Every finding on record at Pearl Pointe Nursing Rehab & Care

Based on interview and record review the facility failed to ensure safety was provided for a resident when given hot coffee. This failure resulted in R1 sustaining a second degree burn to her arm from hot coffee on 8/1/26. This is for 1 of 2 residents (R1) reviewed for safety and supervision in the sample of 8.The findings include:The Incident Report dated 8/1/26 for R1 showed under the notes section; R1 sustained a thermal burn to her right forearm after accidentally spilling hot coffee. The certified nursing assistant (CNA) delivered the breakfast tray with meal set up and notified this nurse that she had spilled coffee. Upon immediate assessment, a burn measuring 13 centimeters (cm) x 5.3 cm was noted to the right forearm. The area was observed with erythema, skin intact, no active drainage or bleeding noted. Tylenol 650 mg was given for pain. The burn area was cleaned with normal saline, Silvadene and dressing was applied.The Nurses Notes for R1 showed: 8/2/26 at 10:40 AM R1 remains on incident follow-up related to right forearm burn. Burn site remains pink with several small fluid filled blisters that were intact. No drainage, foul odor, or signs/symptoms of infection noted. 8/8/26 at 7:26 PM - R1 was seen by the Nurse Practitioner (NP) that day for a follow-up of the right forearm burn wounds. New treatment order received to apply Santyl in a thick coat directly to slough areas, followed by Silvadene saturated gauze, non-adherent dressing, pad, and wrap with elastic wrap. Continue to monitor wounds for healing and signs/symptoms of infection. The Physician Order dated 8/8/26 for R1 showed she was started on Cephalexin 750 milligrams (mg) 1 capsule by mouth four times a day for a burn wound infection.On 8/27/26 at 12:07 PM, V9 (Cook) stated they have a coffee machine, and the coffee was coming out at 200 degrees; people were getting burned by it, so they called the company for the machine, and they came and turned the temperature down. V9 stated they did not check the temperature on the coffee until someone got burned and then they were made to do it.On 8/28/26 at 9:30 AM, V1 (Administrator) stated she received a phone call on 8/1/26 about the coffee being spilled and R1 having a reddened forearm. V1 stated she spoke with the nurse who filled out an incident report. The initial report was sent in. V1 stated she made sure the nurses contacted the doctor. V1 stated on Monday it was a reddened area. V1 stated she didn't see the blisters. V1 stated she had them gather statements. When she opened the risk management notes saw there were blisters present. V1 stated If the coffee is too hot, they need to bring down the temperature, put ice cubes in the cup if they need to in order to bring the coffee down to the temperature it should be. V1 stated they went over thermal burn precautions, adaptive equipment, a cup with a lid and a spout.On 8/28/26 V12 (CNA) stated she was helping pass room trays and R1 had a room tray that she delivered and set up for her. V12 stated she continued to deliver the rest of the room trays. When she was done and was walking back up the hall and she noticed R1's blankets were wet. R1 had spilled her coffee so she removed the wet blanket and when she pulled it back, she noticed R1's arm was red. V12 stated she could tell that R1's arm was burned. V12 stated the nurse came down and assessed her.On 8/28/26 at 10:44 AM, V11 (Licensed Practical Nurse/LPN) stated the CNA came on got her and she went to R1's room to look at her arm. V11 stated R1's arm was bright red and had started to blister. V11 stated she put a cool cloth on it, cleaned it and put Silvadene cream on it. R1 had some grimacing. V11 stated R1 had several blisters that were scattered on her arm after it happened.On 8/28/26 at 10:49 AM V14 (Wound Nurse Practitioner/NP) stated she saw R1 once and she had second degree burns to her right forearm. They were shallow, open blisters that were not infected when she saw her. V14 stated she was told this happened because of a hot coffee spill. It was a second degree burn to her arm. V14 stated it probably could have been prevented if the coffee wasn't too hot. Sometimes the wet material next to the skin can make the burn worse.On 8/28/26 at 11:23 AM, V13 (NP) stated R1 had a second degree burn from the coffee. It did become infected and she was put on an antibiotic. V13 stated thatR1's son did not want her sent out; he wanted her treated in the facility. V13 stated it looked like a typical burn and then became reddened around the outside with slough present. V13 stated she was told this happened from the hot coffee that was spilled. V13 stated she was assuming the coffee was too hot to be served and caused the second-degree burn.The Face Sheet dated 8/28/26 for R1 showed diagnoses including dementia, generalized anxiety disorder, left femur fracture, venous insufficiency, dementia, chronic venous hypertension, varicose veins of lower extremities, essential hypertension, morbid obesity, hypothyroidism, weakness, atherosclerosis, delusional disorders, left clubfoot, and osteoarthritis.The facility's Hot Liquids Safety policy (no date) showed coffee served shall not exceed the temperature of 143 degrees F (Fahrenheit) at the time the resident receives the coffee. If the facility sends coffee to the nursing units or dining room in insulated containers the temperature shall not exceed 180 degrees F.

