Every finding on record at Pearl of Naperville, The

Based on interview and record review, the facility failed to ensure staff responded timely to residents' requests for care assistance and/or pain medication in accordance with their policy.This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for call light response in the sample of 4.The findings include:1.On May 4, 2026, at 10:15 AM, V5 (Staffing Coordinator) stated she received a call from V6 (Agency CNA/ Certified Nursing Assistant) on April 29, 2026, at around 8:00 PM. V5 stated at the same time, she received a call from V7 (LPN/ Licensed Practical Nurse) who was working the 7:00 PM until 7:30 AM shift on April 29, 2026. V5 stated V6 was working, the 2:00 PM to 10:00 PM shift on April 29, 2026. V5 stated during the phone call with V6, V6 was talking loudly and raising her voice while complaining that V7 accused her of being on break for over an hour and not answering R1's call light for 59 minutes.V7 provided a written statement, dated April 29, 2026, that described how V7 was approached by V4 (Human Resources Director/Manager on Duty) on April 29, 2026, around 7:50 PM and was informed R1 had complained to V4 that R1's call light was unanswered for 45 minutes and R1 was requesting CNA (Certified Nursing Assistance) assistance to go to the bathroom. V7's statement showed the call light display board included a timer and 59 minutes had elapsed since R1 had activated his call light. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia, unspecified, neuromuscular dysfunction of the bladder, neurogenic bowel, fusion of the thoracic spine and peripheral vascular disease. R1's MDS (Minimum Data Set), dated January 29, 2026, showed R1 was cognitively intact and required set up assistance from staff for eating, oral care, upper body dressing and rolling side to side in bed, partial assistance with footwear, coming to a standing position and transfer, and substantial assistance with bathing and toileting. On May 4, 2026, at 12:07 PM, R1 was observed in his room, up in his wheelchair, with a blanket covering his legs. R1 stated to surveyor, If you're from the state, I don't want to talk to you.On May 4, 2026, at 3:20 PM, V3 (ADON/Assistant Director of Nursing) showed the call light display boards and stated they are new and were installed around 6 months ago. V3 stated there were 2 call light display boards, one at each nurse's station, and the board alarms and displays which room the call light was activated from, and how long the call light has been activated, and updates the time at minute intervals. On May 4, 2026, at 3:26 PM, V12 (Licensed Practical Nurse/LPN) stated she worked on the 100 unit (where R1 resides) on April 29, 2026, 7AM-7:30 PM shift. V12 stated she did witness V4 approach the nurses' station and inform both V12 and V7 that R1 had complained he needed assistance to go to the bathroom and had been waiting with his call light on for 45 minutes. V12 stated she also observed V6 and V7 speaking loudly to each other near the nurses' station but was unsure if there were any residents present at the time. V12 stated she told both V6 and V7 to calm down before she left the facility. 2. R2's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, unspecified asthma, anxiety disorder, and unspecified psychosis.R2's MDS (Minimum Data Set) dated March 5, 2026, showed R2 was cognitively intact, and required staff assistance with ADL's including set up assistance with eating and oral hygiene, supervision with personal hygiene, partial assistance with bed mobility sit to stand, transfer, upper body dressing and personal hygiene, substantial assistance with lower body dressing and bathing.R2 was identified as the Resident Council President on the meeting minutes dated April 9, 2026. The April meeting minutes showed an identified concern with call lights not being answered in a timely manner during the overnight shifts and call lights being turned off before the needs are met. On May 5, 2026, at 11:05 AM, R2 stated a concern was raised regarding call lights being answered timely on the overnight shift and stated she remembered R4 had raised the concern. R2 explained she had her own experience with call lights not being answered or being answered and the need not being met. R2 explained she waited for pain medication for an hour after her call light was on and the staff did not bring the pain medication. R2 could not recall the exact date and time when that happened. R2 further stated the call lights being answered timely is also a concern on weekends when there are more agency staff present. 3. R3 is was admitted to the facility on [DATE], with multiple diagnosis including Type 2 Diabetes, Lymphedema, Respiratory Failure, Morbid (Severe) Obesity, Obstructive Sleep Apnea, Chronic Diastolic (Congestive) Heart Failure, Essential Hypertension, Peripheral Vascular Disease, Venous Insufficiency(Chronic)(Peripheral), Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, Presence of Right Artificial Knee, and Iron Deficiency Anemia (chronic). R3's MDS (Minimum Data Set), dated April 16, 2026, showed R3 was cognitively intact. R3 requires supervision/touching assistance with eating, oral hygiene, and personal hygiene tasks. Substantial/ maximum assistance for upper body dressing, transferring to a sit to standing position, Chair/bed-to-chair transfer, and walking 10 feet. R3 was dependent on toilet hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, bed mobility, transferring to a tub or shower and operating a wheelchair. On May 4, 2026, at 12:30 PM, R3 was sitting in the dining room in a wheelchair on his phone after eating lunch. R3 was dressed in appropriate clothing and footwear, well-groomed and free of odor. R3 stated when he uses his call light, it is not always answered in a reasonable timeframe, and his needs are not always met. R3 states this happens more when agency staff are assigned to work. 4. R4's EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE], with multiple diagnosis including Acute Posthemorrhagic Anemia, Noninfective Gastroenteritis and Colitis, Gastrointestinal Hemorrhage, Essential (Primary) Hypertension, Hyperlipidemia, Hypothyroidism, Orthostatic Hypotension, Anemia, Adjustment Disorder, Unspecified Intellectual Disabilities, Diverticulosis of Intestine without Perforation or Abscess without Bleeding, Gastro-Esophageal Reflux Diseases without Esophagitis.R4's MDS (Minimum Data Set), dated April 3, 2026, showed R4 was cognitively intact. R4 requires set-up or clean-up assistance with eating, bed mobility, and using a wheelchair. Requires supervision or touching assistance with oral hygiene, toilet hygiene, upper body dressing, personal hygiene, transfers, walking with assistive device. And requires partial/moderate assistance with showering/bathing, lower body dressing, and putting on or taking off footwear.On May 5, 2026, at11:05 AM, R4 was identified as someone who complained about call light response times at the April 9, 2026, Resident Council Meeting minutes. Per the April Resident Council Meeting minutes, residents complained about call light response times on night shift. On May 5, 2026 at 11:28 AM, R4 was sitting in the lounge area in a wheelchair, while coloring. R4 was dressed in appropriate clothing and footwear, well-groomed and free of odor. R4 stated that once during night shift I had to wait for about an hour for someone to answer my call light. R4 stated it occurred on a Monday night, April 27, 2026. On May 4, 2026, at 3:55 PM, V1 (Administrator) stated the new call light display board had been installed about 6 months ago. V1 stated the call light display times are not stored and unable to be retrieved. V1 also stated he was unaware of any residents having to wait more than 45 minutes for their call light to be answered.On May 5, 2026, at 9:38 AM, V2 (Director of Nursing) stated the expectation for staff is to answer call lights as they pass by a room and if unable to provide for the residents' need, seek staff who are able to meet the need. V2 also stated waiting 45 minutes for a call light to be answered is an excessive amount of time to wait. The facility's policy titled Call Light Use, dated July 6, 2023, showed the facility aims to meet residents' needs as timely as possible, and the call light system is used to alert staff of resident's needs. The facility's policy titled Resident Rights-Exercise of Rights, dated January 17, 2025, showed, Intent: All activities and interactions with residents by any staff, temporary agency staff or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth.while providing care and services, staff will respect each residents individuality, as well as honor and value their input.

Based on interview and record review, the facility failed to provide residents or their representatives with written notices for room changes. This applies to 5 of 5 residents (R1-R5) reviewed for resident rights.The findings include:1.On 2/04/2026 at 10:30 AM, R1 was in her room, upset. R1 said she moved into her current room without being notified for the reason of the move on 1/28/2026. R1 said she had been admitted to the facility in 2021 and had always resided in the same room. R1 said maintenance staff came to her room and started packing her personal belongings on 1/28/2026, and she became upset because she had not been informed prior to the room change. R1 said then the management staff came to her room and informed her that her daughter (V14) was notified of the room change. R1 said she made her own decisions and filed a grievance on 1/28/2026. R1 continued to say she was still so upset with the facility's failure to notify her prior to the room change and was still unsure why she was moved. On 2/04/2026 at 12:30 PM, V12 (Maintenance Director) said on the morning of 1/28/2026, he was informed to assist in R1's room move. V12 said when he started to move R1 in the afternoon, she became very upset and yelled for an explanation regarding her decision to be moved. V12 said he immediately stopped and informed V10 (Social Worker Director/SWD) and V11 (Admissions Director) of R1's concern. V12 said after V10 and V11 spoke to R1, she agreed to the move but was still upset.R1's Grievance form, dated 1/28/2026, said, Resident questioned the reason for the room change. The form said V10 (Social Worker Director) and V11 (Admissions Director) met with R1 and explained the reason for the move and that V14 (R1's Family Member) was also notified of the resolution.On 2/04/2026 at 11:40 AM, V11 (Admissions Director) said the facility was scheduled to start remodeling in the unit where R1 previously resided, and management had decided she had to be moved to another room. V11 said she was not aware of the facility's process for notifying residents or representatives regarding room changes. V11 said she believed V10 (Social Worker Director/SWD) had notified V14 (R1's daughter) prior to the change. V11 said she assisted in explaining the reason for the room change to R1 during the move.On 2/04/2026 at 1:45 PM, V10 (SWD) said she contacted V14 prior to the room change, and V14 agreed as long as R1 approved the room change. V10 said during the room change, she responded to R1's grievance regarding the move and explained to her the reason for the move. V10 said then R1 agreed to the room change. V10 said she was not aware of V14's emailed grievance to V1 (Administrator) requesting a further explanation regarding the reason for R1's room change on 1/29/2026. V10 said she was also not aware of the facility's policy regarding the need to provide residents or their representatives with a written notice regarding room changes, prior to the move. V10 said she only obtained verbal consents for room changes and never notified the new roommates of the change. V10 said R1 was cognitively intact and able to make her own decisions. V10 said residents had the right to be informed of their room changes prior to the move and explained the reason for the move.V10's social service note, dated 1/28/2026 at 4:50 PM, said she contacted V14 to obtain consent for R1's room change. V14's (R1's Family Member) e-mail grievance, dated 1/29/2026, said she had a concern regarding R1's room move. The e-mail said, Social worker stated she had spoken with [R1] and she was OK with moving to another room. Just after this call, [R1] called me very upset to tell me that your staff was present in her room and packing all of [R1's] belongings in boxes. She was unaware why they were doing this. This was very upsetting for [R1]. Your staff should have handled this better as big changes like this are very stressful for the elderly.2. On 2/04/2026 at 12:40 PM, V9 (Family Member) was visiting R2 (R1's roommate). V9 said R2 was nonverbal, and he was her Power of Attorney (POA). V9 said R2 was moved multiple times during her stay at the facility, and he never received a written notice prior to her room moves. V9 said last week during his daily visit, he noticed R1 had been moved to the room, and she was visibly upset regarding her move. V9 said he was also not made aware prior to R1 moving in.3. On 2/04/2026 at 12:45 PM, R3 was visibly upset in her room. R3 said on the evening of 1/30/2026 after bingo, she went to her room, and her bed was gone. R3 said she was extremely upset because the facility staff had moved her to another room without her knowledge. R3 said she had then informed her she was moved because her wound culture showed she had an infection and required her to be placed in Transmission-Based Precautions. R3 said most of her personal belongings were still in the other room. R3 continued to say the facility staff had still not informed her why she was not notified prior to her room change.4. On 2/04/2026 at 1 PM, R5 was in her room and said R4 (her roommate) had recently moved in. R5 said she was not notified prior to the room move. R5 said she was a long-term resident, and she wished her roommate was some she could talk to. R5 said it was upsetting because R4 was non-verbal. R4 was in bed and unable to be interviewed because she was non-verbal. R4's EMR (Electronic Medical Record) showed she moved in with R5 on 1/30/2026 and was severely cognitively impaired.On 2/04/2026 at 2 PM, V1 (Administrator) said the facility was scheduled to start remodeling resident rooms and residents were being moved within the facility. V1 said the facility was not following their notification policy regarding room moves; they were not providing residents or their representatives with written notices prior to and with an explanation for the move. V1 said residents and their representatives should be notified accordingly of room moves because it was their right to be informed of where they were moving within the facility.The facility's policy titled Resident Right- Choose/Be Notified of Room/Roommate Change, dated 5/01/2024, said the facility allowed the resident and or their legal representatives the right to choose a roommate, be notified of room changes, as well as roommate changes in such a manner to acknowledge and respect resident rights. The residents have the right to share a room with his or her roommate of choice when practicable, and both residents have to consent to the arrangement. The residents also have the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility changes.

Based on interview and record review, the facility failed to ensure QAPI (Quality Assurance Performance Improvement) meetings were held quarterly, and the required members were in attendance. This has the potential to affect all 93 residents residing in the facility. The Findings include: CMS form 671, completed on December 15, 2025, by V1 (Administrator) shows a census of 93 residents residing in the facility.V1 (Administrator) provided the QAPI meeting attendance records from November 2024 through December 9, 2025. The attendance document showed the QAPI meeting attendance on November 11, 2024, did not have the signature of the Director of Nursing or indicate their presence at the meeting. The attendance document showed the QAPI meeting attendance on December 10, 2024, did not have the signature of the Administrator, nor indicated their presence at the meeting. The next QAPI meeting attendance document was dated July 8, 2025, and the Medical Director/or designee signature was missing. There was no attendance records provided for the months of January 2025, February 2025, March 2025, April 2025, May 2025, or June 2025. The QAPI meeting, dated November 11, 2025, did not have the signature of either the Medical Director nor the Administrator, and did not indicate their presence at the meeting. Review of the facility provided QAPI meeting attendance from November 12, 2024, through December 9, 2025, did not show that any staff nurses or CNA's (Certified Nursing Assistants) participated in the meeting. On December 17, 2025, at 2:45 PM, V1 stated at the beginning of January 2025, the facility reduced their QAPI meetings from monthly to quarterly. V1 stated there was supposed to be a meeting held on April 8, 2025, however, he had no attendance record to validate the QAPI meeting had taken place on that date, nor any indication of any one's presence at that meeting. V1 stated the QAPI committee is led by V1. V1 explained the QAPI meetings are expected to be attended by the Medical Director, managers of all departments, Infection Preventionist within the facility, as well as vendor partners such as the dialysis services, pharmacy, laboratory, and dietary services. V1 stated he does not include staff nurses or CNAs (Certified Nursing Assistants) in the QAPI process. V1 stated the project outcomes of the QAPI committee activities have the potential to impact all staff and residents. The facility's policy for QAPI program showed the Facility's QAPI committee should be chaired by the Administrator and Director of Nursing. The QAPI committee members included Administrative Managers, Social Services, Maintenance and Environmental, Dietary, Business Office, Human Resources, MDS Coordinator, Infection Preventionist, ADON, Therapy, and Unit Nurses/CNAs. The QAPI committee should meet quarterly, monthly, and weekly for focused huddles for issues.

Based on interview and record review, the facility failed to follow CDC (Centers for Disease Control and Prevention) guidelines for pneumococcal vaccines. This applies to 5 of 5 residents (R8, R12, R21, R39, and R50) reviewed for immunizations in the sample of 20. The findings include:1. The EMR (Electronic Medical Record) showed R8 was a [AGE] year-old resident admitted to the facility on [DATE]. R8's Immunization Report, dated December 17, 2025, showed R8 received the PCV20 (Pneumococcal Conjugate Vaccine 20-valent) vaccine on October 25, 2023, and October 10, 2025. R8's October 2023 MAR (Medication Administration Record) showed R8 received the PCV20 vaccine in the facility on October 25, 2023. R8's October 2025 MAR showed R8 received the PCV20 vaccine in the facility on October 10, 2025. 2. The EMR showed R12 was an [AGE] year-old resident admitted to the facility on [DATE]. R12's Immunization Report, dated December 17, 2025, showed R12 received the PCV20 vaccine on October 25, 2023, and October 10, 2025. R12's October 2023 MAR showed R12 was administered the PCV20 vaccine in the facility on October 25, 2023. R12's October 2025 MAR showed R12 was administered the PCV20 vaccine in the facility on October 10, 2025. 3. The EMR showed R21 was a [AGE] year-old resident admitted to the facility on [DATE]. R21's Immunization Report, dated December 17, 2025, showed R21 received the PCV20 vaccine on October 25, 2023, and October 10, 2025. R21's October 2023 MAR showed R21 was administered the PCV20 vaccine in the facility on October 25, 2023. R21's October 2025 MAR showed R21 was administered the PCV20 vaccine in the facility on October 10, 2025. 4. The EMR showed R39 was an [AGE] year-old resident admitted to the facility on [DATE]. R39's Immunization Report, dated December 17, 2025, showed R39 received the PCV20 vaccine on October 25, 2023, and October 10, 2025. R39's October 2023 MAR showed R39 was administered the PCV20 vaccine in the facility on October 25, 2023. R39's October 2025 MAR showed R39 was administered the PCV20 vaccine in the facility on October 10, 2025. 5. The EMR showed R50 was an [AGE] year-old resident admitted to the facility on [DATE]. R50's Immunization Report, dated December 17, 2025, showed R50 received the PCV20 vaccine on October 25, 2023, and October 10, 2025. R50's October 2023 MAR showed R50 was administered the PCV20 vaccine in the facility on October 25, 2023. R50's October 2025 MAR showed R50 was administered the PCV20 vaccine in the facility on October 10, 2025. On December 17, 2025, at 10:05 AM, V3 (Infection Preventionist Nurse) said she is responsible for resident vaccinations in the facility. V3 said she thinks residents should receive a pneumococcal vaccine every eight years. V3 said R8, R12, R21, R39, and R50 were offered a second PCV20 vaccine because V3 offers the vaccine every year even if the residents received the PCV20 vaccine already. On December 17, 2025, at 10:48 AM, V7 (Regional Nurse Consultant) said the facility follows CDC guidelines for pneumococcal vaccination timing and utilize the CDC timeline for pneumococcal vaccination. V7 said per CDC guidelines, if a resident received the PCV20 vaccine they should not get a second PCV20 vaccine. V7 said V3 should not have offered residents a second PCV20 vaccine because their pneumococcal vaccination was complete after the first PCV20 vaccine. The CDC's Pneumococcal Vaccine Timing for Adults, dated March 2025, showed adults [AGE] years old and older should receive one PCV20 vaccine. The documentation did not show adults [AGE] years old and older should receive a second PCV20 vaccine. The facility's policy titled Infection Control - Influenza and Pneumococcal Immunizations for Residents, dated June 1, 2025, showed Intent: It is the policy of the facility to ensure that the resident receives Influenza and Pneumococcal immunizations, in accordance with state and federal regulations, and national guidelines. Pneumococcal Immunization. 2. Each resident is offered pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized.

