 19. The findings include: On 10/29/24 at 10:30 AM, during the resident council meeting hosted by this surveyor and attended by R52, R70, R43 and R80, a concern was brought up by residents that beard coverings are often not being worn when staff are serving food. On 10/29/24 at 12:23 PM, the noon meal was being served on the first floor. V5 (Cook) was scooping and plating the food from a portable serving table. The plates were then handed to V4 (Dietary Aide) to put on trays and add liquids and other food items before handing it to staff to serve to the residents on the first floor. V4 had a beard and mustache and did not have any face covering over his beard. At 12:30 PM the first floor service was over and V4 and V5 took the portable serving table up to the second floor to serve those residents. V5 verified that she and V4 had been together serving the entire first floor. At 12:34 PM, V4 and V5 were beginning the meal service for second floor. V4 still had no face covering on. At 12:38 PM, V7 (Dietary Aide) went up to V4 and told him he needed gloves and handed him a face mask which V4 then applied. On 10/29/24 at 1:47 PM, R52 said that V4 is the staff he was referring to who will not wear a beard covering when he is serving food. On 10/29/24 at 2:09 PM, V6 (Dietary Manager) said staff who have beards should be wearing at least a face mask to cover their facial hair when serving or plating food. V6 said some staff don't like the beard coverings the facility has so she is going to try and order new ones. R52, R70, R43 and R80's face sheets and dietary orders all show they reside on the first floor are served food from the facility kitchen. The facility provided Hair Restraints/jewelry/Nail Polish/False Eyelashes policy revised 2017 shows that food and nutrition employees should wear hair restraints and beard guards.

Based on observation, interview, and record review the facility failed to monitor a resident during medication administration. This applies to 1 of 4 residents (R79) reviewed for pharmacy services in the sample of 19. The findings include: On 10/28/2024 at 9:43 AM, R79 was observed sitting up in her bed with medications sitting in a pill cup on her bedside table. R79 said the medications in the cup were her medications and she forgot to take them. R79 said the medications were left by the nurse about an hour prior. On 10/29/2024 at 9:11 AM, V3 Licensed Practical Nurse (LPN) said [R79] does not have a self-administration order for medications. V3 said she would not leave medications at the bedside for [R79]. V3 said the nurse should stay with a resident during medication administration because they could choke or drop a pill on the floor. On 10/30/2024 at 9:16 AM, V2 Director of Nursing (DON) said medications should not be left at the bedside and the nurse should make sure the resident takes the medications. R79's Order Summary Report dated 10/28/2024 does not list a self-administration order for medications. The facility's Administering Medications policy dated 11/2020, states . Residents may self-administer their own medication only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely and resident has successfully completed a competency for self-administration.

Based on interview and record review the facility failed to supply a bed hold notice to a resident representative at the time of transfer for 1 of 1 resident (R1) reviewed for resident rights in the sample of 3. The findings include: R1's Notice of Involuntary Transfer or Discharge form dated 5/21/24 showed, R1 was transferred out of the facility due to the safety of individuals in the facility were endangered. The same form had a box checked that indicated a copy of the facility bed hold policy was given to the resident or their responsible party. On 6/25/24 at 10:07 AM, V4 (Social Service Director) stated she was responsible for completing the form. V4 said she did not actually send a copy of the bed hold policy at that time. V4 said the bed was held for the required 10 days automatically, so she just checked the box to show that. On 6/25/24 at 12:30 PM, V2 (Director of Nurses) stated she did not have any documentation of a bed hold notice sent with R1 at the transfer. V2 said the form box was marked incorrectly and nothing was ever provided to the resident or his state guardian. The facility's undated Holding Bed Space policy states: 1. Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, a representative of the business office will provide information concerning our bed-hold policy.

Based on observation, interview, and record review the facility failed to provide pain control for a resident with fractured ribs for 1 of 1 resident (R289) reviewed for pain. This failure resulted in R289 experiencing difficulty sleeping, difficulty participating in therapy and uncontrolled pain. The findings include: R289's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include multiple fractures of ribs, left side, need for assistance with personal care, abnormalities of gait and mobility, opioid dependence, spinal stenosis, low back pain, and intervertebral disc degeneration lumbar and lumbosacral region. R289's 9/20/23 Clinical Admission note entered at 7:19 PM showed R289 reported an aching and radiating pain to left lower back at a 4 on the pain scale with the frequency of the pain being constant. R289's care plan initiated 9/21/23 showed, [R289] has acute/chronic pain related to disease process and multiple left rib fractures . [R289] will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date . Administer analgesia as per orders Evaluate the effectiveness of pain interventions per facility policy. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. R289's September 2023 Physician Order Sheet showed R289 was admitted with an order for oxycodone-acetaminophen 10-325 (1 tablet) to be administered as needed every 4 hours for pain. R289's 9/20/23 Admission Summary entered at 8:07 PM showed, Resident arrived to facility at 3:40 PM. Resident alert and oriented x 3 . Resident admitted to the facility for therapy due to a fall at home. Resident does complain of pain to left ribs due to multiple non-displaced fractures of the 6-10 ribs . On 9/28/23 at 10:29 AM, R289 said, Over the weekend, I think it was Sunday (9/24/23). I had pain in my shoulder and side. I have 6 broken ribs. I guess they didn't get my oxycodone from the pharmacy. Then last night at bedtime I asked for my pain medication and they said they didn't have it. They said there was not an order for the oxycodone so they gave me a muscle relaxer instead. I've been taking the oxycodone here so it didn't make sense. It was about 7-8 PM last night when I requested it for pain. I rated my pain at an 8 at that time. When I asked the nurse last night where the oxycodone was, she threw her hands up and walked out of my room. I didn't sleep last night so it was hard to do therapy this morning. I didn't sleep because I was in pain all night. On 9/28/23 at 11:07 AM, V8 RN (Registered Nurse) said R289 does have an order for oxycodone but she doesn't have any here (in the facility) currently. V8 said the sticker had been pulled so she believed it was reordered. V8 said the record showed it was last ordered on 9/28/23 (the day of this interview). V8 said the facility does have a supply of common medications from the pharmacy that she thought included oxycodone. At 1:28 PM, V8 said R289 still did not receive oxycodone. V8 said the NP (Nurse Practitioner) was in the facility today and said he had electronically sent in the prescription this morning. V8 said the NP was going to his office and was going to check and see what happened with the prescription. V8 said the nurses cannot take anything from the convenience supply without the prescription first so they were waiting for that. V8 confirmed R28 was still requesting the oxycodone at this time. V8 said, Well, she has broken ribs so of course she is requesting it The facility's Controlled Drug Receipt/Record/Disposition Form for R289's supply of oxycodone showed a dose given on 9/24/23 at 5:48 AM was the last tablet of oxycodone available for R289 until the next pharmacy delivery. The facility's pharmacy requisition dated 9/24/23 at 9:09 PM showed R289's supply of oxycodone was received at the facility (16 hours after R289's last dose was administered). The facility's Controlled Drug Receipt/Record/Disposition Form for R289's supply of oxycodone received on 9/24/23 at 9:09 PM showed R289's supply of oxycodone was exhausted again on 9/27/23 at 11:03 AM. R289's September 2023 eMAR (electronic Medication Administration Record) showed R289's last dose of oxycodone was given on 9/27/23 at 11:02 AM (approximately 26 hours prior). On 9/28/23 at 1:49 PM, V2 DON (Director of Nursing) said, We typically reorder medications before they run out which is the goal. We have the [convenience supply] we can get medications out when that happens so we don't leave the resident without their medication. Sometimes we do need a new prescription. It is important to treat the resident's pain because it can cause a lot of other issues for the resident. The facility's policy and procedure revised 10/2020 showed, Pain Assessment and Management; Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain Management id defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals .

Based on observation, interview and record review the facility failed to ensure sufficient staffing for all 86 residents residing in the facility. The findings include: The facility's 9/28/23 federal 672 form for resident census and conditions of residents documents 86 residents residing in the facility. The same form shows none of the residents to be independent with ADL's (activities of daily living) for bathing, dressing, transferring, toilet use or eating. All residents are dependent on staff or require 1-2 staff for assistance. On 9/28/23 at 9:00 AM, V10 CNA (Certified Nursing Assistant) said she had worked in the facility since January. The staffing is usually 4 CNA's on each floor. When working with call offs there has been only 3 on the floor. V10 stated, with only 3 staff it is hard to get the mechanical lifts, getting all the residents out of bed, and get residents fed that need assistance. The call lights will take longer to answer, and showers sometimes must be rescheduled to second shift or the next day. V10 said at times staff are still trying to get people up after breakfast. On 9/28/23 at 9:43 AM, V11 CNA said now that some of the summer help has returned to school, there has been a shortage of staff. V11 said staff will stay over to cover the next shift or come in early. There have been as low as 2 aides on the floor. V11 stated, if there are only 2, no showers or charting is getting done, and we try to answer call lights as soon as possible. V11 said weekends are harder because there is no extra staff from the offices to help pass trays and answer call lights. On 9/28/23 at 11:20 AM, V9 CNA said today there are 5 staff on the floor because the state is here, but at times has had 2 aides on the floor. V9 said, When short on staff, we leave residents in bed and just change them, we try to get them done at least once a shift. There is no way to get the mechanical lift transfers because that requires 2 people, and scheduled showers will get bed baths, and call lights take longer. V9 said some residents maybe wait 1-2 hours but when there is no staff it is hard to get to call lights. V9 stated, Weekends are worse with call offs, that is the biggest issue. If residents stay in bed, they cannot do activities or get out of their rooms. V9 said on second shift, one of the CNA's has to take the smokers out, and that pulls away from the floor, leaving call lights unanswered and residents waiting to get into bed. On 9/27/23, R12 said the second shift is mostly short staffed. The call lights take too long to get answered. She said it took 3 hours to get assistance for the bathroom over the past weekend. She said there needs to be more staff on the day shift as well. Some days they do not get her out of bed until after 9:30 AM, and activities have already started. On 9/26/23 R42 said she can hear the staff talking about how short they are, and the aides tell her there is not enough help. She puts on her call light for assistance getting into the bathroom and must wait so long she had considered just transferring herself. She said in the morning it is over 30 minutes of waiting. R42 said the staffing is stretched. On 9/27/23 at 10:30 AM, during a resident group meeting, R59 said there is not enough staff. Lots of call offs, especially on the weekends, and there is no replacement, they just work short. R59 said, There's supposed to be 2 aides per hall but 1 to 2 CNAs call off most weekends. Nurses refuse to help out with aide tasks. R59 said there is long wait for call lights. R59 said he self-transfers at times because he gets tired of waiting. R59 said, We have mentioned staffing, call offs, and bad equipment repeatedly at monthly resident council meetings but nothing ever changes. And the smoking policy is dumb. Must have a staff member outside to smoke. It is 15-20 minutes for the CNA or activity aide to be off floor with smokers. Later in day activity aides are gone. We lose the much needed CNA on the floor to help, but they outside with smokers. That takes time away from caring for us. The resident council meeting minutes for June, July, August, and September 2023 each document concerns with call light response times and residents wanting CNA's from both halls to help. The September minutes show a request for increasing the CNA scheduling on the weekends. The June 6th minutes show too many call offs in groups and not enough on call staff to cover the hours. During the survey from 9/26/23 to 9/28/23, CNA's were observed on the floor answering call lights, assisting residents with ADL's, and passing meal trays. Each of the wings had 2 CNA's working, and each wing had a nurse. Multiple call lights were lit up throughout the day and were answered after varying amount of time, from 5 minutes to 20 minutes. On 9/28/23 at 8:18 AM, V2 DON (Director of Nursing) said V7 was completing the CNA schedules, but she is no longer in the facility. V2 said, The schedule is put out a month at a time and then there is a daily assignment sheet. That sheet will reflect call offs and open shifts. With a census of 86, there should be 8 CNA's in the building during first and second shifts. Four working on each floor. Over the night shift, there should be 2 on each floor. V2 said the facility has no agency aides, only in house CNA's. To cover the call off's the facility will offer bonuses and if no one picks it up then the managers come in and work on the floor. V2 said, When it gets down to 2 CNA's, a manager should come in. Do not recall if there has been only 2 CNA's working on the floor, since starting as the DON. It is the expectation for the nurses to be helping. The 1/5/2023 facility assessment staffing plan states: staffing adjustments are constantly changing and may by adjusted as census, resident's conditions, or acuity changes. The administrator will increase the staffing of other department staff to assist with resident needs. Nurse managers can be flexible in their schedules to assist on the floor as needed as can department managers. Agency staff is used to supplement facility staff.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by staff for one of three residents (R2) reviewed for abuse in the sample of 8. This failure resulted in bruising and R2 crying and distressed into the following day. The Immediate Jeopardy began on 12/3/22 when V20 (Certified Nursing Assistant/CNA) heard R2 screaming after V22 (CNA) entered R2's room to provide care. V2 (Director of Nursing/DON) and V4 (Regional Director of Operations/RDO) were notified of the Immediate Jeopardy on 1/13/23 at 11:00 AM. V1 (Administrator) was on leave. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 1/17/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's face sheet showed a [AGE] year-old woman with diagnoses of hemiplegia and hemiparesis affecting the left non-dominant side, need for assistance with personal care, hypertension, osteoporosis and repeated falls. On 1/11/23 at 1:42 PM, R2 was in her room in her motorized chair. R2 became visibly upset when relaying the events of 12/3/22. On 1/11/23 at 10:09 AM, V3 (CNA) said she heard R2 had bruises about a month ago and an agency CNA got walked out. At 10:18 AM, V8 (CNA) said, There was an issue with R2 about a month ago. A CNA was 'rough' with her. R2 told me that girl (CNA) made her cry. I saw the bruises (on R2). There was one bruise on the right lower arm and two to the upper arm. I asked R2 if she told anyone, and she said she told the nurse. It happened on a weekend before Christmas. I didn't chart the bruises. I heard it wasn't documented. I asked the nurse (V10) what happened. At 10:38 AM, V10 (Licensed Practical Nurse/LPN) said she was in R2's room. V10 stated, I believe V11 (Medical Records) was in her room too. R2 said a CNA was rough with her, roughed her up when getting ready for bed. I saw the bruises on her arm and was concerned for neglect or abuse. I went straight to V2 (DON). V2 told me they were 'taking care of it.' It didn't happen on my shift, so I didn't document anything. I'm guessing it was already documented and didn't need to start another 72-hour assessment. It was around the first weekend in December. It was about a month ago, the weekend of 12/4 or 12/17/22. It happened on my weekend off so when I came in on Monday, I found out. At 1:42 PM, R2 said her bruises (now gone) were from that one lady they got out of here. R2 stated, I was on the toilet and told her she needed to be kinder. She (CNA) started yelling at me louder and louder. My left side is paralyzed, and she (CNA) was trying to get my shirt over my head without unbuttoning it. My left side is paralyzed, and she told me to be quiet as she was going to do it her way and not the way I wanted. She bounced me up against the wall and twisted my right arm. I screamed for her to stop, and she told me I better start listening. I got bruises. She hit me. I was really crying hard. She (CNA) didn't even care they were coming to save me. They escorted her out. I couldn't stop crying. I was afraid she was going to come back and hurt me. At 1:50 PM, R4 (R2's roommate) said, It all happened so fast. R2 was in the bathroom with the CNA. R2 started yelling and screaming for the CNA to leave her alone. I got out into the hall to get help. R2 was traumatized. She was crying and screaming. It was kind of a big deal. There should be a record of it. She (CNA) was rougher with R2 than she needed to be. At 3:45 PM, V18 (Registered Nurse/RN) said R2 told her about the incident with the CNA after the fact. V18 said, I looked in R2's electronic medical record, and there was no documentation of the incident. At 6:54 PM, V20 (CNA) said on the evening of 12/3/22, she witnessed R2 being forcibly held in a painful position by V22 (CNA) as she (R2) screamed. V20 said V22 did not release her hold on R2 until she (V20) told her to, despite R2's screams. V20 said, It's a sad, sad situation. On 12/3/22, R2's call light was on. I told V22 the light was on. V22 got on her phone. I again told her she needed to answer R2's light. Shortly after V22 went to answer R2's call light, I heard R2 yelling and screaming. I was at the nurses' station. I ran down to R2's room. I don't remember the CNA's name. R2 was sitting on the toilet and her right buttock was halfway off the seat. V22 had R2's right side pushed against the bathroom wall and her left (paralyzed) arm extended above her head. R2 can't move her left side and you must be careful with it. She (V22) hit her (R2's) right side on something. The grab bar and toilet paper holder were on R2's right side. R2 was visibly in pain, crying, had tears and was still screaming at the CNA. You must put R2's left arm in a top first and the CNA wanted to put it over her head. R2 will tell you how to take care of her and dress her. She (V22 CNA) roughed her up pretty good. R2 had bruises to the right side, her wrist, and arm later that night. I told V21 (Registered Nurse/RN) about it and V21 notified V1 (Administrator). V21 talked to me about it and took notes. I wrote a statement and gave it to V21. No one else ever asked me about it. R2 was upset and still shook up the next day too. A day or so later R2 said 'That lady hurt me.' You could see it in her face. She (R2) was so upset V22 hurt her. This was hands down 100% abuse. I walked in on V22 hurting her. You can't ignore them (residents) and just do stuff your way. She had the right to be protected and be safe. That's our job, to advocate for them. R2's roommate was in the room at the time and heard everything. At 11:00 PM, V21 (RN) said she wasn't sure of the date of the incident with R2, but it was on the evening shift. V21 said, I usually work nights and I picked up an evening shift that day. V21 said she was notified by V20 (CNA) of an abuse incident between V22 and R2. V21 said she assessed R2 and interviewed her. V21 said R2 was alert and oriented. R2 had bruises to both arms. V21 said, I was taken aback when V1 told me not to document anything in R2's record or anywhere else. I didn't document anything. I didn't want to get fired. I assumed it would be taken care of. It should not have happened. R2 was very upset. She was very emotional and crying. R2 told me she didn't deserve to be treated that way. I have no doubt this situation occurred. I feel it will continue if it's not documented, reported and investigated. If something like this is going to be covered up, what else could be covered up? At 9:15 AM, R2 said the CNA was hitting her. R2 said she didn't want to talk about it anymore. R2 said, They took good care of me after the fact. At 9:50 AM, V19 (RN) said R2 told her a CNA was super rough with her. She said she was attacked by a CNA. At 10:19 AM, V22 was unable to be contacted. V22's contact phone number was called and was disconnected. The facility was not able to obtain a working phone number, birthdate, social security number or perform a Healthcare Worker Background Check as V22's social security number was not available to the facility. V22 was contracted through an agency and background check details were not available. On 1/13/23 at 10:55 AM, V4 (RDO) said V2 was new and R2's incident was reported as a behavior. R2 didn't like the CNA and had a preference. At 10:55 AM, V2 confirmed 12/3/22 was the only second shift V20 and V21 worked together. At 1:20 PM, V25 (CNA) said she worked the day after the incident happened with R2. V25 said, I didn't see any bruises, but they were maybe on her arm. I got upset. R2 was upset, crying and saying she wanted to leave the facility. I asked if someone knew what happened and the nurse was aware of what happened. The facility's 5/2019 Abuse, Neglect Exploitation Policy showed abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This assumes that all instances of abuse of all residents, irrespective of any mental or physical, even those in a coma, cause physical harm, pain or mental anguish. Treating any resident in a manner that does not uphold a resident's sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetrates a disrespectful/or potentially abusive attitude towards the resident(s). R2's electronic medical records showed no documentation of the 12/3/22 incident or subsequent bruises. There was no documentation of R2's physician notification of the incident. R2's 12/12/22 facility assessment showed she was cognitively intact. This assessment showed R2 required extensive assistance to dress, toilet, personal hygiene and transfers. R2's care plan showed she had decreased upper body dressing skills related to medical complexities. Interventions for dressing included to assist resident to fasten/unfasten shirt, instruct resident to put each arm into sleeves and bring front together, and provide assistance as needed for any step she cannot complete. R2's Activity of Daily Living (ADL) care plan showed to allow sufficient time for dressing and undressing. R4's 10/28/22 facility assessment showed she was cognitively intact. Time reports for V20 (CNA) and V21 (CNA) showed the only date they worked together on second shift was 12/3/22. The Immediate Jeopardy that began on 12/3/22 was removed on 1/17/23 when the facility took the following actions to remove the Immediacy. V2 (DON) and V38 (Infection Prevention Nurse) assessed R2 for injury and emotional distress. All residents' abuse assessments were reviewed and updated as appropriate by V26 (Social Service Director). A formal abuse investigation was opened and sent to IDPH for R2 on 1/12/23 and police were notified. All residents' abuse care plans were reviewed and updated as appropriate by V26. A targeted in-service for V1 (Administrator) was done on 1/13/23 and included the facility's abuse policy, prevention and proper reporting steps. All facility staff were in-serviced prior to starting their shifts by V2 (DON) and V4 (RDO). In servicing included abuse policy and prevention, types of abuse, steps to prevention, how to and when to report allegations of abuse, and honoring resident preferences. Inservice completion was 100% compliance with one employee off on a leave. All staff will complete an abuse post-test by 1/18/23 indicating abuse policy/prevention and reporting procedures. Quality Assurance (QA) tools will be utilized to monitor compliance with this immediate remedy. The ADON (Assistant Director of Nursing), DON, RDO and/or designee will conduct a random audit of 5 residents a week for the next 12 weeks. This audit will include physical and psychological assessment of the residents to determine no abuse occurred. The audit will be ongoing and sporadic after 12 weeks. Trends will be discussed at the facility's morning meetings and any necessary corrective actions taken immediately. The results of each audit will be reviewed, reported and discussed in the next Quality Assurance/ QAPI (Quality Assurance Performance Improvement meeting. The audit will be ongoing and sporadic after 12 weeks. On 1/17/23 at 9:00 AM, a review of the facility's in-servicing and posttest documentation was done. R2 declined a physical exam.

Based on interview and record review the facility failed to assess, monitor, and identify a resident experiencing a change of condition following a fall. This failure resulted in a delayed identification of a left femur fracture. This applies to 1 of 3 resident (R2) reviewed for change of condition in the sample of 4. The findings include: R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set assessment dated [DATE], showed her cognition was severely impaired, with no behaviors, no rejection of cares, requires two person assist with bed mobility, transfer, toileting, and limited range of motion to bilateral upper and bilateral lower extremities. V10's (CNA) statement dated [DATE] documents On [DATE] around 6:40 PM, she was walking down the north hall and she was passing (R2's room) and R2 was observed laying on the floor. She entered the room to make sure she was okay and called for help. V7 (LPN) and V14 (RN) R2's nurse responded. She rolled R2 from her left side onto her back and assisted V14 transferring R1 back to her wheelchair. R2's electronic medical record showed no assessments were documented for R2's fall on [DATE]. The nurses note dated [DATE] documents R2 noted with difficulty transferring new orders for PT evaluation. R2's Physical Therapy Evaluation report dated [DATE] documents exhibiting a decline in activities of daily living and functional mobility. Assessment identifies two performance deficits in transfers and ambulation due to deficits in bilateral lower extremity strength, functional activity tolerance, impaired standing balance . Standing balance= poor unable (total dependence). R2's baseline mechanical lift. Care giver goals to able to help her transfer and walk like before. The nurses note dated [DATE] documents R2 has been yelling very loudly for several days when staff try to move, change her, or even put a sheet on top of her. (There was no physical assessment documented at this time). The fax report to V4 (Physician) dated [DATE] documents Can (R2) have something for increasing pain? She is calling out in pain and grimacing when she is sitting in her wheelchair and during cares. R2's SBAR (Situation Background Assessment Recommendations) form dated [DATE] documents increased lethargy, decreased intake, Screams with cares. The nurses note dated [DATE] documents R2 yelling out in pain. At shift change the CNAs reported R2 would not straighten her left leg. Nurse assessed and found it was contracted, tried to straighten leg MD notified, and x-ray ordered. The nurses note dated [DATE] documents left leg contracted and on [DATE] R2 was admitted to hospice. The nurses note dated [DATE] showed R2 expired at the facility. R2's imaging report dated [DATE] showed acute displaced fracture of the left femur. R2's electronic medical records showed there were no assessments performed until [DATE] when R1's leg was found to be contracted. R2's Vitals Records showed no vitals were recorded on [DATE]. Vitals were not performed until [DATE] and next on [DATE]. R2's Skin Evaluation reports showed there were no assessments documented until [DATE]. On [DATE] at 9:35 AM, V7 (Licensed Practical Nurse) said she was summoned to R2's room sometime last month and R2 was lying on the floor in her room near the bathroom. V14 (RN) and V10 (CNA) were in the room, and we assisted her back into her wheelchair. V14 was her nurse that day. If a resident has a fall nursing should assess the resident and post fall monitoring for 72 hrs. She cared for R2 after her fall and noticed a change from her norm and contributed that to her urinary tract infection. She did not perform a physical assessment on R2. On [DATE] at 2:00 PM, V10 (CNA) said she was walking past R2's room and she was lying on the floor on her left side. She notified V14 (RN) R2's nurse asked V7 (LPN) to come to R2's room to help. We transferred her back into her wheelchair and she left the room. After R2's fall she required a mechanical lift for transfers, she used to be a sit to stand lift. On [DATE] at 2:45 PM, V14 (RN) said she did not assess R2 when she was found on the floor. On [DATE] at 2:22 PM, V13 (Physical Therapist) said R2 was referred to therapy because she had a decline and couldn't walk. When he assessed R2 she was not herself, she couldn't do anything. On [DATE] at 1:48 PM, V11 (Agency CNA) he worked on [DATE] and in the beginning of the shift a day nurse called for help to reposition R2 in her wheelchair because she was sliding out of her wheelchair. After dinner time R2 looked very tired and she was not herself we transferred her with the mechanical lift and she could not sit in the sling properly we had to grip the sling because she was dead weight, her feet were positioned upward in the sling. Something wasn't right. She used to transfer using a sit to stand machine a week before, then I was told she is a mechanical lift. On [DATE] at 1:22 PM, V7 (RN) said she was R2's nurse on [DATE]. It was reported to her by the day shift R2 stayed in bed, but could not recall why. R2 was not acting right, she stayed in bed for my shift (2nd shift) as well. She had increased behaviors and seemed like she was in pain. At the end of my shift a CNA reported her left leg was bent and she could not straighten her leg. R2's left leg was contracted. She assess R2's leg prior to this. On [DATE] at 9:19 AM, V5(LPN) said post fall monitoring should be done for 72 hours and if staff notice a change in a residents condition they should notify the physician. New complaints of pain could indicate a change and nursing should perform an assessment. The facility's Change in a Resident's Condition or Status Policy revised 2013, states, If any direct care staff note a change in the residents' condition they are to notify the nurse. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: An accident or incident involving the resident . The Fall Management Policy revised 2013 states, 1. Anytime a resident sustains a fall, a report of that occurrence is to be completed by the licensed nurse. 2. The person who identifies or finds the injured residents is to notify a licensed nurse immediately .4. Based on the nurse's findings post occurrence treatment is executed which may range from first aide to emergent transfer to the hospital. 5. The family and doctor will be notified of the occurrence. 6. Documentation will support the monitoring, findings, and action taken. 7. A separate accident/incident/ unusual occurrence report is to be completed .8. Assessment protocol is to be followed to guide nurses in conducting and documenting post fall screenings.