Based on observation, interview and record review the facility failed to ensure the kitchen was maintained in a clean manner, the cleaning schedule was followed, and dirty mop water wasn't emptied in the dish room/dish table sink.This has the potential to affect all 75 residents in the facility.The findings include:The Facility Data Sheet dated 8/27/26 showed a census of 75 residents.On 8/28/26 at 8:06 AM a tour of the kitchen was conducted. There was a rolling mop bucket filled with dirty water that had an odor present next to the dish cleaning area. The floors in the kitchen were dirty and sticky; shoes stuck to the floor and made noises when walking in the kitchen. There was a thick brown buildup of something on the floor near the baseboards in the kitchen. There was a disposable glove and paper debris under the wire rack near the stove. There were used/wet paper towels on the floor that were wadded up under the food rack in the kitchen. The hand-washing sink was dirty. There were old dry brown and orange substances on the wall. There were plastic cups and paper on the floor by the sink area. The stainless-steel table that held the coffee machine was dirty and had a white substance built up on the side of it and old streaks all over it. There were new and old coffee spills on the top shelf and lower shelf of the table. The ice machine had numerous streaks down the front and sides. There was a white substance built up on the machine. The metal cart by the kitchen doors that had scoops and dessert cups stored on it were dirty; there was a thick white substance stuck to it in various areas. The black cart by the kitchen doors that held condiments were dirty with substances stuck to it and old crumbs in the condiment holders. V10 (Dietary Manager/DM) emptied the dirty water from the mop bucket in the sink in the dishwashing area where they spray off the dishes. There was one cook, one dietary aide, and V10 present in the kitchen.On 8/28/26 at 8:15 AM, V9 (Cook) stated they have three cooks and three dietary aides. There is 1 cook, one dietary aide, and the manager on days. The cook stated as soon as he was done cooking and plating the food, he helped do dishes and then starts prepping and cooking lunch. V19 (Dietary Aide) stated she does dishes when the dirty ones come back to the kitchen. They stated there wasn't enough time to get any deep cleaning done in the kitchen.On 8/28/26 at 8:25 AM, V10 (Dietary Manager) stated after they sweep and mop after breakfast there will still be black marks present on the floor because it's in the tiles. V10 did not acknowledge the buildup of some substance around the perimeter of the kitchen next to the baseboards. V10 stated there was a dietary aide checklist for cleaning in the kitchen. He stated the cooks clean the kitchen weekly.On 8/28/26 at 8:27 AM, V1 (Administrator) stated the kitchen was recently inspected by the county health department and did not pass inspection. V1 stated the last time she was in the kitchen was on Monday. She stated she did not go in, walk around and look at the kitchen but did look inside the doors. V1 stated from what she saw at that time the kitchen needed to be cleaned. V1 was notified of the observations made in the kitchen and she stated that was unacceptable. V1 stated cleaning schedules should be followed in the kitchen.The Dietary Cleaning Schedule (no date) showed daily duties as follows: wipe food carts clean after each meal, wipe dishwasher clean after each meal, wipe storage shelves clean, clean sink and drain three times a day, wipe utility carts clean after each use, sweep and mop floors, and wipe the refrigerator clean. The range hood was to get thoroughly cleaned once a month.The facility's Cleaning and sanitizing Dietary Areas and Equipment policy (no date) showed all kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease or other soil. The facility will provide sanitary food service that meets state and federal regulations.