Based on interview and record review, the facility failed to notify the PASARR (Pre-admission Screening and Resident Review) program of residents with a newly diagnosed mental disorder. This applies to 2 of 2 residents (R1 and R8) reviewed for PASARR in the sample of 20. The findings include:1. The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses present on admission including malignant neoplasm, acute lymphoblastic leukemia, leiomyoma of uterus, anemia, anxiety and conversion disorder with seizures or convulsions. The EMR continued to show R1 was diagnosed with unspecified psychosis not due to a substance or known physiological condition on March 17, 2025. R1's admission MDS (Minimum Data Set), dated April 24, 2024, showed R1 had a psychiatric diagnosis of anxiety disorder. The MDS did not show R1 had a diagnosis of a psychotic disorder. R1's Quarterly MDS, dated [DATE], showed R1 had psychiatric diagnoses of anxiety disorder and psychotic disorder. R1's Notice of PASARR Level I Screen Outcome, dated April 20, 2024, showed R1 did not have a known or suspected mental health diagnosis. The PASARR documented, The Level I screen indicates that a PASARR disability is not present because of the following reason: There is no evidence of a PASARR condition of an intellectual/developmental disability or a serios behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. On December 16, 2025, at 11:17 AM, V2 (DON/Director of Nursing) said R1 received a new diagnosis of psychosis in March 2025 and there is documentation in a psychiatric note. The facility does not have documentation to show a new PASARR screening was completed following R1's new diagnosis of psychosis. 2. The EMR showed R8 was admitted to the facility on [DATE], with multiple diagnoses present on admission including benign neoplasm of meninges, prothrombin gene mutation, depression, post-traumatic stress disorder, stoke, and convulsions. The EMR continued to show R8 was diagnosed with bipolar disorder dated September 20, 2024. R8's admission MDS, dated [DATE], showed R8 had psychiatric diagnoses of depression and post-traumatic stress disorder. The MDS did not show R8 had a diagnosis of bipolar disorder. R8's Quarterly MDS, dated [DATE], showed R8 had psychiatric diagnoses of depression, post-traumatic stress disorder, and bipolar disorder. R8's Notice of PASARR Level I Screen Outcome, dated September 16, 2022, showed R8 did not have any known or suspected mental health diagnosis, and R8 was not receiving any mental health medications. R8's PASARR continued to show The Level I screen indicated a PASARR disability is not present because of the following reason: There is no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. On December 16, 2025, at 12:57 PM, V9 (MDS Coordinator) said when R8 was readmitted to the facility from the hospital in September 2024, the hospital documentation showed R8 had a diagnosis of bipolar disorder. V9 said something must have happened in the hospital for R8 to get a bipolar disorder diagnosis, but V9 is unsure what occurred. The facility does not have documentation to show a new PASARR screening was completed following R8's new diagnosis of bipolar disorder. On December 17, 2025, at 1:00 PM, V4 (Social Services Director) said she is in charge of submitting resident information to the PASARR program if a resident needs to be reevaluated. V4 said R1 and R8's information has not been resubmitted to the PASARR program following their new mental health diagnoses. V4 said R1 and R8 should have had information submitted to the PASARR program at the time of their new mental health diagnosis.

Based on interview and record review, the facility failed to have sufficient documentation to support a new mental health diagnosis. This applies to 1 of 1 resident (R1) reviewed for professional standards in the sample of 20. The findings include:The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses present on admission including malignant neoplasm, acute lymphoblastic leukemia, leiomyoma of uterus, anemia, anxiety and conversion disorder with seizures or convulsions. The EMR continued to show R1 was diagnosed with unspecified psychosis not due to a substance or known physiological condition on March 17, 2025. R1's admission MDS (Minimum Data Set) dated April 24, 2024, showed R1 had a psychiatric diagnosis of anxiety disorder. The MDS did not show R1 had a diagnosis of a psychotic disorder. R1's Quarterly MDS dated [DATE], showed R1 had psychiatric diagnoses of anxiety disorder and psychotic disorder. R1's Notice of PASARR Level I Screen Outcome dated April 20, 2024, showed R1 did not have a known or suspected mental health diagnosis. The PASARR continued to show R1 was receiving escitalopram (antidepressant medication) and risperidone (antipsychotic medication) for seizures. On December 16, 2025, at 11:17 AM, V2 (DON/Director of Nursing) said R1 received a diagnosis of psychosis because there was a pharmacy recommendation showing R1 needed a diagnosis for her risperidone. V2 said there is a psychiatry note to correlate this diagnosis. R1's pharmacy recommendation dated February 27, 2025, showed [R1] is receiving risperidone but lacks an allowable diagnosis to support its use (listed on MAR/Medication Administration Record). Please circle the accurate indication for use below for nursing to update: schizophrenia, schizoaffective disorder, psychosis NOS (not otherwise specified), atypical psychosis, brief psychosis, mania, bipolar disorder, depression with psychotic features, treatment refractory major depression or behavioral or psychological symptoms of dementia. The recommendation was signed by V10 (Psychiatric Nurse Practitioner) on March 15, 2025, and add diagnosis of atypical psychosis was written. A Nursing Home Psychiatry Note dated February 10, 2025, at 11:23 AM, by V10 showed R1's review of systems with pertinent positives were Neurological positive: confusion, weakness, vision impairment. Psychiatric positive: anxiety, depression, irritability. The documentation continued to show R1's DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) diagnoses were conversion disorder with seizures or convulsions, unspecified anxiety disorder, and unspecified malignant neoplasm of brain. A Nursing Home Psychiatry Note dated March 17, 2025, at 11:02 AM, by V10 showed R1's review of systems with pertinent positives were Neurological positive: confusion, weakness, vision impairment. Psychiatric positive: anxiety, depression, irritability. The documentation continued to show R1's DSM-5 diagnoses were conversion disorder with seizures or convulsions, unspecified anxiety disorder, unspecified malignant neoplasm of brain, and unspecified psychosis. The documentation did not show any new psychiatric behaviors or symptoms to support a new diagnosis of psychosis. R1's behavior monitoring for the period of February 1, 2025, to April 30, 2025, showed R1 did not have any behaviors of psychosis or depression. On December 15, 2025, at 12:08 PM, V11 (R1's Family) said he visits R1 every other day. V11 said R1 had brain surgery in November 2024, and since then R1 is minimally responsive and only reacts slightly when V11 talks to R1. V11 said R1 has mostly been lying in bed since her surgery and doesn't really interact with anyone. V11 said he has not seen a change in R1 since the surgery in November 2024. On December 17, 2025, at 12:46 PM, V2 said since R1's surgery around November 2024, R1 very rarely gets out of bed. V2 said R1 is not as responsive as before the surgery. V2 said R1 has not had any significant mental change since the surgery. The facility does not have documentation to show any change in R1's symptoms or behaviors at the time of the new diagnosis of psychosis.

Based on interview and record review, the facility failed to follow their policy and issue a NOMNC (Notice of Medicare Non-Coverage) to residents at the end of their Medicare coverage. This applies to 3 of 3 residents (R34, R48, and R51) reviewed for beneficiary notification in the sample of 20. The findings include:1. The EMR (Electronic Medical Record) showed R34 was admitted to the facility on [DATE]. R34's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review showed R34's Medicare Part A Skilled episode start date was April 1, 2025, and R34's last covered day of Part A service was May 20, 2025. The facility does not have documentation to show R34 was provided a NOMNC prior to the end of R34's Medicare Part A stay. 2. The EMR showed R48 was admitted to the facility on [DATE]. R48's SNF Beneficiary Protection Notification Review showed R48's Medicare Part A Skilled episode start date was August 22, 2025, and R48's last covered day of Part A service was October 4, 2025. The facility does not have documentation to show R48 was provided a NOMNC prior to the end of R48's Medicare Part A stay. 3. The EMR showed R51 was admitted to the facility on [DATE]. R51's SNF Beneficiary Protection Notification Review showed R51's Medicare Part A Skilled episode start date was October 1, 2025, and R51's last covered day of Part A service was November 26, 2025. The facility does not have documentation to show R51 was provided a NOMNC prior to the end of R51's Medicare Part A stay. On December 16, 2025, at 1:03 PM, V4 (Social Services Director) said she did not issue R34, R48, or R51 a NOMNC. V4 said she did not know she was supposed to issue residents a NOMNC at the end of their Medicare Part A stay and had never issued one to a resident. V4 said R34, R48, and R51 should have been issued a NOMNC because they still had Medicare Part A days remaining. The facility's policy titled Medicare and Insurance Payment Policy, dated April 25, 2025, showed, Medicare and Insurance Payment Policy, Policy Purpose: This policy explains how the facility will handle Medicare and insurance payments for residents and patients, and outlines the use of arbitration agreements as allowed by federal and state regulations. 1. Coverage and Payment: The facility will bill Medicare, Medicaid, or private insurance for covered skilled nursing services, therapy, and other medically necessary care. Residents and families will be notified of any non-covered services and may be financially responsible for those charges. Residents have the right to receive a clear explanation of their benefits and coverage before services are provided. 2. Medicare Guidelines: Skilled nursing facility services are covered under Medicare Part A if eligibility requirements are met (e.g., 3-day qualifying hospital stay, physician certification, and daily skilled need). When the end of Medicare benefits is determined a resident/POA (Power of Attorney) will be notified with a Notice of Medicare Non-Coverage. Resident have the right to appeal Medicare coverage decisions through the Quality Improvement Organization (QIO).

Based on observation, interview, and record review, the facility failed to ensure resident rooms and hallways were adequately cleaned and free of debris and urine odors, and failed to follow the facility's policy to deep clean each resident room at least once every quarter. This applies to all 79 residents residing in the facility. The findings include: The Facility Data Sheet, dated April 21, 2025, shows 79 residents reside in the facility. 1. On April 21, 2025 at 10:03 AM, upon entrance to the facility and while walking in the resident hallways, a strong urine odor was present throughout the facility. The white/light gray tiled section of the hallway near R8 and R9's room, in front of the nurse's station, appeared dirty with multiple black/brown marks and smudges. Multiple trash receptacles and soiled linen receptacles in the hallway where R8 and R9 reside were full, and some old meal trays were sitting on top of the trash receptacles. 2. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, dementia, hypertension, insomnia, adult failure to thrive, falls, lack of coordination, and difficulty walking. R1's MDS (Minimum Data Set), dated March 21, 2025, shows R1 is rarely/never understood, has moderate cognitive impairment, requires setup assistance with eating and personal hygiene, and supervision with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder. On April 21, 2025 at 10:24 AM, R1 was sitting up in a wheelchair in her room. R1 was unable to answer questions regarding the condition of her room. On the floor near R1's bed was a piece of dark brown wood, possibly from the headboard of R1's bed. Also, on the floor near R1, was a piece of plexiglass, approximately 18 to 24 inches long by 4 inches wide. The plexiglass appeared to be from an overhead lighting fixture. Multiple wadded up paper towels, medication cups, and food debris was strewn on the floor near R1. On April 21, 2025 at 1:31 PM, R1 was transferring herself from her wheelchair to her bed without staff present to assist her. Copious amounts of food debris, including dark brown food crumbs littered the floor around R1's wheelchair and the seat of R1's wheelchair. Multiple clear, plastic food wrappers were strewn around R1's bed and wheelchair. 3. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, atrial fibrillation, anemia, PVD (Peripheral Vascular Disease), congestive heart failure, lymphedema, cardiac arrhythmia, muscle wasting and atrophy, difficulty walking, lack of coordination, repeated falls, and overactive bladder. R3's MDS, dated [DATE], shows R3 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with oral and personal hygiene, and substantial/maximal assistance with all other ADLs. R3 is frequently incontinent of bowel and bladder On April 21, 2025 at 10:33 AM, R3 was sitting up in her wheelchair in the hallway just outside of her room. The floor in the hallway just outside of R3's doorway was filled with clutter, including the support legs from another resident's wheelchair, paper wrappers from drinking straws, full trash bins, and crumpled paper towels. The hallway floor appeared dirty and smudged with a black substance. Food debris was present on the floor. No housekeeping staff were observed sweeping or mopping the hallway floor. R3 pointed inside her room doorway and said her bed was located nearest to the door. Just inside R3's doorway, next to R3's bed on the floor, was a whole banana with a completely black banana peel, multiple foil-wrapped candies, and an empty plastic drinking cup, turned on its side, as well as food debris. R3 said, Oh, if I leave my room, someone will come in here and clean it up sometime today. 4. The EMR shows R4 was admitted to the facility on [DATE], with multiple diagnoses including wedge compression fracture of T11-T12 vertebra, cirrhosis of the liver, schizoaffective disorder, dementia, gallbladder disease, psychosis, and history of falling. R4's MDS dated [DATE], shows R4 is rarely/never understood, has moderate cognitive impairment, requires setup assistance with eating, partial/moderate assistance with oral and personal hygiene, substantial/maximal assistance with toilet hygiene, showering, and lower body dressing, and dependent on facility staff for bed mobility, and transfers between surfaces. R4 is frequently incontinent of urine, and always incontinent of stool. R4's care plan for potential for falls, initiated on November 9, 2024, shows multiple interventions, including, rooms and hallways should be clutter-free. Floors and surfaces should be clean and dry. On April 21, at 10:25 AM, R4 was walking in the hallway outside of her room. R4 had multiple bed blankets stacked up on her walker as she was walking towards her room. There was debris on the floor in the hallway outside of R4's room, which R4 had to step over to walk into her room, including a crumpled brown paper towel, multiple small medication cups, a torn plastic bag, and copious amounts of a crumbled dark black substance, which appeared like dried, caked mud from the bottom of someone's shoes. Once R4 entered her room, she took the blankets she was carrying on her walker and placed the folded blankets on almost every surface in her room, including the heating/air conditioning unit on the wall. The garbage can in R4's room was overflowing, and small medication cups were littered on the floor of her room next to the garbage can. 5. On April 21, 2025 at 2:15 PM, R5 said she is the Resident Council President, and has resided at the facility for many years. R5's room had a lot of personal clutter from the many personal items R5 preferred to keep in her room. R5's floor had debris on the floor and appeared to need sweeping. R5 said, There used to be a great housekeeper here named (V13). I don't think she works here anymore. Since she left, my room has not been kept clean. I really miss her. 6. On April 21, 2025 at 12:52 PM, the floor in R6's room had a large area, approximately six to eight feet in diameter of a dark brown, crumbled food item. R6 was not in the room at the time. R6's half-eaten lunch meal tray had a few pieces of chocolate brownie remaining on the tray. 7. On April 21, 2025 at 10:23 AM, R7 was lying in bed in his room. R7 was lying directly on the low air loss mattress. No sheets were on the bed. Three white sheets were crumpled in [NAME] on the floor of his room and food debris was on the floor. On April 21, 2025 at 1:08 PM, V3 (Housekeeping Director) said, Most of the residents eat in their rooms. There are 52 rooms in the facility. After each meal, the housekeeping staff has to go to each resident room to sweep. We have three housekeepers here right now to clean the resident rooms, and a person to clean the hallways, and help me with maintenance. We clean/buff the hallway floors two times a month. It was done three weeks ago. We do a deep clean of one room per week. On April 21, 2025 at 1:35 PM, V10 (Housekeeper) said she was responsible for cleaning resident rooms only, and was not assigned to clean resident hallways. On April 22, 2025 at 10:53 AM, V1 (Administrator) and V3 (Housekeeping Director) said the facility does a deep cleaning of one resident room per week, so each room gets deep cleaned one time per year. V3 corrected his previous statement and said the facility has 56 resident rooms, not 52 as stated on April 21, 2025. V1 (Administrator) said the facility does not have documentation to show each resident room is deep cleaned at least quarterly as shown in the facility's policy. V3 continued to say the facility has one person assigned to clean the hallways and empty hallway trash receptacles, another person to clean the public restroom, showers, internet cafe area, and dining room, and assist with maintenance, and a total of three housekeepers, each assigned to one of the three resident hallways. The housekeepers assigned to a block of rooms in a resident hallway are responsible to clean inside the resident rooms, including sweeping the floors in those resident rooms. V3 said the staff member (V11) assigned to clean the hallway floors did not work on April 20 or 21, 2025. V12 (Housekeeper) was expected to clean the hallway floors as well as his other duties of picking up hallway trash, cleaning the public restroom, showers, internet cafe area, and dining room. V1 (Administrator) said V13 (Housekeeper) has taken a medical leave and only works at the facility sporadically. The facility does not have documentation to show monthly cleaning schedules for quarterly deep cleaning of each resident room. The facility does not have documentation to show the use of audit tools to ensure compliance with the facility policy. The facility's policy entitled Physical Environment, adopted 07/11/2018, shows, Policy: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Procedures: 1. Routine Deep Cleaning: A. Each resident room will be deep cleaned at least once every quarter. B. A cleaning schedule shall be developed at the beginning of each month by the Housekeeping Supervisor. C. Schedule considerations include room occupancy, resident needs, and staff availability.10. Post-Cleaning Procedures: .C. Document the completion of cleaning, including the date, time, and staff involved in the housekeeping log.12. Training and Accountability: A. All housekeeping staff shall receive training on deep cleaning procedures and infection control practices. B. The Housekeeping Supervisor will conduct regular audits to ensure compliance with the policy .