Based on interview and record review the facility failed to ensure the safety of a totally dependent resident during cares. This failure resulted in R1 falling out of bed and sustaining a left femur fracture. The facility failed to ensure the safety of resident who was found on the floor who sustained a left femur fracture. This applies to 2 of 3 residents (R1, R2) reviewed for safety in the sample of 4. The findings include: 1. R1's Final Incident Report dated 9/12/22 documents on 9/3/22 R1 is a [AGE] year-old female, altert and orient x3 with diagnoses including [CONDITION(S)] of the cervical spine, hypertensive [CONDITION(S)], chronic kidney disease, severe [CONDITION(S)], [CONDITION(S)] and anxiety .R1 contacted V9 (Certified Nursing Assistant-CNA) and reported she had an incontinent episode. R1 was positioned side lying in the bed and holding onto the siderail .her left leg flung over her right leg and slid of the bed landing on the floor .R1 complained of left pain, upon assessment crepitus was identified in the left leg with orders received for x-rays. The x-ray results revealed there was fracture of the left distal femur .R1 was sent out to the local hospital. On 9/21/22 at 9:19 AM, V5 (LPN) said she was R1's nurse on 9/3/22 when she fell . V9 (CNA) came out of R1's room and said she slipped out of bed during cares. V9 reported to her R1 swung her left leg over her right leg and fell on to the floor. R1 requires two people assist with her activities of daily living and there should have been two staff present during cares. R1 was sent out to the local hospital and sustained a left femur fracture and did not return to the facility. On 9/21/22 at 11:49 AM, V9 (CNA) said she was providing incontinence care to R1. R1 was lying on her right side and her left leg flung out of the bed and she fell on the floor. R1 is total care resident that requires two people assist, she is unable to stand and has limited movement to her legs. Having another person would have helped. R1's Minimum Data Set assessment dated [DATE], shows she is cognitively intact, total dependent on staff requiring two person assist with bed mobility, transfers, toileting, bathing and has limited range on motion to both lower extremities. The nurses note dated 9/4/22 documents radiology tech here to do x-rays of bilateral lower extremities. Fracture noted to left femur .technician unable to perform all x-rays due to fracture .resident sent out to the local hospital. R1's imaging report dated 9/4/22 showed acute supracondylar left femoral fracture. 2. R2's Final Incident Report documents on 9/4/22, R2 demonstrates increased pain to her left leg .New orders were received to complete x-rays of left hip and pelvis. X-ray results revealed a fracture to the left femur .the determination was made that the resident had too many comorbidities to withstand surgery and recommended for hospice .No incidents or accidents were identified to have occurred .R2 most likely attempted to transfer herself unsuccessfully and was able to place herself back into the bed. R2 was capable of completing floor recovery into a low bed by herself. R2's Physician Order Sheets dated through September 2022 showed she is an [AGE] year-old female with diagnoses including dementia with behavior disturbance, [CONDITION(S)] in right knee, anxiety, abnormalities of gait and mobility, [CONDITION(S)], and fracture of the left femur. R2's Minimum Data Set assessment dated [DATE], showed her cognition was severely impaired, with no behaviors, no rejection of cares, requires two person assist with bed mobility, transfer, toileting, and has limited range of motion to both upper and lower extremities to both sides. On 9/21/22 at 9:35 AM, V7 (Licensed Practical Nurse) said she was summoned to R2's room sometime last month and R2 was lying on the floor in her room near the bathroom. V14 (RN) and V10 (CNA) were in the room, and we assisted her back into her wheelchair. Maybe she slid from her wheelchair. R2 has bad knees and if she could not get herself back up if she had a fall. V14 was her nurse that day. On 9/21/22 at 2:00 PM, V10 (CNA) said on 8/20/22 she was walking past R2's room and she was lying on the floor on her left side. She notified V14 (RN) R2's nurse asked V7 (LPN) to come to R2's room to help. We transferred her back into her wheelchair and she left the room. After R2's fall she required a mechanical lift for transfers. She was asked about R2's fall by V1 (Administrator) and was asked to make a statement. She provided a written statement to V1 and kept a copy. The fall was not reported by her nurse V14. On 9/21/22 at 2:45 PM, V14 (RN) denied R2 had a fall. When questioned the second time she said she remembers R2 was on the floor. I know I had someone with me but could not recall who. V14 could not recall the date of the incident. It happened in the summer. I'm sure I notified the POA and V2 (DON). She did not assess R2 when she fell and said she did not see a correlation of her fall and the fracture. On 9/21/22 at 10:49 AM, V12 (CNA) said No way could R2 get herself back up from the floor if she had a fall. R2 did not try to get out of bed. On 9/21/22 at 9:28 AM, V6 (LPN) said R2 was confused, unable to communicate and no could not get herself back in bed if she had a fall. On 9/21/22 at 2:42 PM, V3 (ADON) said something traumatic happened she had a broken hip. On 9/21/22 at 3:06 PM, V2 (DON) said if a resident falls, staff should assess the resident including a physical and skin assessment, vitals, pain, and notify the POA and physician. V2 said she was not aware of R2's fall. When asked about how R2 sustained her fracture she said, the only thing can be determined she had a fall and could have gotten herself back in bed. Things like that happen. On 9/21/22 at 12:37 PM, V1 (Administrator) said she was not aware of R1 having any falls. On 9/21/22 at 12:20 PM, V4 (Physician) said he was not notified of R2 having a fall. R2's fracture can be caused by trauma. V10's statement dated 8/20/22 documents On August 20, 22 around 6:40 PM, she was walking down the north hall and she was passing (R2's room) and R2 was laying on the floor. She entered the room to make sure she was okay and called for help. V7 (LPN) responded first followed by V14 (RN). I rolled her from her left side onto her back. and assisted V14 transferring R1 back to her wheelchair but was unable to recall if R2 could bear weight on her legs at that time. R2's x-ray report dated 9/5/22 showed an acute subcapital fracture of the left femur. The facility's Accident Incident Reports provided on 9/21/22 from June 2022 to September 2022 showed there were no fall reports for R2. R2's nurses' notes reviewed for August 2022 showed there were no falls documented. R2' Fall Risk Assessment Report dated 5/6/22 showed she is at risk for falls. The facility's Accident and Incidents: Supervision, Investigating, and Reporting Policy revised 2013 states, The facility provides an environment that is free from accident hazards over which the facility has control. The facility provides supervision and assistive devices to each resident to prevent avoidable accidents .All accidents or incidents involving residents, employees, occurring on our premises shall be investigated and reported to the Administrator . The Fall Management Policy revised 2013 states, 1. Anytime a resident sustains a fall, a report of that occurrence is to be completed by the licensed nurse. 2. The person who identifies or finds the injured residents is to notify a licensed nurse immediately .4. Based on the nurse's findings post occurrence treatment is executed which may range from first aide to emergent transfer to the hospital. 5. The family and doctor will be notified of the occurrence. 6. Documentation will support the monitoring, findings, and action taken. 7. A separate accident/incident/ unusual occurrence report is to be completed .8. Assessment protocol is to be followed to guide nurses in conducting and documenting post fall screenings.

Based on interview and record review the facility failed to ensure a resident's pain was assessed and treated after sustaining a fall. This applies to 1 of 3 (R2) residents reviewed for pain in the sample of 4. This failure resulted in R2 screaming in pain with cares. The findings include: R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set assessment dated [DATE], showed her cognition was severely impaired, with no behaviors, no rejection of cares, required two person assist with bed mobility, transfer, toileting, and has limited range of motion to both upper and lower extremities to both sides. R2's Fall Risk Assessment Report dated 5/6/22 showed she is at risk for falls. R2's electronic census report showed on 8/25/22 she moved to room [ROOM NUMBER]. On 9/21/22 at 2:00 PM, V10 (CNA) said on 8/20/22 she was walking past R2's room and she was lying on the floor on her left side. She notified V14 (RN) R2's nurse asked V7 (LPN) to come to R2's room to help. On 9/21/22 at 9:35 AM, V7 (Licensed Practical Nurse) said she was summoned to R2's room sometime last month and R2 was lying on the floor in her room near the bathroom. V14 (RN) and V10 (CNA) were in the room, and we assisted her back into her wheelchair. On 9/21/22 at 2:45 PM, V14 (RN) denied R2 had a fall. When questioned the second time she said she remembers R2 was on the floor. I know I had someone with me but could not recall who. On 9/21/22 at 2:27 PM, R4 said she was R2's roommate for 2-3 weeks. R4 said R2 was confused and she would scream and scream every time someone touched her. The staff would used the mechanical sit to stand lift in the beginning to get her up until she really screamed then they used the mechanical lift. I heard her leg was broken that would explain the screaming. On 9/21/22 at 2:00 PM, V10 (CNA) said when R2 moved into R4's room her pain became unbearable. On 9/21/22 at 1:22 PM, V7 (RN) said on 9/4/22 R2 was upset and screaming, she was not acting right. On 9/21/22 at 2:42 PM, V3 (ADON) said R2 was showing signs and symptoms of pain, something happened to her. On 9/21/22 at 3:06 PM, V2 (DON) said if a resident falls, staff should assess the resident including a pain assessment. On 9/21/22 at 12:20 PM, V4 (Physician) said he ordered pain medications for R2 for her pain. The nurses note dated 8/31/22 documents R2 has been yelling very loudly for several days when staff try to move her, change her, or even put a sheet on top of her. The fax report to V4 (Physician) dated 9/1/22 documents Can (R2) have something for increasing pain? She is callout in pain and grimacing when she is sitting in her wheelchair and during cares. There was a new order received for [MEDICATION(S)]. R2's SBAR (Situation Background Assessment Recommendations) form dated 9/4/22 documents increased lethargy, decreased intake, Screams with cares. The nurses note dated 9/4/22 documents R2 yelling out in pain .she spit out the prn pain medication .R2 continued to yell out in pain .V4 (Physician) notified and new orders received. R2's MAR (Medication Administration Record) for August 2022 and September 2022 shows a pain assessment should be completed every shift, but the pain assessment form showed there was no documentation completed on the pain assessment form until 9/4/22. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MAR for September showed she did not receive pain medication until 9/5/22. V10's statement dated 8/20/22 documents On August 20, 22 around 6:40 PM, she was walking down the north hall and she was passing (R2's room) and R2 was laying on the floor. She entered the room to make sure she was okay and called for help. V7 (LPN) responded first followed by V14 (RN). R2's imaging report dated 9/5/22 showed acute displaced fracture of the left femur. The facility's Pain Assessment and Management Policy dated 2020 states, The pain management program is based on a facility-wide commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals .Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Effectively recognizing the presence of pain;c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; bf. Identifying and using specific strategies for different levels and sources of pain; G. Monitoring for the effectiveness of interventions; and Rh. Modifying approaches as necessary .1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's electronic medical record .Reporting: Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain .3. Prolonged, unrelieved pain despite care plan interventions .