Based on observation, interview and record review the facility failed to have a pest control program in place to ensure it is free from pests.This has the potential to affect all 75 residents in the facility.The findings include:The Facility Data Sheet dated 8/27/26 showed a census of 75 residents.On 8/27/26 and 8/28/26 during normal business hours flies and gnats were noticed throughout the facility. The most gnats were noted on 8/28/26 at 8:06 AM during a limited kitchen inspection. V9 (Cook) and V19 (Dietary Aide) confirmed there is a problem with flies and gnats in the kitchen. V10 (Dietary Manager) was present and stated they had gnats in the kitchen and did not pass the local health department inspection. V10 stated they used boiling water, vinegar, brown sugar and dish soap and put it down the drains for a few days to try and fix the problem of the gnats. V10 stated V6 (Maintenance Director) recently fixed the drain in the kitchen and the gnats were better.On 8/27/26 at 10:50 AM V6 (Maintenance Director) stated they did not have any contracts with a pest control company, and no one had been coming out. V6 stated part of the problem was that staff keep doors open during smoke breaks for residents. V6 stated the gnat problem in the facility was in the kitchen due to grease in the pipes. V6 stated they had to call someone recently to descale the drains. V6 stated he was not aware of gnats anywhere else.On 8/27/26 at 10:50 AM the doors to the courtyard were propped open for residents to go outside and smoke. The interior doors and exterior doors to the courtyard were observed open at 11:02 AM, 11:11 AM, 11:18 AM, 11:22 AM, and 11:38 AM.On 8/27/26 at 11:59 AM, R7 stated there were problems with flies and gnats in the building. At 1:24 PM, R3 and R5 complained about flies and gnats being a problem in the building.On 8/27/26 at 2:09 PM, V4 (Wound Nurse) stated there was a problem with gnats and flies in the building. V4 was standing at the nurse's station on the first floor and stated the kitchen is right here and the front doors. V4 confirmed the side doors were kept open to get people in and out for smoke breaks.On 8/28/26 at 8:34 AM V1 (Administrator) stated, she was not aware the pest control company was not coming out. V1 stated V6 (Maintenance Director) came to her and stated they needed to have someone come out because of a drain problem and gnats. V1 stated when a new company takes over a building the contracts usually follow so there was no lapse in coverage. V1 stated when she started looking into it she found that the previous company had not been paying the bills. V1 stated the last time the pest control company came out was in May 2026.The last Pest Control Service Report for the facility was dated 5/8/26 and showed there were door gaps/damage in the facility that allows pest access.The Sewer and Drain company receipt dated 8/21/26 for the facility showed a drain in the basement had to be descaled and was clogged with grease.The facility's Pest Control policy (no date) showed it is essential for infection prevention and control programs to maintain an environment that is free from pests and rodents. Organizations must develop policies and procedures for an effective pest control program, Generally, organizations contract with outside services to provide an effective program including but not limited to bait stations, traps, and sprays. Effective interventions against pests and rodents may include internal and external methods. If staff, residents, and/or visitors notice an increased presence of pests and rodents they shall notify the building maintenance department or designee. Coordination with the building's pest control contractor will be implemented to correct an increase in pests or rodents.

Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions were followed for residents with open wounds during wound care for 2 of 3 resident reviewed for wounds and infection control in the sample of 8.The findings include:1. On 8/27/26 at 1:09 PM, V4 (Wound Nurse) was at R3's bedside for wound care to his left lower leg, posterior/Achilles area. V4 had gloves on but not a gown. V4 removed the old dressing from R3's wound and discarded it. V4 removed her gloves, used hand sanitizer and applied new gloves. V4 used wound cleanser to soak off a folded up 4 x 4 that was packed in the wound and had adhered to the wound. V4 stated they pack the wound with the 4 x 4 gauze and fold it to fit in the wound to pack it. V4 removed the 4 x 4, removed her gloves, used hand sanitizer, and put clean gloves on. V4 cleaned the wound with wound cleanser and a clean 4 x 4. V4 discarded the 4 x 4, removed her gloves, used hand sanitizer and put on new gloves. R3 had a large open area to the back of his leg that was bleeding. V4 put Dakins soaked gauze that was folded up to fit into the wound. V4 removed her gloves, used hand sanitizer, and applied clean gloves. V4 applied a 5.3-inch x 6 inch, soft silicone foam dressing with border over the top of the packed wound. V4 removed her gloves, used hand sanitizer, put new gloves on and labeled the dressing. V4 applied an elastic bandage around the dressing and stated that was to help keep the dressing on and in place. V4 removed her gloves and washed her hands. There wasn't an enhanced barrier precaution (EPB) sign on the door or posted in R3's room.On 8/27/26 at 2:23 PM, V2 (Director of Nursing/DON) stated enhanced barrier precautions were to be used for anyone with wounds, catheters and things like that because there was potential for contamination. V2 stated staff should follow the enhanced barrier precautions signs. V2 stated if a resident has wounds, then the EBP sign should be on the door. Staff should wear gloves and gowns for close contact care. V2 stated it was part of the facility's policy.The Face Sheet dated 8/28/26 for R3 showed diagnoses including right femur fracture, acute posthemorrhagic anemia, fall, hypertension, pressure ulcer, rhabdomyolysis, dehydration, alcohol abuse, and thrombocytopenia.The Physician's Orders dated 8/28/26 for R3 showed a treatment order for his wound to the Achilles area to cleanse with normal saline, pack wound with Dakins soaked gauze, cover with foam dressing twice daily. There was no order for enhanced barrier precautions.The facility's Enhanced Barrier Precautions Guidelines policy (no date) showed it is the policy of this facility to implement enhanced barrier precautions - EBP for the prevention of transmission of multidrug-resistant organisms. An order for EBP will be obtained for residents with any of the following: wounds. Personal protective equipment for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High contact resident care activities include: wound care.2. On 8/27/26 at 2:09 PM R4 was lying in bed on her side waiting for V4 (Wound Nurse) to provide wound care. V5 (Certified Nursing Assistant/CNA) was at bedside to assist V4. V4 and V5 had gloves on but did not have a gown on. V4 and V5 pulled R4 closer to the side of the bed so she could hold onto the bed rail to help keep herself on her side during the wound care. V4 cleaned the open wound between R4's but crack that was like a slit; she used wound cleanser. V4 removed her gloves, used hand sanitizer, put clean gloves on and placed collagen to the slit. V4 stated nothing went over the collagen. V4 removed the disposable chux from under the R4 and disposed of it in the garbage. V4 removed her gloves, used hand sanitizer and placed a body pillow behind R4's back per her request. V5 then placed pillows between R4's legs and knees. There was an enhanced barrier precaution sign on R4's door and it was shown to V4 wound nurse. V4 stated she did not think that was supposed to be up on the door. V4 was asked what the sign meant for someone with wounds and she stated that gloves were to be worn. V4 was asked if gowns were to be worn and she stated no. V4 stated the only person with a wound that she had to wear gown and gloves was R1 because she had a burn. V4 was shown the sign stated gloves and gown should be worn for residents with wound care which was any skin opening that required a dressing.On 8/27/26 at 2:23 PM, V2 (DON) stated enhanced barrier precautions were to be used for anyone with wounds, catheters and things like that because there was potential for contamination. V2 stated staff should follow the enhanced barrier precautions signs. V2 stated if a resident has wounds, then the EBP sign should be on the door. Staff should wear gloves and gowns for close contact care. V2 stated it was part of the facility's policy.The Face Sheet Dated 8/28/26 for R4 showed diagnoses including chronic obstructive pulmonary disease, personality disorder, type 2 diabetes mellitus, necrotizing fasciitis, post-traumatic stress disorder, morbid obesity, muscle weakness, stage 3 pressure ulcer of sacral region, polycystic ovarian syndrome, bipolar disorder, major depressive disorder, post-traumatic stress disorder, hypertension, obstructive sleep apnea, hypothyroidism, large plaque parapsoriasis, chronic atrial fibrillation, fibromyalgia, and deep venous thrombosis.The Care Plan dated 6/19/26 for R4 showed she is on enhanced barrier precautions for wounds or skin opening that requires a dressing. Follow EBP guidelines when providing care and coming into direct contact with potentially infected material or devices that put me at risk. Direct care activities include.wound care or any skin opening requiring a dressing.The facility's Enhanced Barrier Precautions Guidelines policy (no date) showed, It is the policy of this facility to implement enhanced barrier precautions - EBP for the prevention of transmission of multidrug-resistant organisms. An order for EBP will be obtained for residents with any of the following: wounds. Personal protective equipment for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High contact resident care activities include: wound care.