Based on interview and record review, the facility failed to ensure prescribed medications were available and administered in accordance with facility policy. This applies to 1 of 3 residents (R3) reviewed for medication administration in the sample of 9. The findings include: The EMR (Electronic Medical Record) showed R3 was admitted to the facility on [DATE], with multiple diagnoses including interstitial pulmonary disease, pulmonary fibrosis, polymyositis organ involvement unspecified, fracture of unspecified tarsal bones right foot, dysphagia, heart failure unspecified, difficulty walking, unspecified glaucoma, and essential hypertension. R3's MDS (Minimum Data Set), dated February 19, 2025, showed R3 was cognitively intact, and required assistance with ADLs including set up assistance with eating and oral hygiene, supervision with bed mobility side to side, partial assistance with upper body dressing, personal hygiene, substantial assistance with bathing, sitting up in bed, and dependent on staff for lower body dressing, toileting, and transfer. R3's physician order summary showed Mycophenolate Mofetil 500 mg. oral tablet give 3 tablets, 1500 mg every 12 hours ordered February 15, 2025. Dorzolamide HCl ophthalmic solution 2% instill 1 drop in left eye 3 times a day was ordered on February 15, 2025. Pantoprazole sodium delayed release 40 mg two times a day, give first dose at 6:00 AM, was ordered on February 16, 2025. R3's February 2025 EMAR (Electronic Medication Administration Record) showed Pantoprazole sodium extended release 40 mg was not documented as administered on February 21, and February 28, the 06:00 AM doses. R3's March 2025 EMAR showed Dorzolamide HCL ophthalmic solution 2% was not documented as administered because it was unavailable, on March 1st, 2025, at 9:00 PM, and March 2, 2025, at 9:00 AM dose and 5:00 PM. Mycophenolate mofetil 500 mg was not documented as administered because it was unavailable on March 2, 2025, at 9:00 AM. On March 1, 2025, at 12:38 PM, R3 expressed frustration regarding not receiving her medications as prescribed while in the facility. R3 stated she is well aware of what medications she takes, and stated she knows what medication to take and when to take it, because she took her medications herself when at home. R3 stated the facility runs out of her medication, even though she provides some of the medication she takes from home supply, and stated the staff have brought her the wrong medication and feels staff get upset with her when she won't take the medication being offered her because she knows the medication is not right. On March 2, 2025, at 6:20 PM, a medication cart audit was completed with V16 (Licensed Practical Nurse/LPN) to ensure medication ordered was available to be administered. R3's medication supply was missing 2 ordered medications, Dorzolamide HCL ophthalmic solution 2% and Mycophenolate mofetil 500 mg (milligrams), dose 1500 mg. V16 stated she did not administer either medication at the scheduled 9:00 AM dose, because the medication was not available. V16 also stated R3 told her this morning she did not receive her Mycophenolate mofetil last evening because the medication was not available. The facility's policy titled Medication Administration, dated April 18, 2024, showed, Guideline .14. Document as each medication is prepared on the MAR .18. If medication is not given as ordered document the reason on the MAR .19. If the medication is given at a different time, update the MAR to reflect administration time .21. If medication error is identified, notify MD/NP .24. If medication is ordered but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication .

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for 5 of 8 residents (R2-R6) reviewed for call lights. Findings include: 1) On 02/05/25 at 11:10 AM, R2 was in her bed. R2's call light was not visible, and R2 said she hadn't had a call light for at least a couple of months. R2 said she gets help when they make rounds, and having a call light for emergencies would be helpful. R2 confirmed knowing the function of call light and having the ability to use it appropriately. V4 (Director of Maintenance) and V5(Registered Nurse) witnessed R2 not having the working call light access. R2's EMR (Electronic Medical Records) showed R2 is a [AGE] year-old female, with diagnoses including diabetes, restless leg syndrome, spinal stenosis, intraverbal disc degeneration with back pain, and hypertensive cardiac diseases. R2's MDS (Minimum Data Set), dated 11/09/2024, showed R2 is cognitively intact and requires one person's assistance for activities of daily living. R2's Current care plan, dated 11/05/2024, showed R2 is a fall risk potential resident with a fall event on 11/08/2024, and intervention included the call light to be within reach of the resident. 2) On 02/05/2025 at 11:45 AM, R4 was in her bed. R4 did not have a call light, and R4 said she hadn't had one for a long time. R4 and R4's roommate said this problem is not new. R4 confirmed knowing the call light's function and ability to use it appropriately. V8 (Certified Nursing Assistant) said R4 had her call light within reach earlier, and she might have dropped it. V8 was asked to show the call light, and she was unable to show one. R4's EMR (Electronic Medical Records) showed R4 is a [AGE] year-old female, with diagnoses including diabetes type 2, hemiplegia, pathological fracture, and hypertension. R4's MDS (Minimum Data Set), dated 11/05/2024, showed that R4 is cognitively intact and requires supervision of one person's assistance for activities of daily living. R4's Current care plan, dated 02/01/2025, showed R4 is a potential fall risk resident due to hemiplegia and hemiparesis with a fall event on 10/12/2024, and intervention included the call light to be within reach of the resident. 3) On 02/05/2025 at 12:00PM, R3 was in the dining room, ambulating with a walker, said she is a roommate of R2, and they don't have call light access. R3 said when R2 (Roommate) had a fall, she had to come out of her room and scream for help. R3 said it has been reported, and nothing has been done yet. R3 confirmed knowing the function of the call light and being able to use it appropriately. R3 said if there are any emergencies that would be a problem. V4 (Director of Maintenance) witnessed not having the working call light for R3. R3's EMR (Electronic Medical Records) showed R3 is a [AGE] year-old female, with diagnoses including pain in both legs, abnormality of gait, cellulitis of left limb, history of falls, and hypertension. R3's MDS (Minimum Data Set), dated 02/28/2024, showed R3 is cognitively moderately intact and requires the supervision of one staff assistance for daily living activities. R3's current care plan, dated 12/20/2024, showed R3 is a fall-risk potential resident due to poor balance and unsteady gait. The intervention included the call light being within reach of the resident. 4) On 02/05/2025 at 12:27 PM, R5's call light was on the floor by the head end of R5's bedside. R5 was asked where R5's call light was, and how R5 called for help. R5 said, I don't know what to do, and confirmed knowing the function of the call light and using it appropriately. V2(Director of Nursing), V2(Assistant Director of Nursing), and V5(Registered Nurse) witnessed R5 not having the call light within reach. R5's EMR (Electronic Medical Records) showed R5 is a [AGE] year-old female, with diagnoses including hemiplegia, diabetes, cardiac disease, morbid obesity, and end-stage renal failure dependent on dialysis. R5's MDS (Minimum Data Set), dated 11/245/2024, showed R5 is cognitively intact and two persons maximum assistance for activities of daily living, including mobility and transfer. R5's care plan, dated 01/082024, showed R5 is a potential fall risk resident due to incontinence and muscle weakness, and intervention included the call light being within reach of the resident. 5) On 02/05/2025 at 2:00 PM, R6's call light was not visible, and R6 said she didn't know where it was. R6 confirmed knowing the function of the call light and using it appropriately. V5(Registered Nurse) witnessed the call light under the blanket, and not having a call light within reach of R6. R6's EMR (Electronic Medical Records) showed R6 is an [AGE] year-old female, with diagnoses including osteoarthritis, congestive heart failure, high blood pressure with low heart rate, and unsteady gait. R6's MDS (Minimum Data Set), dated 11/27/2024, showed R6 is cognitively moderately intact and one to two persons maximum assistance for activities of daily living, including mobility and transfer. R6's care plan, dated 11/26/2024, showed R6 is a fall risk potential resident with a recent incident dated 12/24/2024, and intervention included the call light being within reach of the resident. During an interview on 02/05/2025, at different times, V2 (Director of Nursing), V3(Assist Director of Nursing), V4 (Director of Maintenance), R5(Registered Nurse), and V8 (Certified Nursing Assistant) all indicated residents should have call light access. A policy titled Call Lights Use, revised on 06/2024, showed residents capable of using call lights appropriately will have call lights accessible at all times. Direct care staff will check these residents during check-and-change rounds and ADL care, and call lights will be checked by the maintenance director and maintained at least monthly and as needed.

Based on interview and record review, the facility failed to provide staff in sufficient quantity to meet the residents' bathing, incontinence, and mobility care needs, and ensure timely answering of call lights during the evening and night shifts. This applies to 4 of 5 residents (R1, R3, R5, R6) reviewed for ADL care in the sample of 6. The findings include: The Facility Data sheet completed by V1 (Administrator), dated January 31, 2025, showed the facility census was 87. The Resident Council Meeting Minutes of November 22, 2024, showed one member requested more staff were needed each shift. The minutes reflect V1's (Administrator) response indicated it was quality of staff not quantity of staff the facility was looking for. On January 31, 2025, at 12:50 PM, V4 (Staff Scheduler) stated the staffing pattern included CNAs (Certified Nursing Assistants) work 8-hour shifts, and Nurses work 12-hour shifts. V4 stated there are 3-4 scheduled CNAs for the overnight shift (10PM-6AM), and 5-6 CNAs scheduled for the evening shift (2PM-10 PM) and 6-7 CNAs scheduled for the day shift (6AM-2:00 PM). Review of the schedules as worked from January 23, through January 31, 2025, showed over the course of 9 days: The CNAs for the evening shift worked with 4 staff on 4 out of 9 days and worked with 5 staff on 5 out of 9 days. During the evening shift, 4 of 9 shifts worked with less than the staffing pattern described by V4. During the overnight shift, 10 PM-6 AM, 5 out of 9 days worked with 3 CNAs, and 4 out of 9 shifts worked with 4 CNAs. Based on the resident census of 87, the CNA ratio of staff to residents on the overnight shift for 4 staff was 1:22 and 3 staff 1:29. 1). R1's MDS (Minimum Data Set), dated January 1, 2025, showed R1 was cognitively intact and required assistance with ADLs partial assistance with eating, upper body dressing, and personal hygiene, substantial assistance with lower body dressing, bathing, tub transfer and toileting and dependent on staff for bed mobility and transfer. The mobility device is listed as a wheelchair. On February 1, 2025, at 12:26 PM, R1 stated he used to get around the facility in his electric wheelchair, but he has not gotten out of bed into his chair since October 31, 2024. R1 stated when he asks staff to get him out of bed, staff tell him it takes too long to get him up and they don't have time. R1 stated his son brings him water and keeps it in R1's bedside refrigerator, and staff appreciate that because when R1 asks for water, the staff don't have to walk so far to bring the water to him. R1 stated he doesn't get showers because staff tell him they don't have time. During the night shift of January 23, 2025, R1 stated he waited an extended period for his call light to be answered and a resident peer closed the door to his room, which made him feel unsafe. On February 1, 2025, at 3:37 PM, V18 (Maintenance Director) stated R1's wheelchair is in good repair and able to be used. V18 stated there is also an alternative wheelchair with supportive seating available for use already in the facility that R1 could use if needed. R1's wheelchair was parked in his room. R1's POC (Point of Care) documentation showed R1 did not receive a shower between January 9, 2025, and January 20, 2025. On February 1, 2025, at 12:15 PM, R2 stated he did close the door to R1's room during the night shift on January 23, 2025. R2 stated he closed R1's door because R1 was yelling for staff to help him. The staffing schedule, dated January 23, 2025, showed there were 3 CNAs working the night shift. 2). R3's MDS, dated [DATE], showed R3 was cognitively intact and required assistance with ADLs including set up assistance with eating, oral hygiene, and personal hygiene, supervision with upper body dressing, substantial assistance with dressing, and dependent on staff for toileting, bathing, bed mobility and transfer. On January 31, 2025, at 1:24 PM, R3 identified herself as the Resident Council President. R3 stated she waited over an hour for her call light to be answered on January 29, 2025. R3 requested V14 to provide incontinence care during the evening shift on January 29, 2025. The schedule dated January 29, 2025, showed V14 worked both the evening and night shift that day. R3 stated she was not provided incontinence care by V14. 3). R5's MDS, dated [DATE]. 2024, showed R5 was cognitively intact and required assistance with ADLs including set up assistance with eating, and oral hygiene, partial assistance with personal hygiene, substantial assistance with toileting, bathing, dressing, and bed mobility, dependent on staff for transfer. On January 31, 2025, at 3:11 PM, R5 stated she does not get the assistance she needs with showers. R5 stated she does not get a shower when scheduled. R5's POC documentation for the past 30 days for showers, showed R5 received one shower on January 14, 2025. According to the facility shower schedule, dated December 6, 2024, R5 is scheduled for a shower on Saturday AM shift and Tuesday PM shift. R5's shower was scheduled to be given on January 25, 2025, on day shift and January 28th PM shift. The staffing assignment sheet for January 25, 2025, day shift showed there were 6 CNAs assigned for that shift. The staff assigned to give R5 a shower had a total of 4 showers assigned to be given. No other staff were assigned to give 4 showers that shift. Of the remaining staff, on that shift, 2 were assigned 1 shower, 2 were assigned 2 showers, and 1 was assigned 3 showers. R5 did not receive a shower that shift. The staffing assignment shift, dated January 28, PM shift, showed there were 5 CNAs assigned to that shift. The staff assigned to give R5 a shower had 4 showers assigned to give that shift. Of the remaining staff, 3 staff had 3 showers assigned to give and 1 staff assigned to 2 showers. The staff assigned to R5 had 17 assigned residents to care for and 4 showers to give. R5 did not receive a shower that shift. 4). R6's MDS (Minimum Data Set), dated January 6, 2025, showed R6 was cognitively intact and required assistance with ADLs including set up assistance with eating, and oral hygiene, supervision with personal hygiene, substantial assistance with bathing, and dependent on staff with lower body dressing, toileting, bed mobility, and transfer. On January 31, 2025, at 3:26 PM, V17 (CNA) was observed giving incontinence care to R6. R6's brief was saturated, as validated by V17. R6 stated he had not been changed since earlier that morning. R6 also stated he was supposed to get a shower that day and did not receive a shower. The staffing assignment sheet, dated January 31, 2025, showed there were 7 CNA staff scheduled for the day shift. The staff assigned to R6 had 13 residents assigned to be cared for and 3 residents assigned to be given showers during that shift. R6 did not receive incontinence care, or a shower as needed that shift. On January 31, 2025, at 4:34 PM, V11 (agency CNA) stated he has been a CNA for [AGE] years and has worked in different facilities. R1 identified V11 as a CNA who takes good care of him. V11 stated compared to other facilities, the assignments at this facility are hard to give good care, because there are too many residents who need a lot of care assigned to one CNA. V11 stated he has spoken to colleagues who also work for the agency who stated working at the facility is a last choice due to the workload of the assignments. On February 1, 2025, at 10:58 AM, V13 (CNA) stated she works on a PRN (as needed) basis and finds the assignments keep her busy the whole shift and she rarely has time to take a break. V13 stated, at times, there is an inequity in the assignments, especially when it comes to shower assignments, as sometimes staff are assigned to 1 shower while other staff are assigned to 4 on the same shift. The facility policy titled Activities of Daily Living Support, dated July 24, 2024, showed, Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs .including appropriate support and assistance with hygiene (bathing, dressing, grooming) Elimination (toileting). Documentation and Record Facility staff will record showers on the shower sheets and or POC after showers are given.

Based on observation, interview, and record review, the facility failed to provide assistance to residents with ADLs (Activities of Daily Living), specifically incontinence care and bathing, in accordance with resident needs and as outlined in their policy. This applies to 4 of 4 residents (R1, R3, R5 and R6) reviewed for ADL care in the sample of 6. The findings include: 1). R6's EMR (Electronic Medical Record) showed R6 was admitted to the facility on [DATE], with multiple diagnoses including encounter for orthopedic after care following surgical amputation, type 2 diabetes with foot ulcer, acquired absence of left above knee, peripheral vascular disease, obstructive sleep apnea, and other disorders of the nervous system. R6's MDS (Minimum Data Set), dated January 6, 2025, showed R6 was cognitively intact and required assistance with ADLs including set up assistance with eating, and oral hygiene, supervision with personal hygiene, substantial assistance with bathing, and dependent on staff with lower body dressing, toileting, bed mobility, and transfer. On January 31, 2025, at 3:26 PM, V17 (Certified Nursing Assistant/CNA) was observed giving incontinence care to R6. R6's brief was saturated; the indicator lines had disappeared from the brief indicating excessive wetness. V17 validated R6's brief was saturated. R6's perianal and posterior upper left thigh skin was pink under white cream. R6 stated the area under his left upper posterior thigh felt like it was burning. R6 stated he had not been changed since earlier that morning. R6 also stated he did not get the shower that was scheduled for that day during the AM shift. R6 stated the CNA on the day shift told R6 he would be getting a shower that day, and then came back around 1:30 PM and told R6 the scheduled had been changed, and R6 would not be getting his shower as scheduled. V17 was asked how showers are documented as given. V17 stated showers are documented in the POC (Point of Care) task in PCC (Point Click Care), the EMR software. On February 1, 2025, at 1:58 PM, V2 (Director of Nursing/DON) stated she was not aware of any schedule or assignment change on January 31, 2025, day/AM shift. V2 stated if a shower is missed as scheduled, it should be done on the next shift. The POC task documentation showed R6 did not receive a shower on Friday January 31, 2025. The facility's shower schedule, dated December 6, 2024, showed R6 was scheduled for a shower on Friday AM shift and Tuesday PM shift each week. 2). R1's EMR showed R1 was admitted to the facility on [DATE], with multiple diagnoses including ALS (Amyotrophic Lateral Sclerosis), ulcerative colitis, juvenile myoclonic epilepsy, benign prostatic hyperplasia without lower urinary tract symptoms, generalized anxiety disorder, and essential hypertension. R1's MDS, dated [DATE], showed R1 was cognitively intact and required assistance with ADLs partial assistance with eating, upper body dressing, and personal hygiene, substantial assistance with lower body dressing, bathing, tub transfer and toileting and dependent on staff for bed mobility and transfer. On February 1, 2025, at 12:26 PM, R1 stated he had not been getting his showers as scheduled, especially in early January. R1 stated he prefers a shower to a bed bath, and has his own sling for the full mechanical lift device used to transfer R1 to the shower gurney. R1 stated he does not feel clean after a bed bath, and has not had a shower, only a bed bath offered to him. R1's bathing POC documentation January 2025, showed R1 did not receive a shower until January 9, 2025, and the next documented shower was January 20, 2025. The facility's shower schedule, dated December 6, 2024, showed R1 was scheduled to receive showers on Monday AM shift and Thursday PM shift each week. 3). R5's EMR showed R5 was admitted to the facility on [DATE], with multiple diagnoses including acute kidney failure, unspecified, type 2 diabetes with diabetic polyneuropathy, unspecified asthma, mild protein calorie malnutrition, obstructive and reflux uropathy, and adult failure to thrive. R5's MDS, dated [DATE]. 2024, showed R5 was cognitively intact and required assistance with ADLs including set up assistance with eating, and oral hygiene, partial assistance with personal hygiene, substantial assistance with toileting, bathing, dressing, and bed mobility, dependent on staff for transfer. On January 31, 2025, at 3:11 PM, R5 stated she does not get the assistance she needs with showers. R5 stated she does not get a shower when scheduled. R5's POC documentation for the past 30 days for showers, showed R5 received one shower on January 14, 2025. Not applicable is documented on January 4, 2025 and January 19, 2025. There is no documentation regarding showers after January 21, 2025. According to the facility shower schedule, dated December 6, 2024, R5 is scheduled for a shower on Saturday AM shift and Tuesday PM shift. 4). R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including asthma, heart failure, type 2 diabetes, obesity (severe), autonomic neuropathy in diseases classified elsewhere, primary osteoarthritis of both right and left knees, and acquired absence of kidney. R3's MDS, dated [DATE], showed R3 was cognitively intact and required assistance with ADLs including set up assistance with eating, oral hygiene, and personal hygiene, supervision with upper body dressing, substantial assistance with dressing, and dependent on staff for toileting, bathing, bed mobility and transfer. On January 31, 2025, at 1:24 PM, R3 stated she is the Resident Council President. R3 stated she had a concern about incontinence care not being done timely, and not getting a shower and hair washed when scheduled. R3 stated on the evening and night shift beginning on January 29, 2025, R3 asked V14 (CNA) to provide her with incontinence care after her zoom meeting call ended at 8:30 PM. R3 stated at 9:00 PM, she put on her call light to request assistance with incontinence care, but no staff came, and V14 did not return to R3's room. R3 stated V15 (CNA) came to her room around 10:00 PM and R3 asked V15 to change her. R3 stated V15 did not change R3 until 5:30 AM on January 30, 2025. R3 stated she did not get her shower and hair washed last week. R3's POC documentation for showers showed there was no documentation of a shower being given to R3 between January 17 and January 27, 2025. According to the facility shower schedule, dated December 6, 2024, R3 is scheduled for shower on Thursday AM shift and Monday PM shift. The facility's policy titled Activities of Daily Living Support, dated July 24, 2024, showed, Policy statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs .in accordance with the plan of care including assistance with Elimination (Toileting) .Showers/bathing will be provided at least weekly, PRN, and or based on resident preferences .Documentation and Record facility staff will record showers on the shower sheet or POC after showers are given.