Based on observation, interview, and record review, the facility neglected to follow their bowel protocol. The facility neglected to follow their intake and output procedure and their urinary catheter care plan for a resident with an indwelling urinary drainage catheter and a [MEDICAL CONDITION] who had a history of [REDACTED]. These failures resulted in a resident not having a bowel movement for six days and being sent to an intensive care unit with [DIAGNOSES REDACTED]. This applies to 1 of 3 residents (R1) reviewed for bowel and bladder function in the sample of 3. The findings include: On (MONTH) 3, (YEAR) at 8:20 AM, R1 was lying in a bed in the intensive care unit of a local hospital. An intravenous line was inserted into R1's right arm with antibiotics being infused into R1. On (MONTH) 3, (YEAR) at 8:20 AM, V13 (R1's hospital ICU Registered Nurse-RN) said when R1 was admitted to the hospital she was very sick. V13 said R1's urine in her catheter bag was very dark and she was lethargic. V13 said R1's [MEDICAL CONDITION] was not draining stool because she had a bowel obstruction. V13 also said R1 was dehydrated and [MEDICAL CONDITION]. V13 said R1 was receiving two different antibiotics due to [MEDICAL CONDITION]. On (MONTH) 7, (YEAR) at 2:25 PM, V2 (Director of Nursing) said R1's Bowel and Bladder Assessment Tracking forms for (MONTH) (YEAR) show R1 did not have a bowel movement for 6 days (July 24, (YEAR) -July 29, (YEAR)). V2 said R1's meal, snack and fluid consumption forms were not filled out correctly either (only 3 meals in the 31 days of (MONTH) (YEAR) were filled in). V2 said if staff had initiated the facility's bowel protocol they may have been able to prevent R1's bowel obstruction. The facility's bowel protocol form provided by V2 with a revision date of (MONTH) 2009 shows Day shift to give MOM (milk of magnesia) 30 milliliters (ml) PO (by mouth) if there has not been a BM (bowel movement) in 72 hours. 3-11 shift to follow up with [MEDICATION NAME] (a laxative) 10 mg suppository if there has not been a BM after the MOM. 11-7 shift to follow up with a fleet enema if there has not been a BM after the suppository. On (MONTH) 7, (YEAR) at 2:13 PM, V3 (Certified Nursing Assistant-CNA) said R1 would not drink much. V3 said on (MONTH) 30, (YEAR) (3-11 PM shift) R1 had been throwing up and there was swelling under R1's [MEDICAL CONDITION]. V3 said she reported the swelling and emesis to V8 (LPN). V3 said when she worked the next afternoon R1's urine was brownish in color and the swelling under R1's [MEDICAL CONDITION] had increased. On (MONTH) 7, (YEAR) at 12:52 PM, V11 (LPN) said she worked on (MONTH) 31, (YEAR) (7 AM-3 PM shift). V11 said she does not know what R1's urine or bowel outputs were that shift. On (MONTH) 7, (YEAR) at 12:37 PM, V8 (LPN) said R1's abdomen was distended and firm on (MONTH) 30, (YEAR) on the 3-11 PM shift. V8 said the next day R1 was very confused and her abdomen was more distended. On (MONTH) 7, (YEAR) at 9:04 PM, V7 (LPN) said the CNAs do not give her an amount of how much fluids R1 drinks. V7 said during her overnight shift on (MONTH) 30 - 31, (YEAR) R1's abdomen was distended and firm around the [MEDICAL CONDITION]. V7 said she does not remember if she looked at R1's catheter that night or not. R1's care plan for the indwelling urinary catheter with a revision date of (MONTH) 5, (YEAR) shows Monitor I&O (intake and output) and record every shift. The facility's policy and procedure titled Intake, Measuring and Recording, with a revision date of (MONTH) 2013 shows The following information should be recorded in the resident's medical record, per facility guidelines: 1. The date and time the resident's fluid intake was measured and recorded. 2. The name and title of the individual who measured and recorded the resident's fluid intake. 3. The amount (in milliliters-ml) of liquid consumed. 4. The type of liquid consumed. R1's care plan for the potential for constipation related to decreased mobility with a revision date of (MONTH) 5, (YEAR) shows Follow facility bowel protocol for bowel management. Record bowel movement pattern each day. Describe amount, color and consistency.

Based on observation, interview, and record review, the facility failed to assess a resident's bowel status and follow the facility's bowel management protocol, and failed to assess a resident's meal and fluid intakes and output. This failure resulted in the resident being admitted to an intensive care unit with the [DIAGNOSES REDACTED]. This applies to 1 of 3 residents (R1) reviewed for fluid intakes and bowel and bladder function. The findings include: R1's (MONTH) 1, (YEAR) history and physical from a local hospital shows she has [DIAGNOSES REDACTED]. On (MONTH) 3, (YEAR) at 8:20 AM, R1 was lying in bed in the intensive care unit (ICU) of a local hospital. An intravenous (IV) line was attached to R1's right arm infusing IV antibiotics to R1. On (MONTH) 3, (YEAR) at 8:20 AM, V13 (R1's ICU Registered Nurse-RN) said when R1 was admitted to the hospital she was very sick. V13 said R1's urine in her catheter bag was very dark and she was lethargic. V13 said R1's [MEDICAL CONDITION] was not draining stool because she had a bowel obstruction. V13 also said R1 was dehydrated and [MEDICAL CONDITION]. V13 said R1 was receiving two different antibiotics due to [MEDICAL CONDITION]. On (MONTH) 7, (YEAR) at 2:13 PM, V3 (Certified Nursing Assistant-CNA) said R1 would not drink much. V3 said R1 had a [MEDICAL CONDITION]. V3 said the CNAs document the resident's outputs in the bowel and bladder book up at the nurse's desk. V3 said she worked (MONTH) 30, (YEAR); the night before R1 was sent to the hospital. V3 said she had called the Nurse (V8-Licensed Practical Nurse-LPN) into R1's room because R1 had been throwing up and there was swelling under R1's [MEDICAL CONDITION]. V3 said from 4-10 PM on (MONTH) 30, (YEAR) R1's urine output was brownish in color. V3 said when she worked the next afternoon R1's urine was brownish in color and the swelling under R1's [MEDICAL CONDITION] had increased. On (MONTH) 7, (YEAR) at 1:20 PM, V6 (LPN) said she worked the day shift (7 AM-3 PM) on (MONTH) 30, (YEAR). V6 said R1 was spitting up a sputum like liquid on her shift. At 12:52 PM, V11 (LPN) said R1 had one emesis during the shift she worked on (MONTH) 31, (YEAR) (7 AM-3 PM shift). V11 said she does not know what R1's urine or bowel outputs were that shift. On (MONTH) 7, (YEAR) at 1:38 PM, V9 (CNA) said she worked (MONTH) 31, (YEAR) on the 7:00 AM - 3:00 PM shift. V9 said R1 did not seem quite right on her shift; she was not making sense. V9 said she reported this to the Nurse on duty. On (MONTH) 7, (YEAR) at 9:04 PM, V7 (LPN) said she worked the overnight shift from (MONTH) 30-July 31, (YEAR). V7 said she does not remember if the CNAs said anything to her about the color or odor of R1's urine. V7 said the CNAs do not give her an amount of how much fluids R1 drinks. V7 said R1 usually does not drink a lot. V7 said R1's abdomen was distended and firm around the [MEDICAL CONDITION]. V7 said she does not remember if she looked at R1's catheter that night or not. On (MONTH) 7, (YEAR) at 12:37 PM, V8 (LPN) said V3 (CNA) called her to R1's room on (MONTH) 30, (YEAR) on the 3-11:00 PM shift. V8 said R1's abdomen was distended and firm and R1 threw up a brown coffee-colored liquid. V8 said when she came in the next day for the 3-11 PM shift R1 was very confused and the abdomen was more distended and she did not like how R1 looked. V8 said R1 usually does not drink well. On (MONTH) 7, (YEAR) at 12:52 PM, V11 (LPN) said R1 had one emesis during the shift she worked on (MONTH) 31, (YEAR) (7 AM-3 PM shift). V11 said she does not know what R1's urine or bowel outputs were that shift. On (MONTH) 7, (YEAR) at 2:25 PM, V2 (Director of Nursing) said R1's Bowel and Bladder Assessment Tracking forms for (MONTH) (YEAR) show R1 did not have a bowel movement for 6 days (July 24, (YEAR) -July 29, (YEAR)). V2 said R1's meal, snack and fluid consumption forms were not filled out correctly either (only 3 meals in the 31 days of (MONTH) were filled in). V2 said if staff had initiated the facility's bowel protocol they may have been able to prevent R1's bowel obstruction. On (MONTH) 7, (YEAR) at 1:58 PM, V12 (RN, ICU Nurse) said she took care of R1 the morning after she was admitted to the hospital. V12 said R1 was very lethargic received two medications to aid with her blood pressure due to her systolic blood pressure being in the sixties on admission. V12 said there was no output to R1's [MEDICAL CONDITION] on admission. V12 said she believes R1 received 5-6 liters of fluids since admission to the hospital. R1's Nurse Progress Notes of (MONTH) 28, (YEAR) show R1 has a history of dehydration. Progress notes of (MONTH) 17, (YEAR) show she has a history of UTI's. R1's (MONTH) 4, (YEAR) Dehydration Risk Screening shows R1 is at risk for dehydration. R1's care plan for the indwelling urinary catheter with a revision date of (MONTH) 5, (YEAR) shows Monitor I&O (intake and output) and record every shift. R1's Nurse Progress Notes of (MONTH) 30, (YEAR) show Resident had an emesis episode of brown water no solids this evening. When assessing resident this Nurse noticed that around her [MEDICAL CONDITION] her abdomen is distended and firm. R1's Nurse Progress Notes of (MONTH) 31, (YEAR) show Resident had large emesis this morning at approximately 9:30 AM of dark brown/black liquid .Ostomy intact to left abdomen with dark brown/black liquid stool inside bag. Left abdomen rounded and firm .Resident continues to complain of some nauseousness and with light groaning. R1's care plan for the potential for constipation related to decreased mobility with a revision date of (MONTH) 5, (YEAR) shows Follow facility bowel protocol for bowel management. Record bowel movement pattern each day. Describe amount, color and consistency. The facility's policy and procedure titled Intake, Measuring and Recording, with a revision date of (MONTH) 2013 shows The following information should be recorded in the resident's medical record, per facility guidelines: 1. The date and time the resident's fluid intake was measured and recorded. 2. The name and title of the individual who measured and recorded the resident's fluid intake. 3. The amount (in milliliters-ml) of liquid consumed. 4. The type of liquid consumed. The facility's policy and procedure titled Output, Measuring and Recording, with a revision date of (MONTH) 2013 shows The purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24 hour period. 7. Carefully observe the level of urine in the graduate. Maintain eye level so that you can see the number reached by the level of the urine. 8. Record the amount noted on the output side of the intake and output record. Record in ml. The facility's policy and procedure titled Catheter Care, Urinary with a revision date of (MONTH) 2013 shows Input/Output 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly report it to the physician or supervisor. 2. Maintain an accurate record of the resident's daily output as indicated. On (MONTH) 7, (YEAR) at 2:25 PM, V2 (Director of Nursing) handed this surveyor the facility's PRN (as needed) Medication Information form with a revision date of (MONTH) 2009. V2 said this form lists the bowel protocol to follow when a resident has not had a bowel movement (BM) in 72 hours. The protocol shows nursing staff should give the resident 30 ml milk of magnesia (MOM) on the day shift, followed up with a [MEDICATION NAME] (laxative) 10 mg (milligram) suppository on the 3-11 shift if no BM after the MOM was given. If there has not been a BM after the suppository, the 11 PM-7 AM shift will follow up with a fleet enema. V14's (Hospital Cardiologist) Consult notes from a local hospital dated (MONTH) 1, (YEAR) show Patient is very lethargic with a metabolic [MEDICAL CONDITION] (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function). Patient had [MEDICAL CONDITION] with systolic blood pressure in the 70's. Urinalysis reported from (another hospital that R1 originally was sent to) showed significant abnormality suggestive of urinary tract infection. White blood cell count was 20.8 (normal range is 4.8-11.0). Lactic acid was 4.0 (normal range is 0.4-2.0).Computertography (CT) of the abdomen showed multiple dilated loops of small bowel and air-fluid level suggestive of small bowel obstruction. [MEDICAL CONDITION] protocol was initiated and patient was given 2.7 liters of normal saline bolus and then transferred to another hospital. Patient received broad-spectrum antibiotics. Blood pressure remains poor in spite of [MEDICATION NAME] (a medication to help stabilize blood pressure) drip. At this point we decided to give two units of blood transfusion as hemoglobin was low with acute abdomen and then also started on [MEDICATION NAME] (another medication to help stabilize blood pressure). Patient received IV steroid. NG tube in place. V14's notes show Assessment: [MEDICAL CONDITION] secondary to septic shock. [MEDICAL CONDITION] most likely cause is ischemic bowel disease contributed by urinary tract infection. Small bowel obstruction with high probability of incarcerated hernia. Metabolic [MEDICAL CONDITION]. [MEDICAL CONDITION]. Plan: Broad -spectrum antibiotics. IV fluid continued at 125 cubic centimeters an hour. Most likely patient is going to need surgical intervention. Because of multi-organ failure patient is going to need multidisciplinary approach and ICU management is anticipated for a few days after surgery.