Based on observation, interview, and record review, the facility failed to ensure a paraplegic resident was provided with a call light according to his needs to 1 of 9 (R1) residents reviewed for accommodation of needs in the sample of 9. The findings include:R1's facility assessment dated [DATE] show R1 has a BIMS of 15-no cognitive impairment.On 6/30/26 at 8:45 AM, R1 was lying in bed. R1 showed this surveyor a regular call light tied to his right hand and placed near his mouth and chin. R1 said he uses his mouth or tongue or chin to push his call light when he needed something. R1 said this was hard. R1 said he had been here since 6/19/26. R1 said the facility knew his condition as paraplegic, and they should have provided a soft touch call light he can easily access since he cannot move his hands due to paraplegia.On 6/30/26 at 11:30 AM, V2 (Nurse Manager) said she had noticed R1 needed an easily access call light like (soft touch call light) due to his limited mobility. R1 is paraplegic. V2 said she thought this was taken care of at the time of R1's admit by V13 (previous Director of Nursing). V2 said she had instructed V4 (Maintenance Director) to order a soft touch call light for R1. V2 said it was important that all residents' needs were met in accordance with their rights. On 6/30/26 at 12PM, V4 showed this surveyor an electronic mail (email) document showing R1's soft touch call light was ordered last 6/25/26 (six days after R1's admit). V4 said it had arrived yesterday and will be provided to R1 today.

Based on observation, interview, and record review, the facility failed to ensure a resident that is totally dependent on staff for Activities of daily living (ADL) care received showers and personal hygiene care. This failure effects 1 of 5 residents (R1) reviewed for ADL care in the sample of 9. The findings include:R1's face sheet shows he was admitted to the facility on [DATE], with diagnosis that includes paraplegia due to injury to C4 and C5 cervical spinal cord.R1's care plan dated 6/22/26 show, R1 has an alteration of neurological status related to quadriplegia/paralysis, self-care deficit, resident is dependent with ADL care, with intervention to provide total care for showers and hygiene.On 6/30/26 at 8:45 AM, R1 was in his room lying in bed. R1 said he was supposed to get a shower yesterday (6/29/26 Monday) and his hair washed but it was not done. R1 said he had been here at the facility since 6/19/26 and his hair had not been washed. R1 said his hair was so itchy. R1's hair was unkempt, greasy, oily with several white flaky substances noted throughout his hair.On 6/30/26 at 11:AM, V3 Certified Nursing Assistant (CNA) said R1's scheduled showers including hair wash were Friday PMs and Mondays PMs. V3 said R1's hair was so greasy consistent with not having been washed in days. V3 (CNA) said showers should be done as scheduled for the residents' cleanliness and comfort.On 6/30/26 at 3:45 PM, V2 (Nurse Manager) said residents should be provided with care including hair washed/showers. The Facility Policy entitled Resident shower (undated) shows it is the practice of this facility to assist residents with bathing to maintain proper hygiene stimulate circulation and help prevent skin issues as per current standard of practice.