Based on interview and record review, the facility failed to provide an environment where residents are treated with dignity and respect and requests for care are honored. This applies to 2 of 3 residents (R1 and R3) reviewed for ADLs (Activities of Daily Living) in the sample of 6. The findings include: 1). The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnosis including ALS (Amyotrophic Lateral Sclerosis), ulcerative colitis, juvenile myoclonic epilepsy, benign prostatic hyperplasia without lower urinary tract symptoms, generalized anxiety disorder, and essential hypertension. R1's MDS (Minimum Data Set), dated January 1, 2025, showed R1 was cognitively intact and required assistance with ADLs partial assistance with eating, upper body dressing, and personal hygiene, substantial assistance with lower body dressing, bathing, tub transfer and toileting and dependent on staff for bed mobility and transfer. The mobility device is listed as a wheelchair. On February 1, 2025, at 12:26 PM, R1 stated he used to get around the facility in his electric wheelchair, but he has not gotten out of bed into his chair since October 31, 2024. R1 stated he is tired of just lying in the bed and only gets out of bed by a gurney to go to medical appointments. R1's electric wheelchair was sitting in his room. R1 stated it is more difficult for him now to manage the control on the wheelchair, but he is still capable of sitting in his chair and staff could assist him to maneuver the wheelchair until his rehabilitation clinic provided an adaptation to the control. R1 also expressed frustration that staff don't even offer to assist him to get out of bed. R1 stated none of his health care providers have told him he could not get out of bed. R1 also stated last Sunday early morning around 6:00 AM, V8 (Certified Nursing Assistant/CNA) and V9 (CNA orientee) provided incontinence care to R1. R1 stated he told them he did not feel clean. R1 stated V8 told him their shift was over and they had to leave, leaving R1 soiled. R1 also complained R2 closed his door during the night shift on January 23, 2025, and he waited a long time for his call light to be answered because R1 wasn't sure if the call light was working. R1 had an adaptive call light that activates when R1 touches the pad with his head. R1 stated he reported to V11 (CNA) and V13 (CNA) while they provided care to him during the evening shift on January 24, 2025. The staff schedule showed V8 was assigned to R1 during the overnight shift January 25, 2025, and V9 was also working that shift. The staff schedule showed V11 was assigned to R1 on the evening shift of January 24, 2025. On January 31, 2025, at 4:34 PM, V11 stated while he and V13 were providing care, R1 reported R2 closed the door to his room during the previous night shift. V11 stated R1 was really upset he was left behind a closed door, and was anxious while telling V11 about it. On February 1, 2025, at 10:58 AM, V13 stated she did assist V11 with R1's care on January 24, 2025, during the evening shift, and R1 did report R2 had closed the door on R1 during the previous overnight shift. On February 1, 2025, at 12:16 PM, R2 stated he did close R1's door during the overnight shift on January 23, 2025. R2 stated he closed R1's door because he was yelling for the staff to come and help him. Review of R1's current physician order summary showed R1 did not have an order for bedrest. R1's orders showed R1 was able to go out on pass with supervision and medications. R1's medical record contained an after-visit summary from the rehabilitation outpatient clinic dated December 3, 2024, that showed R1 needed an appointment to be scheduled at the clinic for a wheelchair evaluation and adjustment of the controller. The facility did not provide documentation the appointment was scheduled when requested. On February 1, 2025, at 3:37 PM, in response to the request for the scheduling of the wheelchair clinic appointment, V1 stated the facility's maintenance staff repaired R1's wheelchair. V18 (Maintenance Director) explained he repaired R1's wheelchair. V18 stated R1's wheelchair is in good repair and able to be used. V18 stated there is also an alternative wheelchair with supportive seating available for use already in the facility that R1 could use. V18 stated he used to see R1 out of bed and going all around the facility and that made R1 happy. V18 stated he has not seen R1 out of bed for months. 2). R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including asthma, heart failure, type 2 diabetes, obesity (severe), autonomic neuropathy in diseases classified elsewhere, primary osteoarthritis of both right and left knees, and acquired absence of kidney. R3's MDS, dated [DATE], showed R3 was cognitively intact and required assistance with ADLs including set up assistance with eating, oral hygiene, and personal hygiene, supervision with upper body dressing, substantial assistance with dressing, and dependent on staff for toileting, bathing, bed mobility and transfer. On January 31, 2025, at 1:24 PM, R3 identified herself as the Resident Council President. R3 stated she does not like to complain because she does not want staff to be mad at her. R3 stated because she is the Resident Council President, other residents come and complain to her regarding care. R3 was unable to provide specific dates or times of recent complaints from residents. R3 stated she was upset recently regarding not being provided incontinence care when she needed it, and not being provided with a shower and getting her hair washed for over a week. R3 stated on the evening and night shift beginning on January 29, 2025, R3 asked V14 (CNA) to provide her with incontinence care after her zoom meeting call ended at 8:30 PM. R3 stated at 9:00 PM, she put on her call light to request assistance with incontinence care, but no staff came, and V14 did not return to R3's room. R3 stated V15 (CNA) came to her room around 10:00 PM, and R3 asked V15 to change her. R3 stated V15 did not change R3 until 5:30 AM on January 30, 2025. R3 stated V15 told her she would not change her at the beginning of her shift because she would not do the work the second shift was supposed to do. V15 declined to be interviewed during this investigation. On February 1, 2025, at 1:58 PM, V1 (Administrator) stated staff should be treating residents as if they are family members, with respect. The facility's policy titled Activities of Daily Living: dated October 22, 2024, showed Policy Statement: Facility ensures that residents receive ADL assistance and maintains the resident's safety and dignity .Procedures 6. Assist the resident to be clean, neat and well groomed . 8. Resident will be up out of bed dressed as per the resident's choice.13. Patient Dignity will always be maintained.

Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 27 opportunities with 3 medication errors resulting in a 11.11% medication error rate. This applies to 1 of 3 residents (R2) reviewed for medication administration in the sample of 3. The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, pulmonary hypertension, peripheral vascular disease, hypertensive chronic kidney disease, chronic pulmonary embolism, hypertension, and anemia. R2's medication care plan dated December 21, 2022, showed, [R2] is on diuretic therapy. The care plan continued to show multiple interventions dated December 21, 2022, including Administer diuretic medications as ordered by physician. Monitor for side effects and effectiveness every shift. R2's Order Summary Report, dated December 31, 2024, at 11:44 AM, showed an order, dated December 20, 2022, for Spironolactone tablet 25 mg, give 50 mg by mouth one time a day for diuretic. The Report continued to show an order, dated September 4, 2024, for Vitamin D3 tablet 1000 unit, give 1000 unit by mouth one time a day for vitamin D insufficiency. The Report showed an order, dated August 29, 2024, for Lidocaine External patch, apply to left knee are topically one time a day for pain, Lidocaine 4% pain patch to left knee. On December 31, 2024, at 9:40 AM, V4 (RN/Registered Nurse) prepared the following medications for R2: one tablet aspirin 81 mg (milligrams), one tablet docusate 100 mg, two tablets potassium chloride 10 mEq (milliequivalents), one tablet spironolactone 25 mg, one tablet metoprolol 100 mg, one tablet vibegron 75 mg, one tablet vitamin D3 2000 units, one tablet diphenhydramine 25 mg, and one lidocaine patch. V4 said she had nine pills to administer to R2. At 9:50 AM, V4 administered R2's medications. At 9:54 AM, V4 removed a lidocaine patch from R2's left lower back and placed the new patch on R2's left lower back. On December 31, 2024, at 11:33 AM, V2 (DON/Director of Nursing) said it is the expectation for a nurse to ensure the correct medication dose is administered to a resident. V2 continued to say V4 should have administered the correct doses of spironolactone and vitamin D3 to R2. V2 said V4 should have followed physician orders and applied the lidocaine patch to the prescribed area of the left knee. The facility's policy titled Medication Administration, dated August 1, 2024, showed, Policy and Procedure, Subject: Medication Administration, Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Level of Responsibility: RN, LPN (Licensed Practical Nurse). Guideline: .5. Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. 6. Read each order entirely. 7. Remove medication from drawer and read label three times; when removing from drawer, before pouring and after pouring .

Based on observation, interview, and record review, the facility failed to ensure a resident was free from sexual abuse. This resulted in R1 being being afraid and in shock. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: R1's face sheet shows she is a [AGE] year-old female admitted to the facility 8/9/23, with diagnoses including major depressive disorder, unspecified dementia, and frontotemporal neurocognitive disorder. R1's Minimum Data Set assessment dated [DATE] shows she is cognitively intact with a Brief Interview for Mental Status score of 15, with no behaviors of psychosis including hallucinations, delusions, no behavioral symptoms or rejections of cares. The facility's Initial Report, dated 10/21/24, documents R1 alleged housekeeping services V4 (Former Employee/Laundry Aide) exposed himself in an appropriate manner. The Final Report documents R1 alleged V4 entered her room and exposed himself while R1 was sleeping. An interview conducted with V4 stated, I have no answer, I do not know what happened. V4 has been employed at the facility as a laundry aide through a community program PAEP (Parents Alliance Employment Project), which is an organization that assists individuals with mild cognitive deficits to obtain and retain employment. R1's roommate was interviewed, but she was not able to recall any disturbances. V4 has been terminated from the facility. V4's statement, dated 10/21/24 at 3:45 PM, states, I do not know why this happened. I do not have an answer for you. I don't know what to say. On 11/1/24 at 9:51 AM, R1 was observed in her room. She was well groomed, alert to person, time, and place. R1 said she has been at the facility over one year and a couple of months. On 10/21/24, in the afternoon, she was in her room lying down on her side facing the window. She was reading a book and fell asleep. She felt something near her face; she opened her eyes and V4 was standing there with his instrument out. She said she jumped from her bed. V4 left her room and stated, I didn't do anything. R1 ran out of her room and reported the incident to staff who were in the hallway. V4's genitals were fully exposed. R1 stated, I was afraid and in shock. R1 reported to V1 (Administrator) it was V4 who exposed himself to her. They called V4's brother and V1, Administrator, promised me he will never be back here. On 11/1/24 at 10:42 AM, V7 (Admissions Director) said on 10/21/24, she was walking down the hallway with V6 (Regional Director of Admissions), when R1 ran out of her room pointing to V4, and said he was in her room and exposed himself to her. R1 pointed to V4 and said, It was you. V4 said, I didn't do anything; I didn't do anything. R1 looked shocked and was visibly distraught. V7 stated she went to V1's office and reported the incident. On 11/1/24 at 11:13 AM, V6 (Regional Director of Admission) said she was walking down the hall on 10/21/24 with V7. R1 came out of her room and pointed to V4. R1 said V4 pulled out his penis and exposed himself to her. R1 was very upset and shaken up. On 11/1/24 at 10:53 AM, V8 (Maintenance Director) said V4 had been employed at the facility for about three months. He (V4) was hired as a laundry aide, but it did not work out. V8 said V4 had been helping him with maintenance. On 10/21/24, he was working outside with V4. He turned around and V4 was not there; he went inside the building and heard a resident yelling. He did not think of anything because that is common in this setting. He then heard his name paged over head to report to V1's office. (V1) asked me where (V4) was. I told (V1), (V4) was outside with me, but then I could not find (V4). V1 reported to him there was an incident with V4 and R1. V4 was in the laundry room. V8 said he asked V4 what happened. V4 was kind of confused and said, I didn't do anything. V8 said he escorted V4 to V1's office and he remained in the room. V1 asked him what happened, and V4 said he didn't remember. V8 said he reviewed the camera, and it showed V4 entering R1's room, but V4 said he does not remember going into R1's room. (V4) has some special needs, and usually does not go into resident rooms by himself, and I was supposed to be with him. (V4) left without telling me where he was going, and I did not know where he was. (V4) did not have any reason going into (R1's) room. (V4's) brother was notified and picked him up from the facility. On 11/1/24 at 11:26 AM, V3 (Assistant Director of Nursing/ADON) said she talked to R1 after the incident. (R1) told me V4 was a nice guy, but something was wrong with him. She said she was lying down sleeping and woke up with (V4's) genitals out in front of her. (R1) has been at the facility for a while, she is pleasant, she knows me by name and comes to me with concerns. R1 does not have any behaviors and if that's what she said happened, I have to believe her. On 11/1/24 at 11:31 AM, V10 (Social Service Director) said R1 reported to her she was lying down in her bed reading a book and V4 exposed himself to her. She followed him out of the room and reported the incident. R1 is alert and oriented and does not have a history of fabrication. V10 would call this abuse. On 11/1/24 at 11:39 AM, V9 (Certified Nursing Assistant-CNA) said R1 is alert with no behaviors. She lets staff know what she needs. R1 is very alert. On 11/1/24 at 1:12 PM, V1 (Administrator) said he was notified by V6 and V7 regarding the incident. (R1) said she was asleep in her room and (V4) exposed himself and she chased after him out of the room. V1 interviewed V4; he had a flat affect and stated, 'I don't know, I don't remember' repeatedly. This was a tough one, there was two different stories and there was no witness. I don't know what happened. If it did happen, V1 would consider this abuse. (V4) was terminated, out of the best interest of everyone, it was not the right setting for him. At 2:21 PM, V1 said he reviewed the camera, and it showed V4 entering R1's room at the same time of the alleged incident. It shows R1 leaving the room after V4 left her room and reporting the incident to V6 and V7, but V4 denied going into R1's room. The facility's Abuse Prevention Program and Policy states, residents have the right to be from abuse, neglect, exploitation, misappropriation, of property or mistreatment . Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means .

Based on interview and record review, the facility failed to investigate and report an allegation of potential abuse/neglect. This applies to 1 of 6 residents (R1) reviewed for potential abuse/neglect in the sample of 10. The findings include: The EMR (Electronic Medical Record) showed R1 is a [AGE] year-old with diagnoses of ALS (amyotrophic lateral scoliosis), gastroenteritis, colitis, epilepsy, BPH (benign prostatic hypertrophy), and lack of coordination. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set), dated August 24,2024, showed R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. The MDS also showed R1 requires substantial assistance from staff for ADL (Activities of Daily Living) including oral care, hygiene, and grooming. On September 30,2024 at 12:36 P.M., R1 stated V9 (CNA, Certified Nurse Assistant from staffing agency) was very rude and had refused to give care when asked. R1 stated this was reported immediately to (V4, ADON/Assistant Director of Nursing) and to (V16, scheduler/MOD/manager on duty) on September 25,2024. V16 said on September 25,2024, sometime during the day shift, R1 had reported to her V9 was rude and refused to help brush R1's teeth. V16 said she made sure V4 was made aware of the complaint from R1. On September 30,2024 at 1:10 P.M., V1 (Administrator) stated he was off for a wee,k including the time R1 had reported the allegation. V1 added V2 (Regional Operation Manager) was the designated designee as the Administrator and Abuse Task Coordinator in V1's absence. V1 added he had not received any report of alleged abuse from V2 when he returned to work. V1 said there was no investigation conducted regarding this allegation from R1. On September 30,2024 at 1:15 P.M., V2 was interviewed, and confirmed she was the designee administrator and abuse task coordinator when V1 was away for a week. V2 also said on September 25, 2024, V2 was the designee as the abuse task coordinator. V2 said she was never informed by any staff including (V4, V3-interim DON and V16) regarding (R1's) allegation. On September 30,2024 at 1:20 P.M., V4 was interviewed via phone with V1 present. V4 said, I remember that (R1) had complained about his nutritional supplement and medications not available and there were no other complaints. I wrote this in the grievance form on September 25,2024. V4 then added she remembered R1 had complained V9 was rude and refused to brush (R1's) teeth. V4 added she reported R1's complaint to V3 and V2, and was advised to document a customer service report. The facility's Abuse policy, dated September 5,2024, showed: NEGLECT .Regardless of the specific nature of the allegation (physical, sexual, verbal/mental abuse, theft, neglect, unreasonable confinement/involuntary seclusion, or exploitation), the investigation shall consist of: -Completion of a written report on the status of the investigation within 24 hours of the occurrence or as soon as possible, but no more than 2 hours. The Facility's undated policy for Abuse showed: Residents have the right to be free from abuse, neglect Neglect is a facility's failure to provide, or willful withholding of adequate personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish and mental illness of a resident .Employees are required to report any allegation of potential abuse, neglect that they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence.