Based on observation, interview, and record review, the facility failed to identify areas of pressure on a resident prior to them deteriorating to deep tissue injuries (DTI) and the facility failed to follow their policy and procedure for dressing changes. This failure contributed to R1 developing 3 deep tissue injuries and one stage I pressure injury to her right foot. This applies to 2 of 3 residents (R1, R2) reviewed for pressure injuries in the sample of 3. The findings include: 1. R1's Minimum Data Set (MDS) assessment of (MONTH) 26, (YEAR) shows she is cognitively intact. R1's Braden Scale (determines a resident's risk of developing a pressure injury) Assessment of (MONTH) 20, (YEAR) and (MONTH) 19, (YEAR) shows she is at high risk for developing a pressure injury. R1's (MONTH) 16, (YEAR) - (MONTH) 15, (YEAR) Treatment Administration Record (TAR) shows an order for [REDACTED]. The TAR shows the order was initiated on (MONTH) 8, (YEAR). R1's Skin Integrity care plan with a revision date of (MONTH) 22, (YEAR) shows [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS) assessment of (MONTH) 26, (YEAR) shows she requires extensive assist of 2 staff members for bed mobility, is dependent on staff for transfers, toileting, personal hygiene and bathing. The MDS shows R1 has impaired range of motion. On (MONTH) 3, (YEAR) at 8:20 AM, R1 was sitting in her bed in the intensive care unit of a local hospital. R1 had a bandage around her right foot and pressure reducing boots on bilaterally. R1 said she also had a pressure injury on her buttocks. R1 said V10 (R1's husband) was the one who did the dressing changes for her pressure injuries at the facility. R1 said V10 was the one who noticed the wounds on her foot. R1's Progress Notes of (MONTH) 22, (YEAR) show Assessed resident for wound care as day RN (Registered Nurse) reported a small open area to her buttocks. Stage III coccyx 1.0 centimeter (cm) x 1.0 cm. Wound base is red with pink peri area that has surrounding scar tissue from previously healed wound. Scant amount of slough (non-viable tissue) noted to wound bed center. R1's Nurse Progress Notes of (MONTH) 25, (YEAR) show it was R1's husband, not the Nursing staff that identified the new pressure injuries to R1's right foot. The notes show Resident's husband notified this Nurse at this time of a new reddened area to (R1's) heel. Nurse assessed area. Large, round, red/dark purple/black area approximately 5 centimeters (cm) across noted to resident's right heel. R1's Progress notes of (MONTH) 26, (YEAR) (the following day) show Resident presents with a deep tissue injury to right great toe 2 cm x 1 cm skin intact. Discolored dark blue/red. Deep tissue injury to right lateral foot below the 5th digit 2.3 cm x 1.5 cm skin intact. Discolored dark red. Deep tissue injury to right lateral heel 4.5 cm x 4.4 cm black in color. Non-blanchable. Stage I to left lateral foot below the 5th digit 1.0 cm x 0.8 cm. Red in color and non-blanchable. Resident also has new area to left buttock 2.0 cm x 1.0 cm. Wound base is pink with pink peri area and no drainage and no odor. R1's Progress Notes of (MONTH) 18, (YEAR) (R1's most recent assessment by facility staff) shows Rounded with (V14-Wound Care Physician/Surgeon) today .Assessment as follows: Right heel: 3.0 cm x 2.3 cm wound bed is pink with granulation tissue noted to bed and pink peri area. Small amount of serosanguinous drainage. No odor. Right foot lateral: 6.0 cm x 3.5 cm dark, dry eschar (dead, non-viable tissue) noted to wound bed with irregular borders and outer edges have granulation tissue forming. Pink peri area. No drainage. No odor. Sacral wound 4.0 cm x 4.0 cm x 1.5 cm. Wound bed is red with surrounding pink scar tissue to the peri area. Scant amount of tan drainage and no odor. R1's (MONTH) 3, (YEAR) Progress Notes written by V15 (Registered Nurse/Wound Care Nurse) show Spoke with resident's husband regarding wound care concerns. Spouse denies that he has been scrubbing wife's wounds as reported by nursing. Showed resident and spouse proper wound care technique for (R1's) right foot wounds and sacral wound. Spouse was given opportunity to return demo wound care .Informed resident and spouse that I will still be seeing them on a regular basis, as I need to be able to personally track progress. On (MONTH) 7, (YEAR) at 2:25 PM, V2 (Director of Nursing) said V10 should not be doing the wound care for R1's pressure injuries. V2 said the Nurses need to do the dressing changes so they can assess for signs of infection and monitor for worsening of the wounds. At 4:42 PM, V2 said staff should be looking at the resident's skin when providing care and when giving showers. V2 said staff should have identified R1's pressure area, not V10 (R1's husband). On (MONTH) 7, (YEAR) at 3:42 PM, V14 (Surgeon/Wound Care Physician) said he expects the Nursing staff to perform the treatments to R1's pressure injuries. V14 said V10 is not qualified to do the dressing changes and the Nursing staff need to monitor the wounds for signs of infection and worsening of the wounds. On (MONTH) 7, (YEAR) at 10:27 AM, V4 (Licensed Practical Nurse-LPN) said the Nurses need to perform the dressing changes to R1 so they can monitor the wound and update the Doctor if the wound gets worse. At 10:50 AM, V5 (LPN) said V10 (R1's husband) did R1's dressing changes. On (MONTH) 7, (YEAR) at 12:52 PM, V11 (LPN) said V10 did do some of the dressing changes. 2. R2's Admission Record shows she was admitted to the facility on (MONTH) 25, (YEAR) with a stage IV pressure injury to her sacral region, a stage III pressure injury to her buttocks and has [DIAGNOSES REDACTED]. On (MONTH) 7, (YEAR) between 8:20 -8:50 AM, V5 (LPN) was performing dressing changes for R2's pressure injuries on her left foot, her bilateral posterior thighs and her coccyx area. V5 sprayed wound cleanser to the wound on R2's foot, wiped the wound bed, cleaned the intact skin around the wound bed (periwound), and using the same gauze wiped inside the wound bed again. While cleaning the pressure injury to R2's right posterior thigh, V5 took gauze and started wiping three inches away from the pressure injury and continued wiping in one continuous motion into the wound bed. V5 cleaned the pressure injury to R2's left posterior thigh using the same technique. V5 said she did not realize that she cleaned the areas around the wounds then cleaned the wound beds with the same contaminated gauze. On (MONTH) 7, (YEAR) at 4:42 PM, V2 (DON) said it is not acceptable to wash the periwound area then the wound bed. Staff should clean from the middle of the wound bed and then go out. V2 said the nurses should use a different gauze to clean the wound bed and the periwound skin. The facility's policy and procedure titled Pressure Ulcer Treatment with a revision date of (MONTH) 2013 shows The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. General Guidelines: 1. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s) .c. Pressure ulcer care. D. Managing bacterial colonization and infection. The policy shows Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the wound care was given. 2. The name and title of the individual performing the care. 3. Any change in the resident's condition. 4. Any change in the wound data (i.e. color, size, pain, drainage, etc.) from last dressing change. 5. Resident tolerance of the procedure. 6. Any problems or complaints made by the resident related to the procedure. The facility's policy and procedure titled Dressings, Dry/Clean with a revision date of (MONTH) 2013 shows 15. Review the wound and surrounding skin for [MEDICAL CONDITION], redness, drainage, tissue healing progress and wound stage. 16. Cleanse the wound. Use a syringe to irrigate the wound, if using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated are (usually, from the center outward). The facility's policy and procedure titled Pressure Ulcers/Skin Breakdown-Clinical Protocol with a revision date of (MONTH) 2013 shows 2. In addition, the nurse shall monitor and document/report the following: a. Vital signs; b. Full screening of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .

Based on observation, interview, and record review, the facility failed to protect residents from physical and mental abuse this resulted in R1 being slapped across the face by a staff member and R2 becoming angry, swearing and attempting to stand. This applies to 2 of 3 residents (R1, R2) reviewed for abuse in the sample of three. The findings include: 1. R2's October 25, 2017 Minimum Data Set (MDS) showed her cognitive skills for daily decision-making were severely impaired. The MDS showed R2 needs extensive physical assistance of one person for transferring, walking and dressing. R2's October 25, 2017 activities care plan showed R2 is only alert and oriented to herself, she enjoys observing activities, reading, and my stuffed dog Teddy. Interventions on the care plan include Offer (R2) her stuffed dog . and Calm and soothe (R2) as needed . R2 had other current care plans for mood problems related to anxiety, depression relating to dementia, impaired cognitive function, behavioral outbursts, and anti-psychotic and anti-anxiety medication use. The facility's February 8, 2018 Final Incident Investigation Report for an abuse allegation concerning R2 showed two Certified Nursing Assistants (V5 and V8-CNAs), and an Activity Aid (V6) were present in the second floor back dining room when V14 (CNA) abused R2 on February 1, 2018. On February 14, 2018 at 9:55 AM, V6 stated it was before lunch when V14 approached R2, stuck her tongue out, and made faces at her to get her riled. V6 also described V14 as shaking her butt at her. V6 stated she told V14 to stop because she was making R2 mad. V6 said V14 laughed. V6 stated R2 reached to grab her cup of supplement shake that was on the table and V14 reached for it too, and it spilled on the table. V6 stated V14 got a clothing protector to wipe it up, then went to the cabinet to get spray cleaner. V6 stated V14 sprayed the cleaner on the table, and then sprayed it at R2. V6's February 5, 2018 written statement showed I told (V14) to stop because (R2) was clearly getting mad . The statement continued and showed (V14) grabbed some spray cleaner and sprayed it at (R2) hitting her arm . V6 stated V8 and V5 were both present during the incident. On February 14, 2018 at 3:35 PM, V8 stated I don't know why a person would do that to a resident and added, I would classify it as abusive. V8's February 4, 2018 written statement showed (V14) deliberately took measures to attempt to anger (R2)-she blew in her face and pulled on her stuffed dog . The statement continued .her success in getting a rise out of (R2) made her (14) smile and laugh . On February 14, 2018 at 2:30 PM, V5 stated V14 stuck her tongue out (at R2) . everyone knows that gets R2 upset . V5 added V14 squirted the table (with the chemical cleaner) and squirted (R2) to get her more upset and (R2) started to stand up . V5's February 6, 2018 written statement showed V14 started messing with (R2) and how you start to get (R2) upset is if you stick your tongue out at R2 which was the first thing (V14) did to upset (R2) . The statement continued V14 went and got a clothing protector and the green bottle of some type cleaning liquid and sprayed it (R2) more than three times . The chemical sprayed at R2 showed a Hazardous Materials Identification System Health rating of 3, indicating the chemical is a serious hazard. On February 15, 2018 at 1:35 PM, V15 (Housekeeping and Laundry Supervisor) stated she would not want that sprayed on a resident because it is not safe for them. On February 15, 2018 at 1:10 PM, V2 (Director of Nursing) stated the review of the surveillance tape showed V14 bent over in front of R2, moved her bottom up and down, and put her own hand on her bottom, shaking it at R2. V14 also took R2's stuffed dog away from her, and waved it up back and forth over R2's head, out of her reach. R2 tried unsuccessfully to reach for it. V2 stated R2 looked so mad she tried to stand up. V2 stated when V14 finally walked away from the table where R2 was sitting with her back against a wall, V14 used her body to shove the table in farther toward where R2 was sitting. In the policy statement of the facility's Abuse Prevention Program (revised November 2013), it showed Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility's November 2013 Reporting Abuse to Facility Management policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy further defines mental abuse as .humiliation, harassment, threats of punishment, or withholding of treatment or services. 2. On February 14, 2018 at 11:26 AM, R1 was sitting in her wheelchair reading a book. R1's MDS (Minimum Data Set) dated December 21, 2017 showed R1 is cognitively intact, requires extensive assistance of two persons for transfers, and requires extensive assistance of one person for dressing. The same MDS showed it is very important to R1 to choose her own bedtime while in the facility. On February 15, 2018 at 9:47 AM, V12 CNA (Certified Nurse Assistant) said R1 prefers to go to bed around 9:30 PM. On February 14, 2018 at 11:26 AM, R1 said that on the evening of January 31, 2018 between the hours of 7:00 PM and 8:30 PM, V13 (CNA) was yelling at me to go to bed. I told her I didn't want to go to bed. I told V13 no and she slapped me across the face. R1 added, It made me feel sad. R1's posture became slumped in the wheelchair and she avoided eye contact during her description of the incident. On February 14, 2018 at 7:50 AM, V2 DON (RN, Director of Nursing) stated during her investigation she determined that between the hours of 7:00 PM and 8:30 PM on January 31, 2018, V13 CNA went into R1's room three times and told her it was time to go to bed. V2 reported that R1 told V13, no it's too early each time. V2 stated that the third time V13 went in, V13 closed the door and told R1 to go to the bathroom. V2 said that R1 told V13 no again. V2 stated V13 said, Yes you are, and R1 said, no I'm not. V2 added R1 shook her fist at V13, and said, I don't want to go to bed. V2 stated V13 then slapped R1 across the face. On February 14, 2018 at 9:30 AM, R7 (R1's former roommate) stated she heard V13 CNA and R1 arguing in loud voices about R1 going to bed on the evening of January 31, 2018. On February 15, 2018 at 10:08 AM, V11 CNA said, It is absolutely not okay to slap a resident! V11 added, That is physical abuse and it's wrong. When asked why she believed what R1 reported to her about being slapped by a staff member, V2 DON stated R1 is alert and orient and she never changed her story throughout the investigation. V2 continued to say R1 has lived here a long time and has never complained about anyone.