Based on interview and record review the facility failed to ensure sufficient staffing was scheduled to provide resident cares. This applies to all 64 residents residing in the facility.The findings include:The facility provided a census report dated 5/17/26 showing 64 residents residing in the facility. The same census showed 30 residents residing on the first floor and 34 residents residing on the second floor.The facility's nursing and CNA (Certified Nursing Assistant) schedule and actual timecards for 5/10/26 were reviewed and showed V12 CNA as the only aide on the first floor from 6AM through 2PM. The facility's schedule and actual timecards for 5/8/26 showed V13 CNA was the only aide on the floor from 6PM through 10 PM.On 5/17/26 at 12:56 PM, R4 (Resident Council President) said they hold a resident council meeting monthly. R4 said the facility's lack of staffing is often the subject of discussion.R1's face sheet showed he was admitted to the facility 1/14/25 with diagnoses to include chronic obstructive pulmonary disease, partial traumatic amputation at level between knee and ankle, reduced mobility, acute respiratory failure with hypoxia, complete traumatic amputation of right shoulder and upper arm, major depressive disorder, superficial frostbite of other sites, hypothermia, and traumatic ischemia of muscle. R1's facility assessment dated [DATE] showed he has no cognitive impairment and dependent on staff for all cares. R1's Care Plan initiated 1/14/25 showed, Resident has a self-care deficit. 'Pair Care' (2 assist due to behaviors) needed for ADL (activities of daily living) assistance; 2 assist with turning and repositioning; . Resident is dependent with ADL care; provide total assistance in all aspects of hygiene/dressing; Resident is non-ambulatory; assist with wheelchair locomotion as needed; Toilet with 2 assist; Total assist with meals; Transfer with mechanical lift x 2. R1's care plan initiated 1/15/25 showed, Resident has amputation of right (above knee amputation), left (above knee amputation), right arm, left arm.On 5/17/26 at 10:59 AM, R1 was sitting up in bed. R1 had both arms and both legs amputated. R1 said, They use a [mechanical lift] for me, I don't really get up in the chair too much because it is uncomfortable and it's a pain in the butt to get me up. I use my call light. the time it takes to get answered depends a lot on the staffing. Lately it hasn't been as often, but a week ago, it was taking 30-45 minutes to get my call light answered. I am not satisfied with my care here. I have issues getting my showers. I received a shower last Monday but before that it was two weeks that I had to go without one. I pretty much had to force them to give me my shower. At times, there is just one CNA here. It happened just the other day. It was actually on Mother's Day (5/10/26). They told me there was only 1 CNA here. I need help getting the urinal and bedpan. I try to be as self-sufficient as possible, but I can't do much without arms and legs. I wear a brief, but I try to be continent but sometimes, I just can't hold it anymore.R2's face sheet showed he was admitted to the facility 12/11/23 with diagnoses to include chronic respiratory failure with hypoxia, hypertension venous insufficiency, lymphedema, atrial fibrillation, morbid obesity due to excess calories, fluid overload, cellulitis of right lower limb, bed confinement status, and bilateral localized swelling of lower limbs.R2's facility assessment dated [DATE] showed he has no cognitive impairment and is dependent on staff for toileting, showers, lower body dressing, and bed mobility. R1's care plan initiated 12/11/23 showed, The resident has incontinence of bladder and/or bowel. Administer appropriate cleansing # peri-care after each incontinent episode. R2's care plan initiated 12/11/23 showed, Resident has a self-care deficit. 2 assist with turning and repositioning; . uses bedpan as needed . R1's care plan initiated 3/3/25 showed, The resident is above ideal body weight range. Resident fits criteria for morbid obesity. current body weight 576 lbs.On 5/17/26 at 12:40 PM, R2 said they try and use 3 CNAs to provide his cares because of his large size. R2 said there are times there is just one CNA working the second floor and if he has a bowel movement and needs changed, they will tell him it is going to be a little bit because they are going to have to find someone from downstairs to come and help. R2 said it can take between 1 and 2 hours for someone to be able to come up and get him changed after a bowel movement on those days. R2 said this happens a couple of times a month that there is only one CNA scheduled for the entire second floor. On 5/17/26 at 9:23 AM, V9 CNA said, If someone calls off, we are just stuck. About once a week, we are asked to work up here with just 2 CNAs. This is a very heavy floor for care. It is very hard with 2.On 5/17/26 at 11:14 AM, V4 LPN (Licensed Practical Nurse) said there are times when there is only one CNA scheduled for the first floor. V4 said often, there is one CNA scheduled for the first floor and two on the second floor with one that is expected to float to the first floor to help out.On 5/17/26 at 1:45 