Based on observation, interview, and record review, the facility failed to provide incontinence care to dependent residents. This applies to 2 of 5 residents (R7 and R10) reviewed for incontinence care in the sample of 10. The Findings include: 1. R7 is an [AGE] year-old, with diagnoses including type 2 diabetes mellitus, osteoarthritis, bipolar disorder, anxiety disorder, dementia, stage 4 kidney disease and adult failure to thrive. R7 was admitted to the facility on [DATE]. R7's MDS (Minimum Data Set), dated March 3, 2024 and September 3, 2024 showed R7's cognition was severely impaired. The MDS showed R7 was dependent from staff for ADL (Activities of Daily Living) including toilet needs and hygiene. R7's care plan, dated September 3, 2024, showed R7 was incontinent of bladder and bowel elimination and requires assistance for toilet needs and hygiene. On September 30,2024, at 11:00 A.M., R7 was sitting in her wheelchair in her room. V7 and V17 (CNAs/Certified Nurse Assistants) assisted R7 to the bathroom. V7 said the last time she changed R7's incontinence brief was around 9: 00 A.M. V17 and V7 did not provide care at this time, due to R7's refusal to rise from the chair. Later, at 2:30PM, V7 and V17 provided care, and R7 was noted to be heavily saturated with urine. R7's pants and clothing were noted to saturated with urine. V7 confirmed no other attempts had been made to provide care to R7 between 11:00AM and 2:30PM. On September 30, 2024 at 4:30 P.M., V10 (LPN/Licensed Practical Nurse/MOD/Manager on Duty on September 21,2024 day shift) said V33 (R7's POA, Power of Attorney for Health Care) had complained on September 21, 2024 when she came in at 11:30 A.M. and saw R7 heavily saturated with urine. V10 said she saw R7's incontinence brief V33 had complained about. V10 said it appeared that the brief was saturated with urine. On October 01,2024 at 10:35 A.M., V11 (LPN, assigned to R7 on September 21,2024 day shift) said V33 came in around 11:30 A.M. on September 21, 2024. V11 said R33 had complained R7 was heavily saturated with urine that was soaked though all the way R7's clothes and bed sheets. V11 said she saw the brief that was heavily saturated with urine. 2. R10, a [AGE] year-old, with diagnoses of Alzheimer's disease, dementia, type 2 diabetes mellitus, stage 4 kidney disease. R10 was admitted to the facility on [DATE]. The MDS, dated [DATE], May 25,2024, and May 25,2023, showed R10's cognition was severely impaired. R10 also requires extensive assistance from staff for ADLs (Activities of Daily Living) including toileting and hygiene. On October 01,2024 at 11:15 A.M., R10 was noted to be in bed. V7 and V26 (Nurse Aide/CNA) were observed providing incontinence to R10. The incontinence briefs that R10's was wearing was heavily saturated with urine, and the brief padding had already coagulated into a gel. V7 and V26 said they have not provided incontinence care to R10 since they came to work at 6:00 A.M. The facility policy for incontinence care, dated October 20,2021, showed: Policy Statement; Our facility will ensure and provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. 12. Incontinence Care a. Incontinence care will be provided by nurse or C.N.A every shift based on incontinence needs of resident. Staff will ensure that incontinence care needs are met. b. Staff will check, and change based on frequency of needs and will keep resident clean and dry.

Based on interview and record review, the facility failed to provide nutritional supplement to prevent weight loss to a resident who had history of significant weight loss. This applies to 1 of 3 residents (R1) reviewed for nutritional supplement in the sample of 10. The findings include: The EMR (Electronic Medical Record) showed R1 is a [AGE] year-old with diagnoses of ALS (amyotrophic lateral scoliosis), gastroenteritis, colitis, epilepsy, BPH (benign prostatic hypertrophy), and lack of coordination. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set), dated August 24,2024, showed R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. The MDS also showed R1 showed no negative behavior including verbal, physical threatening and had not rejected care. The POS (Physician Order Sheet) for the month of September 2024 showed a physician order, dated August 27, 2024, for High Calorie drink two times a day, nursing to give 237 ml-240 ml. with preferred flavor of vanilla or strawberry. The care plan, dated October 01,2024, showed: -R1 has had significant loss in weight which multi-factorial in nature, abdominal pain, and constipation with decreased intake at times; has ongoing varied intake; is a finicky eater, and decreased ability to feed self due to progression of ALS diagnosis. The goal was for R1's nutritional status to be maintained, and without significant weight loss. The intervention included nutritional supplement (High Calorie drink 2 times a day) be given as ordered. The Nutrition/Dietary Notes, dated September 18,2024, showed V14 (Dietitian) had changed the High Calorie drink to a different brand (clear type supplement) due to R1's intollerance to the regular supplement. The notes also showed the supplement was needed to boost calorie intake and prevent R1's weight loss. On October 01,2024 at 12:30 P.M., V14 said R1 had been having loose stools due to the High Calorie drink. V14 also said R1 was not able to tolerate the High Calorie drink, and it was also exacerbated by R1's diagnoses of colitis and gastroenteritis. V14 said this was the reason why the nutritional supplement was changed to the clear supplement on September 18, 2024. V14 added R1 was a high risk of acquiring significant weight loss due to ALS diagnosis, was a very picky eater, meal intake was variable, and most of all, R1 has had history of significant weight loss. V14 added the supplement was an intervention to R1 for weight loss prevention. A review of the EMR (Electronic Medical Record) showed R1 did not recieve the supplement September 19, 20, 21, 25, and 26. V3 (Interim DON/Director of Nursing) and V14 (Nurse) confirmed this information. On September 30,2024 at 1:15 P.M., V5 (Ancillary staff) said she was not able to order the clear supplement because she was off for 10 days. V5 said she only ordered it on September 24,2024, it arrived the 26th, and was given to R1 on the 27th of September 2024. On September 30,2024 at 12:36 P.M., R1 said he cannot tolerate the regular High Calorie drink, as it gives him abdominal pain and loose stools. R1 said due to this reason, it was changed to the clear supplement. R1 confirmed he was not provided the supplement until September 27, 2024. The facility's Weight Management Policy, dated June 20,2024, showed: INTENT: It is the policy of the facility to provide care and services related to weight management . 15. RD to plan person-specific nutrition related goal(s), implement plan/interventions, and reevaluate .

Based on interview and record review, the facility failed to follow physician orders to administer neuromuscular medication to a resident (R1) with diagnosis of ALS (amyotrophic lateral scoliosis) and a neuropathy pain medication to a resident (R2) with diagnosis of diabetic neuropathy. This applies to 2 of 2 residents (R1 and R2) reviewed for significant medications in the sample of 10. The findings include: 1. The EMR (Electronic Medical Record) showed R1 is a [AGE] year-old, with diagnoses of ALS, gastroenteritis, colitis, epilepsy, BPH (benign prostatic hypertrophy), and lack of coordination. R1 was admitted to the facility on [DATE]. R1's MDS (Minimum Data Set) assessment, dated August 24,2024, showed R1 was cognitively intact. R1's care plan, dated October 01, 2024, showed to administer R1's ALS' medication as ordered by the physician to address ALS disease process. The POS (Physician Order Sheet) for the month of September 2024 showed a physician order, dated August 18, 2024, for Riluzole 50 mg film tablet one tab twice a day for ALS. The order was changed on September 5, 2024 for Riluzole 50 mg tablet every 12 hours. Review of Medication Drug Book (2024) showed Riluzole is used for ALS and other motor neuron disease. This medication is used to delay the onset of ventilator-dependence or tracheostomy. On October 1, 2024 at 2:45 P.M., together with V4 (ADON/Assistant Director of Nursing), R1's EMAR (Electronic Medication Administration Record) for the month of September 2024 was reviewed. There was no documentation R1 had received Riluzole 50 mg. film tablet on September 5, 6, 7, and 8 of 2024. V4 said based on the EMAR documentation, R1 missed a total of 8 doses. V4 also said R1 had reported to her that he did not receive his Riluzole medications for many days, and therefore, V4 had reordered the medication on September 9, 2024. On September 30,2024 at 12:36 P.M., R1 said he did not receive his Riluzole 50 mg. film tablet for at least 5 days. R1 said he reported this to V4. R1 also said this medication was ordered by his neurologist to delay the disease process of his ALS. 2. The EMR showed R2 is a [AGE] year old, with diagnoses of diabetic mellitus type 2, RA (rheumatoid arthritis), COPD (chronic obstructed pulmonary disease,) lack of coordination, morbid obesity and neuropathy. R2 was admitted to the facility on [DATE]. R2's MDS, dated [DATE], showed R2's cognition was moderately impaired. R2's care plan, dated August 12,2024, showed R2 was on pain management related to neuropathy and RA. Intervention included administration of pain medications as ordered. The POS for the month of September 2024 showed an order for Gabapentin 100 mg. twice a day for neuropathy pain scheduled to be given 9:00 A.M. and 5:00 P.M. On September 30,2024 at 12:34 P.M., R2 said he was not administered his scheduled 9:00 A.M. morning medications, and was still waiting from V28 (Registered Nurse). V28 reviewed the EMAR and it showed all R2's scheduled 9:00 A.M. medications were not yet administered. On October 01,2024, at 4:30 P.M., V13 (Nurse Practitioner) said R1's Riluzole medication was to for R1's ALS and is a significant medication, and by not administering this medication, it was a significant medication error. V13 said R2's Gabapentin 100 mg. medication twice a day that was scheduled at 9:00 A.M. and 5:00 P.M. was a significant error, since this pain medication for neuropathy should be space equally for administration, to maximize the optimum effect of pain control. The facility's policy for Medication Pass, dated March 20,2024, showed: INTENT: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis.

Based on observation, interview, and record review, the facility failed to ensure that kitchen was maintain clean, foods were stored properly, and washed pans and buckets for beverages were air dried. This applies to 85 residents who receives meals prepared in the facility kitchen. The findings include: Facility provided information that the census on September 16, 2024, was 85 residents with 2 (two) residents on NPO (nothing by mouth) status. On September 16 ,2024, at 10:00 AM during the initial tour of the kitchen with V15 (Food Service Dietary Manager), the following were observed: -a Dietary Aide was washing dishes using the dish machine. The left side of the dish machine were clean dishes and right side were dirty dishes. The dish machine was entirely soiled with heavy buildup of greenish colored lime debris. The floor under the dish machine all the way to the opening of the sewage drain was a heavy buildup of black debris that looks like a mud puddle. The pipe that goes to the sewer drain that was exposed was rusted. V15 said they will clean the dish machine and use a lime build up degreaser. V15 said she does not know when the kitchen was deep cleaned and why there was a buildup of the mud- puddle like under the dish machine. - 2 big plastic buckets stacked wet, and water drops in between buckets water were visible. V15 said they use the buckets as mixing containers for beverages, such as iced tea, orange drink, and fruit punch. -multiple sizes of washed pans stored in the 3 tier shelves cart. All the pans were stacked together and were stored wet, and drops of water noted from inside the pans. -walk in cooler showed 2 large pitchers of orange colored beverage with no label. -walk in freezer showed a large bag, open and no label. Also found staff lunches (yogurts and lunch bag) next to pan of oatmeal for the residents. V15 said staff lunches should be placed on the designated refrigerator for employees and not mixed with residents' food. -walk in freezer showed a large bag of round deli meat that was unlabeled -side of oven next to flat top stove had heavy buildup of debris -dry storage area showed open bag of undated elbow macaroni. On September 16, 2024, a quick tour for second time in the kitchen was made. There were 2 large plastic bucket containers on the food preparation area. These 2 large bucket containers were stacked together and were wet. V15 was aware, and said same buckets were used for mixing beverages. On September 17, 2024, at 10:00 AM, during the observation for the pureed diet preparation, V14 (Cook) had pureed eggs for egg salad sandwich. V14 took a quart size stainless pan from the 3 tier shelves cart. The quart sixe was stored together with other pans that were stacked together. There were drops of water from the pans that were stacked wet. V14 used the quart size pan that was stored wet and not air dried. On September 17, 2024 at 10:15 AM, together with V15, the walk-in cooler was checked. There were 2 staff lunches still stored in the residents' food area. V15 said these employee lunches should be stored in the staff lounge refrigerator. Facility Policy titled Major Kitchen and Floor Cleaning (undated) included as follows: Policy Statement: The Dining Services Department will keep the kitchen maintained in good condition . ensuring is kept cleaned, sanitize . Facility policy titled Air Drying Tableware and Utensils (undated) included as follows: Policy Statement: Food is stored, prepared, distributed and served under sanitary condition .Once utensils are clean and sanitized, they are allowed to air dry . Facility policy titled Labeling and Dating: Air Drying Tableware and Utensils (July 30, 2023) included as follows: Policy Statement: Leftovers and opened foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use .label includes: name of food item; discard date . Facility policy titled Staff Personal Food Storage dated June 14, 2019, included as follows: Policy Statement:1. Food brought in by staff will be in by staff shall be stored in designated areas only .1. Food brought in by staff will be identified with name of owner and date placed in designated refrigerator.

Based on observation, interview, and record review, the facility failed to provide medications for fecal impaction and address the resident's cries of pain related to the impaction. This failure led to R1 suffering pain and anxiety related to fecal impaction and R1 needing to call 911 emergency services for assistance. This applies to 1 of 3 residents (R1) reviewed for pain. The findings include: R1's quarterly MDS (Minimum Data Set), dated 10/13/22, showed R1 was cognitively intact. Hospital ER (emergency room ) records, dated 10/31/22, showed R1 fell in ER room and sustained a fracture to right tibia and had an immobilizer. R1's care plan, revised 10/27/22, included R1 has constipation related to impaired mobility, polypharmacy - potential drug adverse reaction with goal (target date 1/4/22) R1 will pass soft, formed stool at the preferred frequency through the review date). Interventions included to administer stool softeners, laxatives as ordered, Monitor/document/report as needed signs and symptoms of complications related to constipation: Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, [CONDITION(S)] (slow, low pulse), abdominal distension, vomiting, small loose or stools, fecal smearing, bowel sounds, diaphoresis, abdomen: tenderness, guarding, rigidity, fecal compaction. R1's care plan for pain for the same period included resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date (target date 1/4/22). Interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain, monitor/record/report to nurse resident complaints of pain or requests for pain treatment. R1's EMR records document R1 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same POS also included [MEDICATION(S)] Suppository 10 MG every 24 hours as needed for constipation (status active) and [MEDICATION(S)] Packet ([MEDICATION(S)] 3350) Give 17 gram by mouth two times a day for constipation (status active), [MEDICATION(S)] Capsule 100mg ([MEDICATION(S)] Sodium) give one capsule by mouth two times a day for constipation (status active). R1's MAR (Medication Administration Records) printed on 11/12/22 at 13:26:22 showed Fleet Enema and Magnesium [MEDICATION(S)] Solution were not given on 11/11/22 and on 11/12/22 . The same MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's EMR included nurses notes, dated 11/12/2022 05:26, documented as follows: Resident complaints that she is constipated, don't know when last bowel movement. NP [Nurse Practitioner] made aware was made aware, ordered [MEDICATION(S)] supp [suppository] 1 rectally daily as needed, and Senna 2 tab po [tablets by mouth] daily. Given Supp 1 rectally, Resident keep on screaming to push it out for her, placed resident on her side to be able to help her in position. Also pharmacy called for Magnesium [MEDICATION(S)]. On 11/12/22 at 10:32 AM, R1 was heard yelling out repeatedly from her room Somebody help me. R1's cries were heard from all the way down the hallway. On entry to R1's room, R1 was seen lying in bed and appeared very distressed, and was grimacing and moaning with tears in her eyes and stated, The nurse will not get it out of me with her fingers. On further enquiry, R1 stated she is constipated, and she is in excruciating pain. R1 stated she got [MEDICATION(S)] that morning for pain related to a fracture she had had at the hospital after a fall with transfer. R1's right leg was noted to be in an immobilizer cast. R1 kept crying out Help me, help me get it out. When R1's hallway was checked, two staff member, one CNA/Certified Nurses Assistant and a nurse (V7), who was at her nurse's cart were seen further down the same hallway from where R1's room was. Another nurse (V6) was seen in the adjacent hallway which was a few feet from R1's room. V6 (Licensed Practical Nurse) was notified of R1's cries of pain and V6 stated she is not R1's nurse, but will relay this to V7 who is R1's nurse. V6 was then seen going into R1's room briefly to enquire about her concerns, and R1 was heard asking for an enema. On 11/12/22 at 10:48 AM, R1 was still heard yelling from her room, and V7 was asked if she was notified of R1's concerns. V7 stated she has to finish giving the residents in her hallway their medications before she attends to R1. V7 stated V6 is looking for an enema to give to R1. On 11/12/22 at 11:47 AM, R1 was lying in bed and appeared very distressed and was seen dialing the phone and stated, I am still in excruciating pain. They said they don't have an enema and gave me another suppository and told me to wait. I am calling my brother to ask him to go and buy me some Dulcolax [[MEDICATION(S)]] and enema. On 11/12/22 at 11:51 AM, V7 was seen at her med cart passing medications and R1's ongoing cries of pain and concerns of not getting an enema was relayed. V7 stated, It's been an ongoing issue since last night and maybe before that. She (R1) has a history of constipation, and she is pretty impacted. I looked into her rectum and took out what I was able to see outside. The size of the stool feels like a big ball and only the doctors can remove it digitally. The night nurse called the Nurse Practitioner and got an order to give additional Senna 2 tablets daily and I gave it this morning. She also received a suppository last night. The facility did not have Magnesium [MEDICATION(S)] and was unable to locate Enemas. V2 (Director of Nursing) was notified about it and she gave another suppository this morning. On 11/12/22 at around 12:15 PM, the concern of R1's impaction and cry's of pain were relayed to V3 (Regional Nurse). On 11/12/22 at 1:11 PM, V7 stated R1 had called 911 and they [paramedics] arrived when V3 went into the room. V3, who was in the vicinity, verified R1 was on the phone with 911 when she went into the room. V3 stated she repositioned R1 to the side with the assistance of a CNA (Certified Nursing Assistant), and R1 was able to have a bowel movement by the time the paramedics arrived. On 11/12/22 at around 11:30 AM and on 11/14/22 at 9:52 AM, V2 stated R1 had been in the hospital since 10/31/22, and returned to the facility on [DATE]. V2 stated V7 paged her on 11/12/22 and notified her that she cannot find the enema and has no suppository on hand in the unit. V2 stated, I was able to find a suppository up front and gave R1 a suppository as (V7) was tied up. The Magnesium [MEDICATION(S)] and Enemas were house stock, and the facility did not have any on hand as the supply person who orders them was terminated last Thursday. On 11/14/22 at 12:26 PM, V8 (Certified Nurse Practitioner) stated R1 pain medications and immobility can cause constipation. V8 stated somebody from the facility should have called her when the previous stool softeners were found ineffective. V8 stated manual extraction for impaction is based on facility policy. V8 stated if she was notified, she would have ordered to give fleet enema and if that doesn't work, to give another Ducolax suppository. V8 stated if there was still no outcome, she would have tried additional options like Ducolax tablets, magnesium [MEDICATION(S)] or [MEDICATION(S)]. Facility point of care documentation's by nursing staff showed R1's first bowel movement since readmission on 11/10/22 (at 2022) was on 11/12/22 at 12:59 PM. V2 verified this information.