I. Based on observation, and interview, and record review, the facility failed to ensure a safe environment for residents when water in the resident bathrooms on the first floor measured between 125 and 140 degrees Fahrenheit (F). This failure placed the residents with a [DIAGNOSES REDACTED]. This failure resulted in an Immediate Jeopardy (IJ). The IJ began on April 12, 2016 at 11:50 AM when the water temperature in room R30's was 135 degrees F. The IJ was declared to E1 (administrator) on April 13, 2016 at 2:40 PM. The immediacy was removed at 2:00 PM on April 15, 2016. The facility remains out of compliance at a level 2, due to the facility's need to monitor water temperatures at various times of the day and ensure the effectiveness of the repairs. This applies to of residents 2 of 13 (R6, R11) residents reviewed for safety in the sample of 22 and 12 residents (R30-R42) in the supplemental sample. The findings include: On April 12, 2016 at 11:25 AM, the water from the public sink near the nursing station was so hot, the surveyor could not hold her hand under the faucet for longer than one second. On April 12, 2016 at 11:50 AM, R30's hot water in the bathroom was measured at 135 degrees F. The water temperature from the sink in the first floor East hall shower room was measured at 130 degrees F. On April 12, 2016 at 12:10 PM, E3 (Maintenance Director) was notified of high water temperatures. Using a thermometer that was ice bath verified accurate to 32 degrees F, with the surveyor, E3 measured the following temperatures on the north hall of the first floor: R42's bathroom sink water was 140 degrees F, and R35's bathroom sink water was 140 degrees F. R6's bathroom sink water was 136 degrees F, and R34's bathroom sink water was 130 degrees. On the East hall of the first floor, R30's bathroom sink water was 138 degrees F, and R11's bathroom sink water was 125 degrees F. Facility documentation provided on April 12, 2016 showed R34-R40 have a [DIAGNOSES REDACTED]. Additional documentation showed R34-R40 use the bathroom independently. On April 12, 2016 at 12:50 PM, R30 was asked about the water temperature in his bathroom sink. R30 stated, Damned right it's hot! It'll scald you . it's just hot, hot water. On April 12, 2016 at 12:35 PM, R33 stated she uses her sink to wash her face and brush her teeth, and when the water is hot, she has to remember to turn on the cold water with the hot to prevent burning. On April 12, 2016 at 1:00 PM, R31 stated if she didn't turn the cold water on, the water from her bathroom faucet would be too hot. On April 12, 2016 at 11:45 AM, E5 Licensed Practical Nurse (LPN) refused to put her hand under the running water, and stated I know it's too hot. E5 added she thought the water had been that hot for a couple of weeks. E5 stated she mentioned the hot water concern to E3 (Maintenance Director). E5 added that (R37) occasionally uses the public sink to wash her hands. R37's April Physician order [REDACTED]. On April 12, 2016 at 3:10 PM, E6 RN (Registered Nurse) stated she had put her hands under the hot water at the public sink earlier and she had to pull them back because of the hot temperature. E6 added she didn't think to tell maintenance about it. On April 12, 2016 at 2:55 PM, E3 stated the scald alarm should go off at 115 degrees Fahrenheit. E3 confirmed when he was notified of the high water temperature, the scald alarm in the laundry did not go off. On April 12, 2016 at 1:45 PM, E3 stated most of the safety alarms in the facility are monitored, including the fire alarms and the fire panel, but the scald alarm is not monitored. E3 stated he did not have a procedure in place for routinely checking the scald alarm. E3 stated he thought the scald alarm would sound. On April 13, 2016 at 8:35 AM, E3 stated the last water temperatures recorded were on Friday, April 8, 2016. The water temperature log was reviewed and showed the last water temperature recorded was on Friday, April 8, 2016. On April 12, 2016 at 2:30 PM, E8 (Laundry Aide) stated the scald alarm has sounded in the past. E8 stated, When it goes off, I press the acknowledgment button and notify (E3) (Maintenance Director). E8 stated the alarm went off a couple of weeks ago. On April 12, 2016 at 3:00 PM, E3 (Maintenance Director) stated he does not remember being notified of the scald alarm going off. The Center for Medicare and Medicaid' State Operations Manual, appendix PP, as of February 6, 2015 has a Time and Temperature Relationship to Serious Burns table showing that a water temperature of 140 degrees F with an exposure time of 5 seconds can cause a third degree burn. Through observation, interview, and record review, the surveyor team confirmed the facility took the following steps to remove the immediacy of the situation: 1. The facility warned residents of the hot water risk and posted warning signs in affected areas on April 12, 2016. 2. The facility's plumbing contractor identified the need to replace the scald water shutoff valve and the mixing valve on April 12, 2016. The plumbing contractor identified the scald alarm worked for notification but not to shut off the water. 3. The plumber replaced the main mixing valve, the emergency shutoff valve, and the circulating check valves on April 13, 2016. 4. The facility inserviced the staff on how to check the water temperatures, procedures to follow if water temperatures exceed 110 degrees F, and who to notify as of April 15, 2016. 5. Water temperatures are to be taken daily at various times during the day in various locations and documented. Maintenance Supervisor and/or designees will check the scald alarm and mixing valve weekly as of April 13, 2016. II. Based on observation, interview, and record review the facility failed to ensure resident safety by not ensuring a resident with a history of falls was transferred in a safe manner, and failed to supervise a resident at risk for falls, in the bathroom. The facility failed to ensure storage rooms containing biohazardous waste were locked to prevent access by confused residents. This applies to 1 of 13 residents (R7) reviewed for falls in the sample of 22 and 11 residents (R26-29, R34-R40) in the supplemental sample. The findings include: 1. R7's MDS (Minimum Data Set) of January 18, 2016 shows R7 has severe cognitive impairment and requires extensive assistance with transfers, dressing, hygiene, and toileting. R7's Fall assessment dated [DATE] shows she is at a high risk for falls, has a history of falls, has unsteady balance, has dementia, and had a decline in her functional status. R7's ADL (Activities of Daily Living) care plan, revised on March 15, 2016 shows R7 needs 2 staff to assist her with transfers. R7's Fall care plan dated March 15, 2016 shows Resident fell to right side during a transfer with a CNA -(Certified Nurse Assistant) and Resident will decrease risk of falls with transfers with a 2 person transfer with all transfers. The March 15, 2016 intervention shows Re-eval transfer status and change to a 2 person transfer with all transfers to and from wheelchair, toilet, and bed. The February 8, 2016 intervention shows do not leave alone in the bathroom. R7's March 15, 2016 Quarterly Fall Intervention Assessment shows Res exhibits a decline with self performance and transfers, weakness present and has decreased endurance to ambulate with assist .Transfer assessment re-evaluated to 2 assist with transfers. Will in-service nursing to decrease risk of falls with transfers. The facility Fall monitoring report shows R7 had 15 falls from April, 2015 through March, 2016. The Fall report shows on April 27, 2015 R7 slid off the toilet. On April 14, 2016 at 11:50AM, E14 wheeled R7 to the bathroom doorway in her room. E14 transferred R7 from her wheelchair to bathroom, using a grab bar, and R7's legs were unsteady. After transferring R7 to the toilet and removing her pants and incontinence brief, E14 left R7 unattended and unsupervised on the toilet in the bathroom to go look through her closet. E14 could not see R7 from the closet location in the room. E14 then left R7's room, and stepped out into the hallway to ask someone to bring him supplies, while R7 was unsupervised in the bathroom. E14 said R7 was at a high risk for falls, and had good days and bad days. E14 said some days she is stronger than others and she was weak earlier today. E14 said when he was cleaning R7 earlier in the day her legs were shaking. E14 then had R7 stand using the hand rail, and pulled her pants up, and transferred her to the wheelchair. On April 14, 2016 at 12:10PM, E23 (Licensed Nurse) said R7 is at a high risk for falls, and should be transferred with 2 assists at all times because she has had a significant decline ,and it is unsafe to transfer with 1 assist. E23 said R7 should absolutely not be left unsupervised in the bathroom. On April 15, 2015 at 8:50 AM, E2 (Director of Nursing - DON) said R7' health has declined, and she is not as steady on her feet, is difficult to re-direct due to her dementia, and has no safety-awareness. E2 said R7 has been changed to a two person assist with transfers, due to her decline, and she is not able to bear weight as well as she used to. E2 said E14 should not have transferred R7 by himself, and should not have left R7 unsupervised in the bathroom, on the toilet. At 11:55AM, E27 (Restorative Nurse) said she completes transfer assessments on residents quarterly, annually, or with an improvement or decline in condition. E27 said R7's most recent transfer assessment was completed on March 15, 2016 and the assessment determined R7 should be transferred with a 2 staff assist. E27 said R7 should not be left unsupervised in the bathroom. The November, 2013 facility Falls - Clinical Protocol shows After more than one fall, the physician or designee should review the resident's gait, balance, and current medications .A restorative nurse or therapist should monitor the residents mobility status. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. the fall prevention plan of care should be reviewed and updated with each fall. 2.On April 13, 2016 at 1:30 PM, during the environmental tour, the first floor soiled linen room was unlocked and able to be pushed open without a key or security code. Red bagged biohazard garbage was located inside the room. On April 13, 2016 at 1:35 PM, E43 (Environmental Supervisor) stated, This door should be locked. Someone forgot to push the lock on the door knob inside. This room needs a key to get in. At 1:35 PM, E1 (Administrator) said, Yes, I would expect this door to be locked. Residents could be harmed in there. On April 13, 2016 at 1:45 PM, the second floor soiled linen and clean linen rooms were unlocked and able to be opened without a key or security code. The soiled linen room contained red bagged biohazard garbage, an opened bag of powder form sheet rock patching compound, and an open five gallon bucket of joint compound. The clean linen room contained disposable razors and nail clippers. E42 (Housekeeper) said, The aides should be locking these doors. The red biohazard bins contain used linens that are infectious. At 2:00 PM, E25 (Certified Nurse Aide) said, These doors should be locked so residents don't get into the dangerous items in there. R26-R29 and R34-R40 were listed on the the facility produced list of wandering and confused residents. The facility's second floor soiled utility room signage regarding biohazard storage stated: Attn: all staff regarding red bags in isolation rooms (use for) blood, stool, urine and respiratory secretions. The facility's Storage of Isolation/Biohazard Garbage policy dated 11/2013 states: The double bagged garage should be carried to the locked soiled utility room on the designated floor and placed in the red biohazard barrel. The Facility's Storage of Personal Care Items Policy dated 12/4/2015 states: Direct care staff retrieve the supplies as needed from the locked clean utility room. Items will be stored in a safe and clean manner.

Based on interview and record review the facility failed to notify R1's physician, family and the facility administrative staff when R1's [MEDICAL TREATMENT] treatment was cancelled on 5/20/11 because the facility van was not available. This failure prevented R1 from having alternative transportation to the [MEDICAL TREATMENT] treatment center. The facility failed to notify R1's physician on 5/22/11 of her increased [MEDICAL CONDITION]. These failures resulted in R1's development of fluid overload and exacerbation of [MEDICAL CONDITION] on 5/23/11. R1 was transferred on 5/23/11 to the hospital emergency department with shortness of breath and critical lab values. R1 required emergency kidney [MEDICAL TREATMENT] on 5/23/11 and hospitalization for stabilization. This failure resulted in an Immediate Jeopardy that was identified on 5/31/11. The Immediate Jeopardy began on 5/20/11 at 5:00 AM. The immediacy was removed on 6/1/11. The facility remains out of compliance at a level 2 due to the need to evaluate the effectiveness of the corrective measures put into place, the need to complete the in-servicing plan and the ability to ensure physicians and family are notified of all resident changes. This applies to 1 of 2 residents requiring kidney [MEDICAL TREATMENT] at a treatment center outside the facility. (R1). The findings include: The Physician order [REDACTED]. R1 is prescribed to receive kidney [MEDICAL TREATMENT] on Monday, Wednesday and Friday at the [MEDICAL TREATMENT] Center On 5/31/11 at 1:50 PM, E4 (Licensed Practical Nurse -LPN) stated, "Around 2:00 AM (on Friday 5/20/11), I observed that the facility transport van was not in the parking lot at the facility. R1 leaves for her [MEDICAL TREATMENT] treatment at 6:00 AM. I called the van driver (Z1) when I noticed the van missing and left a message for him to call and confirm how R1 was going to her appointment. I did not know the van was out of service. After 6:00 AM, when the driver had not returned my call and and the van was not here, I called the [MEDICAL TREATMENT] center and told them she would not be able to have [MEDICAL TREATMENT] that day." E4 stated, "I told R1 the van was not available and her [MEDICAL TREATMENT] appointment was cancelled. I did not discuss any other options for transportation with her. I did not call the doctor or the family. I guess I should have." On 5/31/11 at 10:20 AM, E3 (Registered Nurse - RN) confirmed she was working the day shift on 5/20/11 when the facility van had a problem and needed service. E3 stated the night nurse (E4) reported to her the van was not available and R1 would not be going to [MEDICAL TREATMENT] that day. E4 stated she had not talked with the resident, family, physician or administrative staff about the cancelled appointment. E4 continued, "R1 did have quite a bit of swelling in her feet over the weekend, but she does spend the majority of her time in the wheelchair. I asked the staff to try to prop up her legs." E4 stated she had not talked to the doctor over the weekend about the increased swelling of R1's feet. On 5/31/11 at 11:20 AM, Z1 (R1's son) was asked if he was notified R1's [MEDICAL TREATMENT] appointment was cancelled on 5/20/11. Z1 responded, "NO, They never called me! The hospital (Facility B) called me because they were concerned why mom missed her appointment on 5/20/11. That is when I found out she did not go on Friday." Z1 continued, "When we visited on Sunday afternoon, I thought she looked bloated; you know like she was full of excess water. She said she was nauseated and I reported it to the nurse. I figured they would take care of it." On 5/31/11 at 11:10 AM, R1 stated, "My son was really upset with the facility that they did not call him (about the [MEDICAL TREATMENT] cancellation)". R1 stated she did not know if they called her doctor and let him know she wasn't going. On 5/31/11 at 3:40 PM, Z4 (Physician) stated, "When R1 got to the emergency department (Facility A) on 5/23/11, they notified my that she had missed her [MEDICAL TREATMENT] appointment on Friday 5/20/11." On 5/31/11 at 2:25 PM, Z3 (Physician) stated, "When she arrived at the hospital (Facility B) I was notified she had missed her [MEDICAL TREATMENT] treatment on Friday. It is obvious missing a [MEDICAL TREATMENT] treatment matters or she would not have been in this situation. It is a fair conclusion that the development of [MEDICAL CONDITION] was resulted from the lack of [MEDICAL TREATMENT]." On 5/31/11 at 1:20 PM, E1 Director of Nurses (DON) stated, "The 11-7 nurse realized the van was not at the facility; she was not aware it was being repaired. The nurse assumed it was OK to cancel the appointment. I was not here on Friday (5/20/11). I found about the missed [MEDICAL TREATMENT] appointment and the emergency transfer to the hospital when I got to work on Monday." The Physician Consultation report on 5/23/11 from (Facility B) documents the following: "R1 missed her [MEDICAL TREATMENT] on Friday (5/20/11) and no one was notified that she could or would not come. No alternate plans made because no one knew what was going on with her." The consultation report also states, "The patient basically has been lost to follow-up. Exactly why she did not call and schedule alternate [MEDICAL TREATMENT] is unclear at this point. At this point, we will treat her emergently. [MEDICAL TREATMENT] again tomorrow." The nurses' note entry for R1 dated 5/20/11 at 5:00 AM states, "Called [MEDICAL TREATMENT] Center about no transportation related to wheelchair van being repaired." There was no documentation the physician, family or administrative staff were notified. R1's care plan dated 5/16/11 states the resident receives [MEDICAL TREATMENT] 3 times per week on Monday, Wednesday and Friday. The interventions include to send the resident to [MEDICAL TREATMENT] as scheduled. Notify the physician of any abnormalities. The facility policy on Physician and Family Notification: Missed or Delayed Appointment policy states: 1. Upon determining that a resident's significant appointment will be delayed or missed do the following: a. Call the attending physician and notify the physician of the significant appointment that will be delayed or missed. b. Follow any orders given by the physician. c. Call the family and notify them of the significant appointment that will be delayed or missed. d. Notify the DON or ADON. 2. Document all the above in the nursing notes. On 5/31/11 at 2:45 PM, E6 Administrator was informed of the Immediate Jeopardy related to the physician and family not being notified of R1's [MEDICAL TREATMENT] treatment cancellation on 5/20/11. Through interview and record review, the surveyor confirmed that the facility took the following actions to remove the immediacy: A. On 5/23/2011 facility began investigation into why R1 did not go to [MEDICAL TREATMENT] appointment on 5/20/11. B. On 5/23/11 Z4 (attending M.D.), E6 (administrator),E1 (director of Nursing, E2 (assistant Director of Nursing) and E5 (Maintenance Director) were notified of the incident involving R1 on 5/20/11. C. On 5/23/11 the van transportation policy was immediately updated to reflect what staff are to do in the event transportation is not available. Nursing is to be notified immediately. D. On 5/26/11 the family was updated on the facility plan related to the incident. E. On 6/1/11 the facility's [MEDICAL TREATMENT] policy was reviewed. If an appointment is missed the physician, family and Director of Nursing will be notified immediately. F. On 6/1/11 bus drivers and the 2 nurses involved in this incident were counseled. G. On 6/1/11 all nurses were inserviced on the transportation policy, [MEDICAL TREATMENT] policy and the care of the [MEDICAL TREATMENT] resident. H. On 6/1/2011 [MEDICAL TREATMENT] residents care plans were reviewed to ensure they contained all details related to [MEDICAL TREATMENT]. I. Met with family and discussed incident in detail and the facility's plan of action.

Based on interview and record review the facility neglected to have/follow their policies on [MEDICAL TREATMENT] transportation to ensure a resident R 1 had transportation to receive a [MEDICAL TREATMENT] treatment on 5/20/11. As a result R1 developed fluid overload and [MEDICAL CONDITION] on 5/23/11. This failure resulted in an Immediate Jeopardy that was identified on 5/31/11. The Immediate Jeopardy began on 5/20/11 at 5:00 AM. The immediacy was removed on 6/1/11. The facility remains out of compliance at a level 2 due to the need to evaluate the effectiveness of the corrective measures put into place, the need to complete the in-servicing plan and the ability to have ensure resident transportation program is in place. This applies to 1 of 2 residents requiring kidney [MEDICAL TREATMENT] at a treatment center outside the facility. (R1). The findings include: The Physician order [REDACTED]. R1 is prescribed to receive kidney [MEDICAL TREATMENT] on Monday, Wednesday and Friday at the [MEDICAL TREATMENT] Center (According to Mapquest, it is 11 miles from the facility). On 5/31/11 at 1:50 PM, E4 Licensed Practical Nurse (LPN) stated, "Around 2:00 AM (on Friday 5/20/11), I observed that the facility transport van was not in the parking lot at the facility. R1 leaves for her [MEDICAL TREATMENT] treatment at 6:00 AM. I called the van driver (Z1) when I noticed the van missing and left a message for him to call and confirm how R1 was going to her appointment. I did not know the van was out of service. After 6:00 AM, when the driver had not returned my call and and the van was not here, I called the [MEDICAL TREATMENT] center and told them she would not be able to have [MEDICAL TREATMENT]." E4 stated, "Usually if the van is unavailable they pass it on to us, but I didn't know. I told R1 the van was not available and her [MEDICAL TREATMENT] appointment was cancelled. I did not discuss any other options for transportation with her. I did not call the doctor or the family. I guess I should have." On 5/31/11 at 10:20 AM, E3 Registered Nurse - (RN) confirmed she was working the day shift on 5/20/11. E3 stated the night nurse (E4) reported to her the van needed service and was not available and R1 would not be going to [MEDICAL TREATMENT] that day. E4 stated she was not aware of any alternative transportation options that were available if the van was broken . E4 stated, "The (Senior Service Van) refuses to go out of town and would not go as far as the [MEDICAL TREATMENT] center. The ambulance service would not be an option because this would have been a non-emergent case." E4 stated she had not talked with the resident, family, physician or administrative staff about the cancelled appointment and other transportation methods available. E4 stated "Usually residents are taken in the facility van. Nursing coordinates the transportation. The drivers and their phone numbers are posted and we call them. I did not know the van was broken till the night nurse told me." On 5/31/11 at 12:30 PM, E5 (Director of Maintenance) stated, "I didn't know the resident (R1) did not go to her appointment on Friday (5/20) until Monday (5/23). Nothing was wrong with the van, they worked on the lift hydraulics. It still worked, it just had to be used manually. In fact, Tuesday (5/17) is when we identified the problem. We used the van until Thursday (5/19) and then I took it in for service. The nursing staff did not let us know R1 had to go to [MEDICAL TREATMENT]. The transportation log is missing. When a resident is scheduled to go to an appointment every week, the driver puts it in the log book. The one time appointments go onto the schedule at the nursing desk. Then the driver checks the schedule and puts everything into the log book." E5 continued, "In fact, the facility van was returned that Friday around 8:30 AM. I was not aware anyone was waiting to go out." E5 stated, "The (Senior Service Van) would have taken the resident to the [MEDICAL TREATMENT] center, it is approximately 15 miles away. They won't go more than 25 miles from town. It is nursing's responsibility to schedule the residents' appointments and put it on the schedule." E5 commented, "Nursing knew the van was going in for service. The DON knew on Thursday (5/19) the van was going to be out for service." On 5/31/11 at 1:40 PM, E6 Administrator stated, "The facility van is the primary method of transportation for the residents. If there is a problem, the floor nurse will call the Director of Nurses or Administrator. They could have notified the (Senior Service Van) or the family as alternate methods of transportation for R1." E6 stated the facility did not have a transportation program/policy until this incident occurred. On 5/31/11 at 11:20 AM, Z1 (R1's son) stated, "If we had know they cancelled the appointment because the van was broken down, we would have found a way to get her there. I can get her in and out of the chair, and I know I could get her out of my car." On 5/31/11 at 11:10 AM R1 stated, "The bus was down, they told me that morning (5/20) that I wasn't going (to [MEDICAL TREATMENT])." R1 stated no one discussed alternate methods of transportation with her. R1 stated, "I don't understand, I go home in the car for family visits, I need help but the [MEDICAL TREATMENT] staff could have helped get me out of the car." On 5/31/11 at 1:20 PM, E1 Director of Nurses (DON) stated, "The 11-7 nurse realized the van was not at the facility; she was not aware it was being repaired. The nurse assumed it was OK to cancel the appointment. I was not here on Friday (5/20/11). There are alternative services available, she just didn't know that. The van driver is the transportation coordinator. He checks the appointment schedule and calendar. He did not make any contact with nursing about the van being in for service. No alternate plans were made." The Physician Consultation report on 5/23/11 from (Facility B) documents the following: "She missed her [MEDICAL TREATMENT] on Friday and no one was notified that she could or would not come. No alternate plans made because no one knew what was going on with her....Exactly why she did not call and schedule alternate [MEDICAL TREATMENT] is unclear at this point." The monthly nursing summary for R1 dated 5/15/11 states, "Alert and orientated times 3. Is a one person assist to partial assist with activities of daily living, and is a 2 person transfer. Is a [MEDICAL TREATMENT] resident, goes on M, W, F to (outside facility) early on those days. Family is involved with personal needs and appointments." The nurses' note dated 5/20/11, 5:00 AM states, "Called [MEDICAL TREATMENT] Center about no transportation related to wheelchair van being repaired." There were no additional nurses' notes or resident assessments documented until 5/23/11 at 1:30 AM. R1's care plan dated 5/16/11 states the resident receives [MEDICAL TREATMENT] 3 times per week on Monday, Wednesday and Friday. The interventions include to send the resident to [MEDICAL TREATMENT] as scheduled. The method of transportation is not listed. The Minimum (MDS) data set [DATE] documents R1 does not have any cognitive deficits, or any problems with short and long term memory. The facility policy dated 12/2010 on Care of a [MEDICAL TREATMENT] Resident states to follow the [MEDICAL TREATMENT] assessment policy, to place [MEDICAL TREATMENT] information (i.e. site, days, time) in the resident's chart, to document [MEDICAL TREATMENT] transportation information in the resident's chart, and to follow the Physician and Family Notification: Missed or Delayed Appointment policy if a [MEDICAL TREATMENT] appointment will be delayed or missed. The policy does not address resident assessment or monitoring the resident will receive when a [MEDICAL TREATMENT] treatment must be delayed or cancelled. The facility policy dated 1/2009 on Physician and Family Notification: Missed or Delayed Appointment policy states: 1. Upon determining that a resident's significant appointment will be delayed or missed do the following: a. Call the attending physician and notify the physician of the significant appointment that will be delayed or missed. b. Follow any orders given by the physician. c. Call the family and notify them of the significant appointment that will be delayed or missed. d. Notify the DON or ADON. 2. Document all the above in the nursing notes. On 5/31/11, E6 (Administrator) was requested to provide the facility transportation program/policy for residents requiring transportation to and from medical appointments. E6 provided a policy, "Transportation of [MEDICAL TREATMENT] Patients". E6 stated they just wrote this policy as a result of this incident. On 5/31/11 at 2:45 PM, E6 Administrator was informed of the Immediate Jeopardy related to R1 missing her [MEDICAL TREATMENT] treatment on 5/20/11 related to lack of transportation. Based on interview and record review the surveyor confirmed that the facility took the following actions to remove the immediacy: A. On 5/23/2011 facility began investigation into why R1 did not go to [MEDICAL TREATMENT] appointment on 5/20/11. B. On 5/23/11 Z4 (attending M.D.), E6 (administrator),E1 (director of Nursing, E2 (assistant Director of Nursing) and E5 (Maintenance Director) were notified of the incident involving R1 on 5/20/11. C. On 5/23/11 the van transportation policy was immediately updated to reflect what staff are to do in the event transportation is not available. Nursing is to be notified immediately. D. On 5/26/11 the family was updated on the facility plan related to the incident. E. On 6/1/11 the facility's [MEDICAL TREATMENT] policy was reviewed. If an appointment is missed the physician, family and Director of Nursing will be notified immediately. F. On 6/1/11 bus drivers and the 2 nurses involved in this incident were counseled. G. On 6/1/11 all nurses were inserviced on the transportation policy, [MEDICAL TREATMENT] policy and the care of the [MEDICAL TREATMENT] resident. H. On 6/1/2011 [MEDICAL TREATMENT] residents care plans were reviewed to ensure they contained all details related to [MEDICAL TREATMENT]. I. Met with family and discussed incident in detail and the facility's plan of action.