Based on observation, interview, and record review, the facility failed to ensure a resident identified as a wandering/elopement risk was provided adequate supervision and failed to develop and implement a procedure for monitoring residents that leave the facility to ensure they return to the facility. This applies to 2 of 5 residents (R1, R2) reviewed for safety concerns in the sample of 8 residents. This failure resulted in R1 wandering from the facility without being witnessed by facility. R1 was found wandering in the neighboring apartment complex parking lot, and R1 crossed a moderately busy street. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on August 30, 2022, when R1 wandered off from the facility without being witnessed by facility staff. V1 (Assistant Administrator), V2 Director of Nursing/DON), and V3 (Regional DON) were notified of the Immediate Jeopardy on September 7, 2022, at 9:57AM. The facility non-compliance remains at a Level 2 because the additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: 1. Face sheet shows R1 is [AGE] years-old, who was admitted to the facility on [DATE]. R1 has multiple diagnoses which include cognitive communication deficit, lack of coordination, and difficulty in walking, not elsewhere classified. Minimum Data Set (MDS), dated [DATE], indicates R1's cognition is moderately impaired. The same MDS indicates R1 requires supervision and assistance of a staff for walking and transfer. Admission progress notes, dated May 26, 2022, documents: (R1) was brought into facility by (V18, R1's son) in a wheelchair. Prior to admission to the facility, (R1) was found by the local police disheveled, confused, and repeating sentences. At this time, it was determined by the police that (R1) could not take care of herself. (R1) was taken to the emergency department (ED) and was admitted for acute kidney injury and mild cognitive impairment. R1's assessment for wandering behavior dated 5/24/22, with a lock date of 5/26/22, indicated R1 was at risk for wandering. Facility did not conduct initial assessment of R1 for elopement risk until she eloped on 8/30/22, Progress note, dated 8/30/22, documents at approximately 8:50 PM, the facility staff received a call from an unknown caller, reporting R1 was seen walking down the block away from the facility. R1 was able to state her name to the unknown caller. The facility did not update care plan addressing R1's elopement/wandering risk behavior. On 9/2/22 at 12:59 PM, R1 was interviewed in the conference room with V4 (Nurse Manager) present during the interview. R1 stated she was out walking; she didn't talk to anyone or bother anybody. R1stated she minded her own business. R1 continued to state when she went out walking, she didn't have any other purpose, she just wanted to take a walk. She was not aware of the time; she knew it was in the evening. R1 added she did not pay attention to the time, she just kept walking until she reached an apartment complex. R1 didn't know how to get back to the facility. R1 stated she believed she was trying to get where her children were, and she did not know how, but it was possible she had gotten lost. R1 continue to add was looking for her children, but she did not know their address. R1 added she used to live in the city with one of her children and when she wandered off, R1 didn't have thoughts of coming back to the facility. R1 continued to state she was trying to get to her children. R1 could not remember if facility had given her instructions of how far she can go from facility's ground. R1 did what she wanted to do. She wanted to be with her children. On 9/2/22 at 1:12 PM, V4 asked R1 Do you remember me talking to you? (Pertaining to the conversation they had, the night after R1 came back from the apartment complex) R1 replied, No. On 9/2/22 at 2:15 PM, V6 (Police Officer) stated, A lady called from an apartment complex and the caller stated she saw (R1) wandering about in the area looking confused. She approached (R1) and asked if she needed help. (R1) was able to state her name, but she didn't know where she came from, or where she was located. V6 then stated he called the facility because he concluded R1 was a resident at the facility, since the facility was nearby. V6 stated R1 was elderly, and the apartment complex was near the nursing home. V6 added the facility was unaware R1 was missing. V6 stated he gave the facility the address of the apartment complex about 150 to 200 yards away from the facility's location. On 9/2/22 at 3:12 PM, V8 (Nurse) stated on 8/30/22 around 8 PM to 8:15 PM, she answered a call asking if the facility was missing a resident. The person who called gave R1's name and their location. V8 stated she immediately looked up R1's name in the computer, and confirmed R1 was one of their residents. V8 approached V9 (Nurse assigned to R1) to check if (R1) was inside the building. Nobody in the facility knew that she (R1) was missing. The call happened between 8:00 PM to 8:15 PM. No one was located at the reception desk at that time. V8 was not sure how R1 got out, and concluded R1 went through the front lobby. The person who called said they would bring (R1) back to the facility. (V8) and (V9) stood outside the facility for about 15-20 minutes and waited for (R1). When (R1) didn't come back, (V8) and (V9) went to the neighboring apartment complex. The fire department (NFD) and police department (NPD) were present on site along with a social worker. According to V8, R1 stated, Did you guys know I was gone, did you miss me? I can't be in charge of what my mind does. V8 and V9 then went and brought R1 back to the facility. V8 then notified V19, former Director of Nursing, about the incident. The staff who were assigned to R1 were asked when R1 was last seen, and the staff responded around 6:30 PM. The residents of the facility often sit or stay in the front porch or front of the building until 8:00 PM. Usually the residents go out there after dinner for fresh air or to smoke, and the staff is supposed to ensure that everyone comes back inside before 8 PM. On 9/2/22 at 3:40 PM, V9 (Nurse) V8 notified V9 about the call she received regarding R1. They were told they were bringing R1 back to the facility, but after a while when R1 did not come back, V8 and V9 went to the apartment complex to get R1. R1 told them she was looking for her son. R1 was alert and oriented, with some confusion. According to V9, R1 was last seen inside the facility around 6:30 PM, and outside around 7 PM. V9 stated the receptionist sits in the front lobby until 8 PM. Some of the residents will go in and out of the building. The facility lacked a specific procedure for monitoring residents leaving and returning into the building. V9 stated, (R1) left the building at a busy time; the nurses were passing medications and staff was not aware (R1) left the building until they received the call. V9 also said, The receptionist is the one who usually monitors the ins and outs of the residents. They have the sign out and sign in logbook at the front desk. On 9/2/22 at 11:47 AM, V4 (Nurse Manager) stated, (R1's) elopement happened on the 30th of August at around 8:15 PM. A staff notified (V4) about (R1) being seen in the neighboring apartment complex. (V8) and (V9) went to pick up (R1), and (V6, Police Officer) followed them and talked to (V4). On 9/2/22 at 11:15 AM, V14 (Housekeeper) stated R1 walks with a walker, and uses her wheelchair for mobility. V14 is very familiar to R1, they talk every time she works in the unit where R1 resides. V14 likes to sit in the front patio like other residents, and never attempted to wander off the facility before. V14 has a good rapport with R1, but V14 noticed R1 was becoming more forgetful lately. On 9/6/22 at 3:28 PM, V13 (Agency Certified Nursing Assistant/CNA) stated, It was the first time I (V13) worked with (R1). (R1) was fine the entire shift. She was pretty much independent; she was able to verbalize when she needed help. (R1) walks with use of walker. At around 6:35 PM on 8/30/22, V13 was checking all her residents, and changing incontinence brief of those residents who needed it. V13 saw R1 standing at the door of her bedroom, and they talked briefly. At around 8:20 PM, V13 couldn't find R1; she alerted the nurse (V9). V13 started looking for her. When V13 talked to V9 again, she was told R1 was with the police officer (V6), and they would bring her back in the facility. V13 also said some residents are not elopement risk, and they are allowed to sit in the front patio or front of the building. V13 guessed (R1) likes to be on the front patio; some residents expressed they had seen her in the front of the building prior to leaving the facility grounds. V13 added, There is no sign out sheet for the residents, and the only way to find out if a resident is outside, is to go outside to the front. V13 stated the staff had no way of finding out if a resident comes back. On 9/2/22 at 2:05 PM, V15 (CNA) stated she floats everywhere in the facility. V15 said she goes to the front porch to check on residents to make sure they are okay. V15 added they have no specific method to monitor resident's location. V15 also stated she is unaware of which residents are at risk for elopement. On 9/7/22 at 2:03 PM, V16 (Restorative Aide/CNA) stated she used to be a CNA for years. V16 stated when she works on the floor, she checks her resident frequently. V16 added she was unaware of a procedure for monitoring residents going outside, and she did not know if the front desk clerk did this task. On 9/2/22 at 12:50 PM, V7 (Receptionist) stated she's in the reception desk from 8 AM until 4 PM, and another person takes over from 4PM to 8PM. V7 stated, The only sign out sheet the facility has is when family picks up a resident to go on a pass somewhere, or if a resident has an appointment outside. However, if they only go out and sit in the front patio, they don't need to sign out. At 4:36 PM, V7 (Receptionist) stated all residents can go outside, except for those residents with a (electronic monitoring device). On 9/2/22 at 10:07 AM, V31 (Maintenance Director) stated he was not aware R1 eloped/wandered off of the facility grounds. V31 stated, The front door lobby is opened from 7:45 AM through 8:00 PM and locked at 8:00 PM. The only way to open the door is via a key code that only the supervisor knows. Residents with (electric monitoring devices) that come near the doors will activate the alarms. At 7:45 PM, the computer that controls the door, automatically locks all the exit doors. It still alarms but it does not open unless the person pushes it hard. These exit doors can't just be opened because it's heavy. On 9/2/22 at 2:41 PM, V11 and V12 (both Nurses) stated, It is hard to monitor residents unless they have a (electronic monitoring device). Most of the time, the nurses find out if a resident is missing when they're giving medication or treatment, and they can't find the resident. They usually check the common areas in the facility. The resident can go out to the front after dinner, but they (residents) should be in by 8PM. V11 and V12 both stated they are new to the facility, and they don't have specific policy and/or process in monitoring the residents' whereabouts. V11 said, When a resident is missing, they check bedrooms and common areas, and do head counts before raising the alarm for elopement. On 9/2/22 at 1:17 PM, V5 (Nurse Consultant) stated, When the facility admits a new resident, the staff must assess them for elopement risk, their cognition and everything, every potential risk. The nurses and social service assess residents for risk behaviors. On 9/6/22 at 12:56 PM, V17 (R3's spouse) stated they don't need to sign in and out of the facility if they are just sitting at front of the building. V17 stated she has seen staff do activities outside the building such as trivia, however, they don't sit down and monitor residents on regular basis. V17 added she has seen residents go in and out of the facility without staff monitoring. On 9/8/22 at 12:36 PM, V26 (Director of Rehab/Occupational Therapist) stated they worked with (R1) from 7/11/22 through 8/11/22. By the time (R1) was discharged from rehab, she needed supervision for activities of daily living (ADL) including ambulation, which means someone or a staff in general has a direct vision of (R1). On 9/9/22 at 11:25 AM, V28 (Physiatrist) stated, (R1) is alert, but her orientation ranges from 1-2. It means she can tell her name and the place, but can't tell the date and time, and situation. Her cognition fluctuates and she's not oriented times 3 or 4. (R1) requires supervision with transfer and ambulation due to decrease safety awareness. V28 stated, (R1's) walking is not 100% stable due to her cognition, and (R1) is always going to need supervision to be able to transfer and ambulate safely. On 9/9/22 at 3:21 PM, V29 (Physician) stated, (R1) is alert and oriented times 1-2, meaning she is alert to herself; sometimes she knows where she's at, and sometimes she does not. (V29) referred (R1) for neuropsychological evaluation to know where (R1) stands, because she's confused, she has some cognitive impairment, and a form of dementia. V29 was not sure if R1 was already seen for neuropsychological evaluation. V29 stated, Due to (R1's)cognition, (R1) is not safe to be out by herself, and (R1) needs to be monitored by staff when she is outside. On 9/2/22 at 4:50 PM, surveyor drove to the address V6 (Police Officer) provided, where they found R1 wandering. It was 0.1 mile or 176 yards from the facility. There was a street to cross from the facility to the apartment complex with cars passing through (To go to and exit from the neighboring hospital). It was also noted on 9/2/22 and 9/7/22 during observations V7 (Receptionist) has no direct visual accessibility of the residents sitting or standing outside or in the front of the building. A review of R1's progress notes indicated several episodes of confusion. On 6/16/22, progress notes showed R1 called 911 several times about being robbed of her purse. On 6/29/22, progress notes documents (R1) alert with some confusion. Progress notes, dated 7/25/22, shows (R1) was alert and verbally responsive with confusion per usual. (R1) is ambulatory and walks around in her bedroom by herself and during night. Noted several times, turning off control of the air mattress and deflating it. (R1) was given instructions not to mess around with the mattress control but was unable to understand and continued to deflate the mattress. R1's Physicians' (V28, V29) and Nurse Practitioners' (V27, V30) Notes from 5/27/22 through 8/10/22 shows multiple documentation entries R1 is alert and oriented x1 (to self), and a few entries of alert oriented x 1-2 (to self and to place). There were also entries R1 was pleasantly confused and forgetful. On 6/10/22, V29 (Physician) documented R1 needed to obtain neuropsychological evaluation. In addition, on 6/17/22, V29 documented R1 was noted to have continued confusion, and neuropsych has been consulted. However, the facility was unable to present documentation of neuropsychological evaluation for R1. 2. R2 is [AGE] years-old who has multiple medical diagnoses which include Alzheimer's disease with late onset. R2's Elopement Risk assessment, dated 1/7/2022, indicates R2 is a high risk for elopement. MDS, dated [DATE], showed R2 is moderately impaired in cognitive skills. R2's functional status shows she requires supervision with one person/staff physical assistance while ambulating. R2's active care plan shows R2 has dementia or impaired thought processes related to Dementia, and R2 has tendency to get confused and wander into other resident's rooms. The facility is located beside a big hospital and an apartment complex. The facility also faces a busy or high traffic street where the residents of the apartment complex, other residential area, employees of other establishments, hospital staffs and visitors pass through. On September 2, 2022, from 11:23 AM through 11:30 AM, there were 6 residents including R2, observed sitting in the front porch and in the front of the building without any relatives and without staff monitoring them. On 9/2/22 at 11:30 AM, R2 was ambulating with her walker in the front porch of the building with no supervision or assistance from staff. Through observations, interview, and record review, the immediacy was removed on 9/8/22 at 1:48 PM, by taking the following actions: 1. R1 was re-assessed for elopement. R1's care plan was reviewed and updated to include being placed on monitoring while outside, being placed on hourly monitoring, being placed on electronic monitoring device, and electronic monitoring device to be checked every shift. On 9/8/22 at 1:00 PM, R1 was observed with an electronic monitoring device to her left ankle. 2. R2 was re-assessed for elopement. R2's care plan was reviewed and updated to include: being placed on monitoring while outside, being placed on hourly monitoring, being placed on electronic monitoring device, and electronic monitoring device to be checked every shift. On 9/8/22 at 12:30 PM, R2 was observed with an electronic monitoring device on her right ankle. 3. Facility initiated in-service on R1 and R2's direct care staff on plan of care to address elopement risk and precautions. This will be ongoing until all direct care staff for R1 and R2 have been provided with in-service. This will be completed by 09/09/2022. The facility presented documentation of the in-services they started with the staff regarding elopement risk/precautions. 4. All residents in the facility who are high risk for elopement and wandering have the potential to be affected by the same deficient practice. 5. Initiation the Audit of (electronic monitoring device) binder weekly and as needed by Social Service and or designee. This will be on an ongoing basis. V2 (Director of Nursing/DON) and designee started to conduct a daily audit of all admissions and readmissions to ensure the elopement assessment has been completed. If a resident is at high risk for elopement, V2 (DON) and designee ensured elopement precautions are in place and implemented. This will be conducted daily and will be ongoing. Furthermore, the facility initiated the audit of resident elopement assessments of residents who are at risk of wandering and elopement to ensure proper care plan is in place; they initiated in-service on Elopement Policy and will be ongoing daily to include all facility and agency staff until all staff have been in-serviced. This will continue until 09/09/2022 for facility staff and will be continued for agency staff on an ongoing basis. 6. The facility initiated an Elopement binder with policy, and list of resident's high risk for elopement/wandering to ensure appropriate training and in-service is provided. V2 (DON) presented the Elopement binder they started with residents' information, their picture and the facility's policy. V21 (new Administrator) stated they would put these elopement binders at the reception desk, and to all their nurses' stations. 7. Facility conducted a Resident Council Meeting on 09/07/2022 at 3:30 PM. They discussed facility policy with regards to going out on pass, utilization of back patio for smoking, including signing in and out when exiting the building through the front door, and when front patio would be utilized by residents. Receptionist will ensure that all residents who go in and out of the facility follow the sign in and out protocol. Staff will conduct head count on assigned residents during rounds, and a staff member will be assigned to monitor and supervise residents when out in the patio. 8. Quality Assurance committee plans to monitor facility performance to make sure the corrective actions are achieved and permanent. V21 (Administrator) will review audits weekly to ensure compliance with the measures put in place to address the safety of residents at high risk for Elopement, will ensure the Plan of Removal will be implemented and completed until compliance date and as indicated. The facility initiated QAPI on 09/07/2022 to discuss with QA committee members about the IJ removal plan and that all corrective actions and safety measures are initiated and consistently implemented.