Based on interview, record review and observation the facility failed to ensure R1 received her prescribed kidney [MEDICAL TREATMENT] treatment on 5/20/11. The facility failed to monitor and assess R1 after the missed appointment on 5/20/11 for complications. R1 required transfer to the hospital emergency department on 5/23/11 with shortness of breath and critical lab values. This failure resulted in R1 going into Fluid Overload and exacerbated her [MEDICAL CONDITION] condition on 5/23/11. R1 required emergency kidney [MEDICAL TREATMENT] on 5/23/11 and hospitalization for stabilization. This failure resulted in an Immediate Jeopardy that was identified on 5/31/11. The Immediate Jeopardy began on 5/20/11 at 5:00 AM. The immediacy was removed on 6/1/11. The facility remains out of compliance at a level 2 due to the need to evaluate the effectiveness of the corrective measures put into place, the need to complete the in-servicing plan and the ability to have ensure all resident [MEDICAL TREATMENT] appointments are met. This applies to 1 of 2 residents resident requiring kidney [MEDICAL TREATMENT] at a treatment center outside the facility. (R1). The findings include: The Physician order [REDACTED]. R1 is prescribed to receive kidney [MEDICAL TREATMENT] on Monday, Wednesday and Friday at the [MEDICAL TREATMENT] Center On 5/31/11 at 1:50 PM, E4 (Licensed Practical Nurse -LPN) stated, "Around 2:00 AM (on Friday 5/20/11), I observed that the facility transport van was not in the parking lot at the facility. R1 leaves for her [MEDICAL TREATMENT] treatment at 6:00 AM. I called the van driver (Z1) when I noticed the van missing and left a message for him to call and confirm how R1 was going to her appointment. I did not know the van was out of service. After 6:00 AM, when the driver had not returned my call and and the van was not here, I called the [MEDICAL TREATMENT] center and told them she would not be able to have [MEDICAL TREATMENT]." E4 continued, "Last winter they tried to cut her [MEDICAL TREATMENT] back to a couple of days, so I assumed missing a treatment would be OK. She looked good." E4 stated, "I told R1 the van was not available and her [MEDICAL TREATMENT] appointment was cancelled. I did not discuss any other options for transportation with her. I did not call the doctor or the family. I guess I should have." On 5/31/11 at 10:20 AM, E3 (Registered Nurse - RN) confirmed she was working the day shift on 5/20/11 when the facility van had a problem and needed service. E3 stated the night nurse (E4) reported to her the van was not available and R1 would not be going to [MEDICAL TREATMENT] that day. E4 stated she was not aware of any alternative transportation options that were available if the van was broken . E4 stated, "The (Senior Service Van) refuses to go out of town and would not go as far as the [MEDICAL TREATMENT] center. The ambulance service would not be an option because this would have been a non-emergent case." E4 stated she had not talked with the resident, family, physician or administrative staff about the cancelled appointment. E4 continued, "I worked over the weekend and R1 seemed OK. She was not short of breath until she went to the hospital on Monday with [MEDICAL CONDITION]. She did have quite a bit of swelling in her feet over the weekend, but she does spend the majority of her time in the wheelchair. I asked the staff to try to prop up her legs." E4 stated she had not talked to the doctor over the weekend about the increased swelling of R1's feet. On 5/31/11 at 1:50 PM, E4 (LPN) stated, "On my first rounds for the night (around midnight) on 5/23/11, R1 was sleeping, and was not short of breath. Around 2 AM, she was awakened and had a sudden onset of shortness of breath. She seemed anxious and asked me to call the doctor. The expressions on her face were that of impending doom or a drowning look, so I called the physician right away and he said to send her right away to the hospital (Facility A)." E4 stated she did not know if the physician was ever informed over the weekend that she missed her [MEDICAL TREATMENT] treatment on Friday. E4 stated she did not tell him when she called about the shortness of breath. On 5/31/11 at 11:20 AM, Z1 (R1's son) stated, "When we visited on Sunday afternoon, I thought she looked bloated; you know like she was full of excess water. She said she was nauseated and I reported it to the nurse. I figured they would take care of it." Z1 continued, "E4 called at 2:41 AM on Monday morning to let us know mom was short of breath and was going to the hospital. This situation was critical. She had gone another day after I noticed she was extremely bloated. They told us they would take care of it." On 5/31/11 at 11:10 AM, R1 was observed finishing her physical therapy session. During interview, R1 stated, "The bus was down, they told me that morning (Friday) that I wasn't going. I usually leave the facility at 6:00 AM and return around 10:30 AM." R1 was asked if anyone discussed alternate methods of transportation and she said that no one had. I don't understand, I go home in the car for family visits, I need help but the [MEDICAL TREATMENT] staff could have helped get me out of the car." R1 stated "My potassium level was very high on Monday and I went to the hospital. I was short of breath and needed to use oxygen. I don't usually use oxygen." On 5/31/11 at 3:40 PM, Z4 (Physician) stated, "I am not her attending physician but I did see her in the emergency department at the hospital (Facility A). I was told then she had missed her [MEDICAL TREATMENT] appointment on Friday. The Fluid Overload on Monday (5/23/11) could have been a result of missing her [MEDICAL TREATMENT] treatment on Friday (5/20/11). [MEDICAL TREATMENT] is a very delicate balance, Too much or too little can cause many problems." On 5/31/11 at 2:25 PM, Z3 (Physician) stated, "When she arrived at the hospital (Facility A) I was notified she had missed her [MEDICAL TREATMENT] treatment on Friday. It is obvious missing a [MEDICAL TREATMENT] treatment matters or she would not have been in this situation. It is a fair conclusion that the development of [MEDICAL CONDITION] resulted from the lack of [MEDICAL TREATMENT]." On 5/31/11 at 1:20 PM, E1 (Director of Nurses - DON) stated, "The 11-7 nurse realized the van was not at the facility; she was not aware it was being repaired. The nurse assumed it was OK to cancel the appointment. I was not here on Friday (5/20/11). I found about the missed [MEDICAL TREATMENT] appointment and the emergency transfer to the hospital when I got to work on Monday. The Physician Consultation report on 5/23/11 by Z4 (Nephrologist) at (Facility B) documents the following: "This is one of numerous admissions for this unfortunate individual who has been on [MEDICAL TREATMENT] now for a number of years. The patient basically, at this point comes in somewhat dyspneic (short of breath), found to be markedly hyperkalemic with a potassium level of 8.0 (Normal lab value 3.5 - 5.1 mmol/L). She was brought to the emergency department at (Facility A). She missed her [MEDICAL TREATMENT] on Friday and no one was notified that she could or would not come. No alternate plans made because no one knew what was going on with her. The patient known to have [MEDICAL CONDITIONS], mild [DIAGNOSES REDACTED], mild trivial and tricuspid regurgitation." The physician documented analysis of R1's lab values in the Consultation report states the following: "It is of note that her BUN on admission was 70, creatinine 7.77. Her potassium level here in 7.4, it was 8 in (Facility A). The patient basically has been lost to follow-up. Exactly why she did not call and schedule alternate [MEDICAL TREATMENT] is unclear at this point. The patient is being dialyzed emergently. She had been treated with [MEDICATION NAME] and [MEDICATION NAME] already, I believe at (Facility A). At this point, [MEDICAL TREATMENT] is being done with 2 K bath which should get her down. However, with a potassium of 8, it is likely that her tissue stores of potassium are very high, and although we are dialyzing her four hours a day, we would probably have to dialyze her again tomorrow to get her potassium up. Shortness of breath is probably related to fluid overload. She apparently is about 7 kilograms (7kg = 15.4 pounds) over her dry weight at this time. At this point, we will treat her emergently. [MEDICAL TREATMENT] again tomorrow." According to "Geriatric Dosage Handbook", Semla, Beizer, Higbee, Lexicomp 12th Edition, 2007; [MEDICATION NAME] is an Antidote used to treat [MEDICAL CONDITION] (High blood Potassium levels). The monthly nursing summary for R1 dated 5/15/11 states, "Alert and orientated times 3. Is a one person assist to partial assist with activities of daily living, and is a 2 person transfer. Is a [MEDICAL TREATMENT] resident, goes on M, W, F to (outside facility) early on those days. Family is involved with personal needs and appointments." The next nurses' note entry dated 5/20/11, 5:00 AM states, "Called [MEDICAL TREATMENT] Center about no transportation related to wheelchair van being repaired." There were no additional nurses' notes until 5/23/11 at 1:30 AM, " (Vital signs) Blood Pressure 172/72. Complains of shortness of breath, oxygen saturation level is 92%, Placed on oxygen at 2 L/M and gave nebulizer treatment which she kept on for 15 minutes. The head of the bed elevated, no shortness of breath noted, does have some expiratory wheezing but clear all other fields." R1's care plan dated 5/16/11 states the resident receives [MEDICAL TREATMENT] 3 times per week on Monday, Wednesday and Friday. The interventions include to send the resident to [MEDICAL TREATMENT] as scheduled. The facility policy dated 12/2010 on Care of a [MEDICAL TREATMENT] Resident states to follow the [MEDICAL TREATMENT] assessment policy, to place [MEDICAL TREATMENT] information (i.e. site, days, time) in the resident's chart, to document [MEDICAL TREATMENT] transportation information in the resident's chart, and to follow the Physician and Family Notification: Missed or Delayed Appointment policy if a [MEDICAL TREATMENT] appointment will be delayed or missed. The facility policy dated 1/2009 on Physician and Family Notification: Missed or Delayed Appointment policy states: 1. Upon determining that a resident's significant appointment will be delayed or missed do the following: a. Call the attending physician and notify the physician of the significant appointment that will be delayed or missed. b. Follow any orders given by the physician. c. Call the family and notify them of the significant appointment that will be delayed or missed. d. Notify the DON or ADON. 2. Document all the above in the nursing notes. The Minimum (MDS) data set [DATE] documents R1 does not have any cognitive deficits, or any problems with short and long term memory. On 5/31/11 at 2:45 PM, E6 (Administrator) was informed of the Immediate Jeopardy related to R1 missing her [MEDICAL TREATMENT] treatment on 5/20/11. Based on interview and record review the surveyor confirmed that the facility took the following actions to remove the immediacy: A. On 5/23/2011 facility began investigation into why R1 did not go to [MEDICAL TREATMENT] appointment on 5/20/11. B. On 5/23/11 Z4 (attending M.D.), E6 (administrator),E1 (director of Nursing, E2 (assistant Director of Nursing) and E5 (Maintenance Director) were notified of the incident involving R1 on 5/20/11. C. On 5/23/11 the van transportation policy was immediately updated to reflect what staff are to do in the event transportation is not available. Nursing is to be notified immediately. D. On 5/26/11 the family was updated on the facility plan related to the incident. E. On 6/1/11 the facility's [MEDICAL TREATMENT] policy was reviewed. If an appointment is missed the physician, family and Director of Nursing will be notified immediately. F. On 6/1/11 bus drivers and the 2 nurses involved in this incident were counseled. G. On 6/1/11 all nurses were inserviced on the transportation policy, [MEDICAL TREATMENT] policy and the care of the [MEDICAL TREATMENT] resident. H. On 6/1/2011 [MEDICAL TREATMENT] residents care plans were reviewed to ensure they contained all details related to [MEDICAL TREATMENT]. I. Met with family and discussed incident in detail and the facility's plan of action.