Based on interviews and record reviews, the facility failed to prevent neglect when the facility was left without a licensed nurse in the building for over four hours. This failure resulted in the potential for serious harm or death when residents did not receive services, monitoring, and medications. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/21/22 at 8:30 PM when the last licensed nurse present in the building left. This failure applies to all residents in the facility. The facility's 5/21/22 Daily Census Sheet showed 67 residents reside in the facility. The Immediate Jeopardy was identified on 6/2/22. V1 (Director of Nursing), V6 (Assistant Administrator), and V22 (Regional Administrator) were notified of the IJ on 6/3/22 at 11:31 AM. Although the immediacy was removed on 06/03/2022, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policies, procedures, audits, and Quality Assurance monitoring. The findings include: On 6/3/22 at 2:20 PM, V6 (Assistant Administrator) stated there were no licensed nurses working at the facility on 5/21/22 from 8:30 PM to 11:05 PM, and from 12:16 AM to 2:40 AM on 5/22/22. V6 added there was a potential for serious harm to the residents because there were no licensed staff members present. On 5/27/22 at 1:51 PM, V8 (Staffing Scheduler) said that on 5/22/22 around 2:00 AM, she received a text that the Fire Department was in the building, and that there were no nurses working in the facility. V8 stated that a minimum of two nurses are necessary to work the 7 PM-7 AM shift. On 5/27/22 at 12:25 PM, R7 stated he called 911 around 1:00 AM on 5/22/22 because he did not get his blood pressure medications, because there were no nurse working to pass medications. R7's 5/25/22 Minimum Data Set (MDS) showed his cognition is intact. R7's May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/26/22 at 1:19 PM, R4 said he experienced a medical crisis on 5/22/22. R4 stated his indwelling urinary catheter was clogged and there was blood in his urine. R4 said that on 5/22/22 when the Fire Department was in the facility, the emergency personnel that were there sent him to the emergency room (ER). R4 stated his catheter was changed in the ER, and labs were drawn, an infection was identified, and antibiotics were started. R4's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's progress notes for 5/21/22 from 5:05 PM showed an order to send R6 to the ER because of abnormal laboratory results. R6's note showed transportation was arranged to pick her up in two hours. R6's 5/22/22 7:20 AM progress note from the next day showed R6 was transferred to the hospitalER on [DATE] at 4:15am, eight hours and 45 minutes later than arranged. R6's May 2022 showed an anticoagulant was among the scheduled medications she missed on 5/21/22. R3's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's 3/24/22 MDS showed her cognition is intact. On 5/27/22 at 1:24 PM, R8 stated only two nurses came in for the 7 PM-7 AM shift on 5/21/22, and they both walked out. R8 stated she had been asking for her medications from 9 PM to 10 PM, and a CNA (Certified Nursing Assistant) even told her that there were no nurses in the building. R8's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Three General Incident Reports (each revised 6/1/22) sent to three physicians all showed Incident: Medication and treatment not administered per orders, approximately bedtime on 5/21/22 until morning of 5/22/22. The three Reports together listed names of 56 residents where medication and treatment was not administered. On 6/2/22 at 1:50 PM, V18 (Physician, Facility Medical Director) said that the facility should have licensed nurses always working because there is potential for a medical crisis needing a licensed nurse to perform lifesaving interventions. V18 said with the residents' medical conditions, there is potential for [CONDITION(S)], fluid overload, infection from not getting antibiotics, labile sugar for those who are insulin dependent and do not get their insulin, exacerbations of congestive heart failure or chronic obstructive pulmonary diseases, or heart attacks and strokes. The facility's Subject: Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention policy/procedure (reviewed 2/8/22) defined Neglect as .the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when the facility staff fails to monitor and or supervise the delivery of patient slash resident care and services to assure care is provided as required. The policy further showed under 3. Prevention 1. The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs . The Immediate Jeopardy that began on 5/21/22 was removed on 06/03/2022 when the facility took the following actions to remove the immediacy: F600 1. Corrective actions which will be accomplished for those residents found to have been affected by the deficient practice Licensed Nurse from Pearl of Rolling Meadows drove to Pearl of Naperville upon receipt of call from Fire Marshal that assigned nurses were not in the facility. o Licensed nurse performed nursing assessment on all facility residents to ensure safety and well-being. o Licensed nurse reviewed and checked medications that are due and administered as scheduled. Physicians/NP were contacted to notify of missed medications and that licensed nurse performed nursing assessments on all residents to ensure their safety and well-being. Staffing plan was created on 05/23/2022 to ensure that an On-Call program is in place to ensure that scheduled staff attend assigned shifts. Staffing plan was created by Administrator. In-services on the Staffing Plan was initiated on 05/23/2022 and is ongoing with licensed nurses, certified C.N.A's including staffing agencies-Nurses/C.N.As scheduled on all shifts. o Verbal in-services started via face to face to licensed nurses and certified nurses, including agency staff on 05/23/2022 and is ongoing. o Care feed (Electronic app) In-services will be initiated and utilized starting 06/03/2022 to cover In-services of staff working during evening/night shifts. o Clipboard Website for staffing agency will be utilized to provide Staffing Plan In-service for those agency staff (Nurses and C.N.A's) scheduled to work in the facility prior to the beginning of the shift. This will be initiated on 06/03/2022. o In-services will be provided in-person by DON, Administrator and or designee Administrator or Designee and Director of Nursing was in-serviced by Regional Administrator on ensuring that Staffing plan created on 05/23/2022 is executed and implemented accordingly [NAME] ensure that all scheduled staff attend assigned shifts. In-service also included: o Administrator or Designee and or DON will check every shift to ensure assigned staff are working their scheduled shifts. This was initiated on 05/23/2022. o Administrator and or DON will assign a charge nurse for every shift that will be responsible for calling Administrator throughout the shift if any unforeseen staffing should arise. This was initiated on 05/23/2022. o Administrator and DON initiated a review and will be ongoing on standby list for staffing (Nurses and C.N.A's) to review available nurses for current and the following shifts. Administrator or Designee confirmed with the standby list of C.N.A's and Nurses noted and written on the Staffing Plan that they will give their availability on a daily and weekly basis. If staff listed on standby list if on vacation, no confirmation on their availability will be necessary based on dates of vacation request. Administrator and DON were in-serviced on 05/23/2022 on ensuring that residents receive adequate supervision and monitoring on all shift by making sure that licensed staff who are scheduled to work are present during their scheduled shift. QAPI meeting was conducted on 006/03/22 attended by Facility Department Heads to discuss F 725 and F600 citations and plan of removal. o Facility reviewed current Staffing Plan and Corrective Actions initiated and are ongoing. o Facility Administrator and designee, VP of Clinical Services, CEO, met with [NAME] Hospital Director of Clinical Services, Medical Director and NP to discuss nursing care opportunities that include facility staffing plan. Facility contacted all physician on 05/22/2022 assigned to residents who missed the medications and obtained order to monitor resident for any symptoms of change in condition for 72 hours. Licensed RN assessed all residents in the facility on 05/22/2022 to identify and change in condition and provided needs as necessary. 2. The facility will identify other residents having the potential to be affected by the same deficient practice All residents in the facility have the potential to be affected by the same deficient practice. 3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and not recur In-services on the Staffing Plan will be ongoing with licensed nurses, certified C.N.A's including staffing agencies-Nurses/C.N.As scheduled on all shifts. o Verbal in-services will be provided via face to face to licensed nurses and certified nurses, including agency staff until all are in-serviced. In-service will be on an ongoing basis for agency staff. o Care feed (Electronic app) In-services will be ongoing and will utilized to cover In-services of staff working during evening/night shifts until all staff are in-serviced. o Clipboard Website for staffing agency will be ongoing to provide Staffing Plan In-service for those agency staff (Nurses and C.N.A's) scheduled to work in the facility prior to the beginning of the shift. This will be ongoing until facility utilizes agencies for staffing. o In-services will be provided in-person by DON, Administrator, or designee. Administrator or Designee and or DON will check every shift to ensure assigned staff are working their scheduled shifts. o Administrator and or DON will assign a charge nurse for every shift that will be responsible for calling Administrator throughout the shift if any unforeseen staffing should arise. o Administrator and DON will continue to review standby list for staffing (Nurses and C.N.A's) to make sure availability of these nurses for current and the following shifts. Administrator or Designee will confirm standby list of C.N.A's and Nurses noted and written on the Staffing Plan that they will give their availability on a daily and weekly basis. If staff listed on standby list is on vacation, no confirmation on their availability will be necessary based on dates of vacation request. Facility will conduct a daily staffing huddle to ensure all shifts are filled and standby list for on call Nurses and C.N.A's have been reviewed and updated. 4. Quality Assurance plans to monitor facility performance to make sure that the corrective actions are achieved and permanent: Administrator will utilize a QA tool to ensure compliance with the Staffing Plan of Removal, to include completion of In-services on Staffing plan on all licensed staff, including agency staff. The results of the monitoring and audits done under this will be submitted to the QAPI Committee for review and follow up monthly. Completion Date: 06/03/2022

Based on interview and record review, the facility failed to ensure licensed nurses were always present in the building to care for residents. This failure resulted in the potential for serious harm or death. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy was noted to begin on 5/21/22 at 8:30 PM when there was no longer a licensed nurse working in the building. This applies to all residents in the facility. The facility's 5/21/22 Daily Census Sheet showed 67 residents reside at the facility. The Immediate Jeopardy was identified on 6/2/22. V1 (Director of Nursing), V6 (Assistant Administrator), and V22 (Regional Administrator) were notified of the Immediate Jeopardy on 6/3/22 at 11:31 AM. Although the immediacy was removed on 06/03/2022, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policies, procedures, audits, and Quality Assurance monitoring. The findings include: R7's 5/25/22 Minimum Data Set (MDS) showed his cognition is intact. On 5/27/22 at 12:25 PM, R7 stated he called 911 around 1:00 AM on 5/22/22 because he did not get his blood pressure medications, because there were no nurse working to pass medications. On 5/27/22 at 1:51 PM, V8 (Staffing Scheduler) said that on 5/22/22 around 2:00 AM, she received a text that the Fire Department was in the building and that there were no nurses working in the facility. V8 stated that a minimum of two nurses are necessary to work the 7 PM-7 AM shift. R8's 3/24/22 MDS showed her cognition is intact. On 5/27/22 at 1:24 PM, R8 stated only two nurses came in for the 7 PM-7 AM shift on 5/21/22, and they both walked out. R8 stated she had been asking for her medication from 9 PM to 10 PM, and a CNA (Certified Nursing Assistant) even told her that there were no nurses in the building. R8 said she did not get her antibiotic and her sleeping and pain medications. The facility's Assignment Sheet for 5/21/22 showed licensed staff V9 (LPN), V17 (Agency LPN), and V5 (RN) were scheduled to work the 7 PM-7 AM shift. On 5/25/22 at 2:59 PM, V4 (CNA) stated she worked the night of 5/21/22. V4 stated that V9 (LPN) was a no-call/no-show for the 7 PM - 7 AM shift, and V5 (RN) and V17 (Agency LPN) both came in to work but did not stay for their shifts. On 5/27/22 at 4:39 PM, V5 said that she came in at 7:10 PM on 5/21/22 for ten minutes and left at 7:20 PM. V5 said she never took report or received the keys to a medication cart. On 5/31/22 at 3:02 PM, V17 stated she stayed at the facility until V10 (Day Shift LPN) left, which was until 8:00 or 8:30 PM. On 6/3/22 at 3:15 PM, V1 Registered Nurse, Director of Nursing (RN, DON) stated there were no licensed nurses caring for residents at the facility on 5/21/22 from 8:30 PM to 11:05 PM (for two hours and 35 minutes), and then again on 5/22/22 from 12:16 AM to 2:40 AM (for two hours and 24 minutes). V1 said because there was no licensed nurse at the facility during those times, there was a potential for serious harm to the residents. V1 said that her expectations are that the facility always has sufficient staff. On 6/3/22 at 2:20 PM, V6 (Assistant Administrator) verified there were no licensed nurses working at the facility on 5/21/22 from 8:30 PM to 11:05 PM, and from 12:16 AM to 2:40 AM on 5/22/22. V6 added there was a potential for serious harm to the residents because there were no licensed staff members present. On 6/2/22 at 1:50 PM, V18 (Physician, Facility Medical Director) said that the facility should have licensed nurses always working because there is potential for a medical crisis needing a licensed nurse to perform lifesaving interventions. V18 said with the residents' medical conditions, there is potential for [CONDITION(S)], fluid overload, infection from not getting antibiotics, labile sugar for those who are insulin dependent and do not get their insulin, exacerbations of congestive heart failure or chronic obstructive pulmonary diseases, or heart attacks and strokes. On 5/26/22 at 12:00pm, V1 (DON) said that the Facility Assessment Tool is used to determine staffing needs. The Purpose section of the Facility Assessment Tool (5/2021-5/2022) showed the purpose .is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents Under 3.2 of the Staffing plan section, the Tool showed Based on your resident population and their needs for care and support, describe your general approach to ensure you have sufficient staff to meet the needs of the residents at any given time . The Tool listed Position- Licensed nurses providing direct care together with Total Number Needed or Average or Range Per Shift, and then described 2 sufficient - 3 if possible . The Immediate Jeopardy that began on 5/21/22 was removed on 06/03/2022 when the facility took the following actions to remove the immediacy: 1. Corrective actions which will be accomplished for those residents found to have been affected by the deficient practice o Staffing plan was created on 05/23/2022 to ensure that an On-Call program is in place to ensure that scheduled staff attend assigned shifts. Staffing plan was created by Administrator. o In-services on the Staffing Plan was initiated on 05/23/2022 and is ongoing with licensed nurses, certified C.N.A's including staffing agencies-Nurses/C.N.As scheduled on all shifts. o Verbal in-services started via face to face to licensed nurses and certified nurses, including agency staff on 05/23/2022 and is ongoing. o Care feed (Electronic app) In-services will be initiated and utilized starting 06/03/2022 to cover In-services of staff working during evening/night shifts. o Clipboard Website for staffing agency will be utilized to provide Staffing Plan In-service for those agency staff (Nurses and C.N.A's) scheduled to work in the facility prior to the beginning of the shift. This will be initiated on 06/03/2022. o In-services will be provided in-person by DON, Administrator and or designee Administrator or Designee and Director of Nursing was in-serviced by Regional Administrator on ensuring that Staffing plan created on 05/23/2022 is executed and implemented accordingly to ensure that all scheduled staff attend assigned shifts. In-service also included: o Administrator or Designee and or DON will check every shift to ensure assigned staff are working their scheduled shifts. This was initiated on 05/23/2022. o Administrator and or DON will assign a charge nurse for every shift that will be responsible for calling Administrator throughout the shift if any unforeseen staffing should arise. This was initiated on 05/23/2022. o Administrator and DON initiated a review and will be ongoing on standby list for staffing (Nurses and C.N.A's) to review available nurses for current and the following shifts. Administrator or Designee confirmed with the standby list of C.N.A's and Nurses noted and written on the Staffing Plan that they will give their availability on a daily and weekly basis. If staff listed on standby list if on vacation, no confirmation on their availability will be necessary based on dates of vacation request. Administrator and DON were in-serviced on 05/23/2022 on ensuring that residents receive adequate supervision and monitoring on all shift by making sure that licensed staff who are scheduled to work are present during their scheduled shift. QAPI meeting was conducted on 006/03/22 attended by Facility Department Heads to discuss F 725 and F600 citations and plan of removal. o Facility reviewed current Staffing Plan and Corrective Actions initiated and are ongoing. o Facility Administrator and designee, VP of Clinical Services, CEO, met with [NAME] Hospital Director of Clinical Services, Medical Director and NP to discuss nursing care opportunities that include facility staffing plan. Facility contacted all physician on 05/22/2022 assigned to residents who missed the medications and obtained order to monitor resident for any symptoms of change in condition for 72 hours. Licensed RN assessed all residents in the facility on 05/22/2022 to identify and change in condition and provided needs as necessary. 2. The facility will identify other residents having the potential to be affected by the same deficient practice All residents in the facility have the potential to be affected by the same deficient practice. 3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and not recur o In-services on the Staffing Plan will be ongoing with licensed nurses, certified C.N.A's including staffing agencies-Nurses/C.N.As scheduled on all shifts. o Verbal in-services will be provided via face to face to licensed nurses and certified nurses, including agency staff until all are in-serviced. In-service will be on an ongoing basis for agency staff. o Care feed (Electronic app) In-services will be ongoing and will utilized to cover In-services of staff working during evening/night shifts until all staff are in-serviced. o Clipboard Website for staffing agency will be ongoing to provide Staffing Plan In-service for those agency staff (Nurses and C.N.A's) scheduled to work in the facility prior to the beginning of the shift. This will be ongoing until facility utilizes agencies for staffing. o In-services will be provided in-person by DON, Administrator, or designee. o Administrator or Designee and or DON will check every shift to ensure assigned staff are working their scheduled shifts. o Administrator and or DON will assign a charge nurse for every shift that will be responsible for calling Administrator throughout the shift if any unforeseen staffing should arise. o Administrator and DON will continue to review standby list for staffing (Nurses and C.N.A's) to make sure availability of these nurses for current and the following shifts. Administrator or Designee will confirm standby list of C.N.A's and Nurses noted and written on the Staffing Plan that they will give their availability on a daily and weekly basis. If staff listed on standby list is on vacation, no confirmation on their availability will be necessary based on dates of vacation request. Facility will conduct a daily staffing huddle to ensure all shifts are filled and standby list for on call Nurses and C.N.A's have been reviewed and updated. 4. Quality Assurance plans to monitor facility performance to make sure that the corrective actions are achieved and permanent: Administrator will utilize a QA tool to ensure compliance with the Staffing Plan of Removal, to include completion of In-services on Staffing plan on all licensed staff, including agency staff. The results of the monitoring and audits done under this will be submitted to the QAPI Committee for review and follow up monthly. Completion Date: 06/03/2022

Based on observation, interview, and record review, the facility failed to ensure a resident was turned safely in bed for cares. This failure resulted in a resident rolling out of the opposite side of the bed from the staff member assisting her and on to the floor, sustaining fractures to her toe and hip joint. This applies to 1 of 3 residents (R1) reviewed for falls. The findings include: R1's Electronic Medical Record (EMR) Face Sheet showed R1 is [AGE] years old, and admitted to the facility on [DATE] with diagnoses including bilateral [CONDITION(S)] of knee, Alzheimer's disease, abnormality of gait, anxiety disorder, [CONDITION(S)], type 2 diabetes, and weakness. R1's 11/05/2021 Minimum Data Set (MDS) showed R1's cognition is moderately impaired and R1 requires extensive physical assistance of one person for bed mobility. The facility's 12/1/2021 State Report showed Resident rolled off the bed and fell on to the floor. The Report continued .On 11/25/2021 at approximately 9:15 AM, R1 was being assisted The nurse was assisting (R1) to turn on her side while guiding her leg, (R1) moved and turned her leg quickly, causing her to slide off the bed The Report further showed an Xray revealed a toe fracture, then .On 11/30/2021, (R1) complained of pain, transferred to [Emergency Department], Xray revealed minimally displaced fracture of the anterior acetabulum (hip socket). On 12/3/21 at 11:00 AM, R1 said on 11/25/2021 when R1 was laying on R1's side in bed, the nurse (V7, Registered Nurse- RN) was putting lotion on R1's sore bottom and said move over a little more, and I threw my leg over. R1 stated, I was on the edge of the bed, I didn't realize I was on the edge and I fell to the floor. Right away my toe, hip and right foot hurt. I have had pain for a long time due to arthritis, but pain in my hip and toe are bad, much worse after the fall. R1 said R1 has a new bed after the fall, It is bigger and has bed rails, it is much better. R1's bed was observed to be wider than the standard bed, and it had half side rails up on both sides of the bed. On 12/9/21 at 2:25 PM, R1 was transferred into bed by two CNAs from wheelchair using a sliding board. During cares with V11 (CNA), R1 was instructed to use half rails to aid with turning which R1 did without problem. When turned on R1's right side, R1 grabbed the right rail with left hand, when turned to R1's left side, R1 grasped left rail with right hand. R1 stated the rail made it possible for R1 to turn and pull herself over, so it hurt less. R1 again stated R1 fell out of the bed when the nurse was cleaning R1; R1 turned and there was no more bed and R1 fell on to the floor. R1 stated R1 broke R1's hip and toe. R1 is noted to be obese, with the bulk of R1's weight around R1's abdomen and hips. R1's Weights and Vitals Summary showed R1 weighed 211.1 pounds on 12/2/21 and R1's height was 64 inches. R1's 11/25/2021 Nursing progress written by V7, RN (who was assigned to R1 at the time of the fall), showed V7 observed R1's call light on, approached room; R1 was laying in bed. R1 said I need to be changed. R1 noted anxious, has diagnosis of anxiety. V7 asked R1 to assist with turning. R1 quickly turned, over-rotating R1's body, causing R1 to slide off the bed. R1 has impaired safety awareness due to dx Alzheimer's. On 12/8/21 at 1:27 PM, V7 was asked how R1 was positioned in bed when R1 rolled out of bed. V7 said when V7 walked in the room, R1 was on R1's back in the middle of the bed. V7 stated V7 was standing on the left side of R1's bed, and R1 rolled over to the right, away from V7. Radiology results report of 11/25/21 show no acute fracture of right wrist and hand, sacrum and coccyx, right and left hip, right shoulder and right elbow. The right foot shows an acute nondisplaced fracture of the proximal phalanx of the great toe. R1's 11/30/2021 Hospital Records show CT image of left hip finds moderate to severe hip arthritis. There is lucency with cortical break consistent with a comminuted fracture of the anterior acetabulum On 12/9/21 at 4:55 PM, V12 (Nurse Practitioner) stated R1 is able to make R1's needs known, and does have anxiety issues. V12 stated V12 received a call after R1 fell off the bed. Multiple X-rays were ordered on a portable basis. V12 stated in general, portable x-rays are not as accurate or reliable as x-rays done in the hospital. The portable x-rays revealed a toe fracture but no other fractures. When R1 began complaining of hip pain, R1 was sent to the hospital for further evaluation. V12 said the fall did cause the fractured toe, and most likely the fractured hip. R1's High Risk for Falls care plan (revised 12/02/2021) showed R1 is unaware of her safety needs and experiences chronic pain in her left leg. The care plan included 11/25/2021 Resident quickly turned while being assisted, over-rotating her body, causing her to slide off the bed . This care plan showed interventions such as anticipate the resident's needs (initiated 11/20/2020), and encourage to transfer and change positions slowly (initiated 02/17/2021). The facility's Fall Prevention policy and procedure (revised 09/20/2021) showed a Policy Statement of All residents will receive adequate supervision, assistance, and assistive devices to aid in prevention for falls. Each resident will be evaluated for safety risks including falls and accidents . The facility's Repositioning a Resident policy and procedure (revised 10/20/2021) showed the Policy Statement as .to aid in the development of an individualized care plan for repositioning . Part 1. a. under Procedure showed Review the resident's care plan to evaluate for any special needs of the resident Part 2.d. showed Evaluate if resident needs intervention to maintain postural alignment, if weight distribution is even . Part 3.a. showed Resident will be assessed and care plan developed and implemented as necessary for turning/repositioning, changing the resident's position, and realigning the body. This will be approached specific to the individual resident . The policy showed Procedure for Repositioning the Resident in Bed (Some steps may change based on special circumstances that would be necessary to ensure safety of staff and/or resident) .b. Check the care plan, assignment sheet or the communication system to determine resident's specific positioning needs . The policy continued k. Move the resident's top leg and shoulder in the direction of the turn . Neither the facility's Fall Prevention or Repositioning a Resident policies and procedures included language regarding the safety of repositioning residents in bed using one assist and turning the resident away from you.

Based on observation, interview, and record review the facility failed to assess and evaluate a resident's pain. Failed to implement and document weekly skin audits, and failed to assist and provide showers/ proper hygiene in order to prevent the development of skin alteration. This failure resulted in R8 having a moisture assoicated skin disorder (very raw and bright red in color) on his scrotum and inner thighs causing R8 to be in pain for at least 3 weeks. This applies to 1 of 1 residents (R8) reviewed for pain and the development of skin alteration in the sample of 16 residents. The findings include: On September 10, 2017 at 11:20 AM, R 8 was by the nursing station sitting in a wheelchair, with stained black pants with patches of white unknown stains and a maroon sweater with white flakes noted on the shoulders and at R 8's back. R 8 stated, I have been waiting for a Nurse because I am in a lot of pain. I hope she comes soon. There was no staff observed in the nursing station or in the hallways. At 11:30 AM, the receptionist was asked to page the nurse. E 4 (Nurse) came and asked R 8 what is the problem, R 8 told E 4 I am in pain. E 4 gave pain medication to R 8 without asking the location or the severity of R 8's pain. At 11:48 AM, R 8 was sitting in a regular chair in the room and said, The pain is down there (pointing at his private area) it is burning like hell! R 8 described the pain at a 20 (for severity/ on the scale of 0 to 10). R 8 continued to state, I am hurting in my scrotum and my groins, and it's a burning pain. They do not usually take me to the bathroom, they just put a pull ups (adult disposable incontinence brief) on me, and they change it when I go to bed at night, and sometime when I ask them to. When you ask the staff, they usually say they will come back and most of the time they will not. I had been telling the Nurses for 3 weeks now about my burning pain down there, they gave me a powder (over the counter powder-not ordered by the doctor). Since I came here, I have not been given a shower, occasionally they will take me to another room (shower room). They (staff) will wet a face towel, and wipe my chest and shoulders, that is it! They never wash me down there so I try my best to clean myself but I need help. I can't stand that long and I can't reach my back end. R 8's Physician order [REDACTED]. R 8's Minimum Data Set, dated dated dated [DATE] showed R 8 is cognitively intact, with a Brief Interview for Mental Status score of 14 out of 15. R 8 needs 2+ person physical assistance for transfer and toilet use and supervision and set up for personal hygiene. On September 10, 2017 at 1:35 PM, E 11 (Certified Nursing Assistant) explained, R 8 is alert and oriented; he at times will tell us if he wants to go to the bathroom, no I did not ask him today if he wanted to use the washroom. I took him to the bathroom at 8:00 AM, he didn't call after that so I assume he is clean, E 11 assisted R 8 in the bathroom and noted R 8's adult disposable incontinence brief was soaked with urine. R 8's scrotum and both inner thighs were inflamed and bright red in color. E 11 took a face towel, wet it, no soap was used and wiped R 8's scrotum. E 11 immediately put a new adult disposable incontinence brief without wiping R 8's scrotum dry. E 11 also explained, He has been complaining about that irritation on his (testicles) and groin. It has been like that for 3 weeks now. The nurses know and they gave him a powder which does not help (with the redness). No, I do not give him showers, the afternoon shift is supposed to give him showers. E 11 opened the computer by the hallway to see when R 8 was last given a shower, E 11 said for the month of August and September (2017) I didn't see that he was given shower or bath at all. At 2:51 PM, R 8 continued to complain of burning pain and discomfort on his scrotum and inner thighs. E 4 (Nurse) said, I will call the Nurse Practitioner (Z 3), and also ask the wound Nurse (E 12) to assess him. R 8's shower sheet dated August 28, 2017 identified R 8 with red/rash the area in inner thighs and perineal area circled on the diagram. There was no documentation found in R 8's electronic clinical record regarding R 8's skin alteration on his scrotum and inner thighs or any physician order [REDACTED]. On September 10, 2017 at 4:00 PM, a skin assessment was conducted with E 12 (weekend Wound Nurse). E 12 identified and described, The front of his scrotum all the way to the back of it and, both inner thighs (halfway down to his knees) are very raw and bright red in color. It is due to moisture and not regularly being washed. They are not cleaning him well. On September 10, 2017 at 4:55 PM, Z 4 (R 8's daughter) explained, He had not been given a shower for at least three weeks that I know of and I complained about this. We come and visit, he looks dirty. Two weeks ago, I saw his bed sheet had a stool smeared on it. He will not defecate in bed, so I know he is not being cleaned properly. I know they had not washed him for at least 3 weeks that is why his groin is getting worse. (R8) said he told the nurses about it (scrotum/groin). R8's electronic treatment record showed an order to do body audit every (Thursday) on day shift for skin observation. This record shows only initials of the nurses but no descriptions of the skin was documented. E 12 (weekend wound Nurse) reviewed R 8's record and was unable to provide documentation on the status of R 8's skin. E 12 said, It's just the initials of the nurse. The facility has no record that this order was followed. E 12 reviewed R 8's electronic record and was unable to provide any documentation regarding this (skin) audit report upon request. On September 12, 2017 at 3:20 PM, E 14 (Director of Nursing) explained that orders (body audit) are nursing protocols/ interventions and if it is written on the electronic treatment record, it should be followed. On September 12, 2017 at 11:55 AM via phone interview Z 3 (Nurse Practioner), I get few calls from that nursing home but none for him (R 8). No, I was not notified about that skin alteration. That is moisture associated skin disorder. It is due to poor hygiene, when urine or feces stays on the skin for a while and it is not cleaned properly, of course, the skin will break.

Based on observation, record review and interview the facility failed to develop and implement interventions for anchoring indwelling urinary catheter (IUC), to avoid excessive tugging on the catheter during transfer and care delivery. Due to the staff failure to transfer R1 safely from bed to wheel chair on 7/26/13 resulted in dislodgement of R1 ' s IUC. As a result R1 suffered from catheter related pain, urethral tear, erosion and bleeding. R1, at the hospital received blood transfusion to build up depleted Red Blood Cells, Hemoglobin and Hematocrit. On 8/10/13 R1, at the hospital underwent cystoscopy, clot evacuation, and fulguration of the bleeding site. This applies for two of three residents (R1 and R3) evaluated for IUC in the sample of four residents. The findings include: R1 ' s admission record showed that he was admitted to the facility on [DATE] for physical rehabilitation status [REDACTED]. The facility per R1 ' s 7/31/13 admission Minimum Data Set (MDS) identified him to be alert, oriented to time, place and person and his Brief Interview for Mental Status (BIMS) score was ' 15. ' R1 ' s 7/26/13 3:45 pm Nurses Notes showed that E3, Certified Nurse Aide (cna) reported to the E4 the Nurse on duty that his IUC was out with balloon intact, bleeding from the penis and cold pack applied to site. The Nurses Notes also showed that the staff contacted urologist per attending physician recommendation, could not get appointment with the urologist to see R1. The urologist office advised the facility to send R1 to hospital if his condition worsens. On 7/27/13 at 7:54 am the facility staff inserted am IUC #16 F with 5 cc balloon, as R1 ' s bladder scan showed he was retaining urine up to 873 cc. On 7/30/13 at 4:27 pm R1 ' s blood pressure was 98/56 and heart rate was 122 per minute, seen by urologist and returned to the facility at 6:30 pm. On 8/2/13 at 7:13 pm R1 was started on antibiotic therapy for Urinary Tract Infection [MEDICAL CONDITION] per urologist order. On 8/3/13 at 0.59 am staff noticed R1 bleeding with clots from the penis around the IUC. At 4:01 pm R1 started to bleed again from the penis, at 8:11pm R1 was admitted to the hospital due to the trauma of penis urethra. R1 ' s hospital records showed that staff inadvertently stepped on IUC while standing, which resulted in acute profuse bleeding due to traumatic removal of IUC balloon still inflated. R1 ' s Hemoglobin dropped due to bleeding, required transfusion of packed red blood cells. On 8/10/13 R1 underwent cystoscopy, clot evaluation, and fulguration of the bleeding site. R1 ' s 7/23/13 IUC plan of care showed no interventions to address the precautions to be taken to transfer him safely. The facility did not evaluate to resolve how R1 ' s IUC got out with its balloon intact. The facility also did not develop interventions even after R1 ' s IUC dislodged, to prevent such occurrences. On 8/13/13 at 1:30 pm E2, the Director of Nurses stated that she spoke to R1 at the hospital and staff involved when the incident occurred, but does not have any thing documented to show the investigation. E2 stated she did a change in condition assessment on 8/3/13 for R1 ' s IUC dislodgement on 7/26/13. This evaluation is not comprehensive to show what are the contributing factors for the dislodgement of IUC or what measures would prevent future such occurrences. On 8/13/13 at 3:30 pm interviewed R1 at another Long Term Care Facility. R1 was able to engage in conversation, explained circumstances surrounding the dislodgement of his IUC. R1 was alert, oriented to time, place and person. R1 stated he does not want even his enemy to go through what he went through with his urinary catheter while he was at the facility. R1 explained that on 7/26/13 night shift aide came to his room to get him up, sat him at his bed side and asked him to stand up. R1 said as he stood up, he felt the pain and screamed and sobbed from the catheter tube pulling. The tube stretched and the whole catheter fell on the floor, the balloon remained with water. At that point R1 said he then noticed E3 was standing on the urine bag and some of the tubing. The aide said she was sorry and she will get help. R1 also said he fell back to bed and bled large amount of blood. R1 said the staff put ice towel on his scrotal area, the towel got wet with blood because he was bleeding profusely from his penis, but nothing helped for a while. R1 stated he could not urinate on his own, so the staff reinserted the catheter on 7/27/13. R1 continued his conversation and said he did not see the urologist until 7/30/13. R1 said by 8/3/13 he has been hurting, bleeding on and off, felt weak, had an infection and that is when they sent him to hospital. At the hospital R1 said he received blood transfusion; via cystoscopy the surgeon removed blood clots and fulgurated the bleeding site. R1 insisted he would never want to go back to the facility. On 8/13/13 at 11:00 am E5 (Occupational Therapy staff) wheeled R3 in his wheel chair from Occupational Therapy area to front dining room. R3 wheel chair had no foot rests. E5 wheeled R3 in his wheel chair and his IUC tubing and the urine collection bag was dragging on the floor. While E5 was wheeling him R3 could not hold his legs up and his right foot frequently stepped on his IUC tubing while it was dragging on the floor. R3 ' s catheter was not anchored to prevent excessive tugging and inadvertent removal of catheter. R3 7/5/13 IUC plan of care did not show interventions as to how the staff should be transferring him or how to anchor the catheter during transfer. The facility Nurse Consultant verified R3 ' s IUC tubing was on the floor next to his shoes, while he was seated in his wheel chair and stationed in front dining hall. On 8/13/13 at 11:07 am R3 stated he had Urinary Tract Infection and infection had just cleared. R3 did not know that the IUC tubing is not supposed to be on the floor, it drags all the time on the floor and he can ' t keep his feet up while he is pushing with his feet. R3 also stated the tube is not secured to his leg.

Based on observation, record review and interview the facility failed to provide adequate supervision of a two person transfer with a mechanical lift and to ensure R1 wears a cervical collar at all times to maintain a C 3 cervical fracture for 1 of 4 sampled residents with staff assisted incident/ accident. (R1) These failures resulted in R1 sustaining a subdural hemorrhage after a fall, fractures to his frontal sinus and a 3.0-centimeter laceration to his left medial eyebrow that required five sutures. Findings Includes: Observation of R1 on 8/23/11 at 2:30 p.m. found his wife is at his bedside. R1's left eyebrow was swollen approximately three centimeters in size. (E5) The Assistant Director of Nursing confirmed there are five sutures to R1's eyebrow. R1's left eye is swollen, bruised and darkened below the eye and his nose is swollen and dark. During the observation, R1 was sleeping with occasional moaning. R1's wife states R1 is having pain at time to his eye after the fall. Interview with (E3) Certified Nursing Assistant (CNA) on 8/23/11 states on 8/10/11 it was the first time he worked with R1's group. E3 said he prepared R1 to go to therapy on 8/10/11 about 11:30a.m... E3 states he sat R1 on the side of his bed to begin a transfer from the bed to the wheel chair. E3 placed the wheel chair to the right side of R1 and noted the leg rest were on the seat of the chair. E3 states he turned to the left to place the leg rest on the other bed in the room and R1 fell forward to his left side landing on his face. E3 states he thought R1 was able to sit up better then he did. E3 stated after R1 fall, the nurse sent him to the therapy room to get a cervical collar to place on R1 neck. E3 states he did not look at R1's Visual /Bedside Kardex Report located in the computer kiosk station. A review of the incident report statement dated 8/11/11 for E3 states, " I did not check the Kardex on the patients I was assigned to today. I walked around with E6 (CNA) and she gave me information about the patients. I was in a hurry and I have done it in the past. I thought it would be okay. The way that R1 was rolling in bed I did not think he would be a two person transfer." E3 states he was sent home about 1:30pm on 8/10/11 for approximately one week while the facility conducted an investigation. The statement from E6 (CNA) dated 8/11/11 " Reviewed the patients that E3 was assigned to. I was telling E3 who gets up for breakfast. That a resident needs to be gotten up with a lift. I told him R1 got up after breakfast, and that when I got him up, I transferred him from bed to chair. I was able to do it by myself." The Visual / Bedside Kardex Report for R1, printed 8/10/11 for the incident investigation, under SPECIAL NEEDS list: # 3 mechanical lift for all transfers, use 2 person assist at all times. And #5 SPECIAL NEED TO WEAR CERVICAL COLLAR AT ALL TIMES EVEN IN THE SHOWER (FYI). A review of the clinical record hospital report dated 4/11/11 identifies R1 to have a recent stroke on 4/4/11 with left side hemi paresis with shallow and speech concerns. During the workup, the hospital record documents R1 to have a (C3) cervical spine fracture. The signed statement from (E8) LPN Treatment Nurse dated 8/10/11 (P.T.) Physical therapy was in the room and applied cervical collar after R1 fell . (E 7's) LPN signed statement dated 8/10/11 writes: cervical collar applied while R1 in supine position. R1 keep in supine position until ambulance arrived. Interview and record review of (E2) Director of Nursing, E3 and E6 on 8/11/11 received one on one in-service and verbal review to check Kardex for assigned tasks to meet the needs of the patients and not to have patient out of sight that need assistance and supervision.