PM, V13 CNA (Certified Nursing Assistant) said, I have worked by myself so many times. As far as I have been told, I'm not by myself because theres a nurse present. I've been back on the floor about 6 months now. When I first started, there was always 3 down here on the first floor, then there was 2, but it's been just me now for the whole first floor. The problem with that is, there are 5 residents down here who we use the [mechanical lift] for transfers, and you are supposed to have two people for the mechanical lifts, but when you are by yourself, you do what you do. On this floor, it's constant call lights, can't get charting done. There is a guy down here with no arms and no legs, we can't answer call lights on time, and there have been times that he has missed out on baths because we have been short-handed. The biggest issue is doing mechanical lifts by yourself. I don't know what they think we are doing. I just do them. Typical staffing now, is one first floor and one second floor, and if there is a 3rd person, they float. Usually, the upstairs aides get me for repositioning [R2], I'll be in the middle of something, but I'll go as soon as I'm done. They don't ask me very often because [R2] makes me hurt because he is so heavy. The weekends are the ones we have the most problems with because the girls want to leave at 6 PM so I end up by myself then. It's usually about 4 hours that I'm by myself. Two weekends ago, I really worked by myself. It used to always be two aides on each floor because then you could provide the resident's cares when they need them, not when you finally can get time to get to them.On 5/18/26 at 10:39 AM, V12 CNA said, I did have to work by myself last weekend on Sunday (5/10/26). Quite frankly, it was rough being the only aide on the floor. I asked for help and was told I would basically have to figure it out. It's challenging to get people up safely, get them down to meals, and it is really hard to get people fed. There are people who eat in their rooms that need to be physically fed and people in the dining room that need to be fed. I was trying to pull the nurse from her medication pass to get help with people who need 2 people to transfer. That was setting her back as well. I couldn't do showers. I'm being honest. On my weekends, they basically schedule 2 CNAs on the second floor and 1 CNA on the first floor. They put other people on the schedule and then both parties are saying there was a miscommunication when people aren't showing up. We have people that take 3 people to turn and reposition because they are quite large. I wouldn't say that there have been injuries from people getting transferred without the right number of staff, but I would say there are falls because people are just transferring themselves because it takes us so long to get to them when they need care.On 5/17/26 at 12:14 PM, V11 (Social Services) said, I was the manager on duty last weekend. They usually like to run 3 CNAs upstairs and 2 downstairs. Sometimes they will staff 2 upstairs and 2 downstairs. It all depends on census.On 5/17/26 at 12:25 PM, V1 (Administrator) said, Typically we schedule 2-3 upstairs and 1-2 downstairs for day shift and evening shift and on night shift, we schedule 2 upstairs and 1 downstairs.The facility does not have a staffing policy and procedure. The Resident Right's Booklet for People Living in Long Term Care facilities with revision date of 11/18 showed, . Your facility must provide services to keep your physical and mental health, at their highest practical levels.

Based on observation, interview, and record review the facility failed to provide shower assistance for residents who are dependent upon staff for assistance. This applies to 2 of 3 residents (R1, R2) reviewed for Activities of Daily Living in the sample of 4. The findings include:1. R1's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disorder (COPD, chronic lung disease), seizures, legal blindness, schizophrenia, and depression. R1's 4/13/26 Quarterly Minimum Data Set (MDS) showed moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 out 15. The MDS showed she was dependent upon staff shower showering. On 5/6/26 at 11:49 AM, V12, V13, and V14 Certified Nursing Assistants stated they were unable to complete showers when only two CNAs were assigned to the first floor, which is the typical number of CNAs. V14 then stated R1 and R2 have not received their showers for a couple of weeks. On 5/6/26 at 1:04 PM, R1 stated I've been having trouble with my showers. R1 stated her shower days are Monday and Friday mornings. R1 said, Let's see .so today is Wednesday so I did get a shower on Monday, but before that, it's been a while. It does happen where I don't get a shower on either Monday or Friday. I don't think two showers a week is asking too much. It just happened a couple of weeks ago where I didn't get a shower the entire week. They tell me they can't do it because they are too busy. They will do a bed bath instead, but it's not the same. I don't think you get as clean and they don't wash my hair. The shower is also relaxing; I like the warm water running over me it just feels good. I've had problems with not getting my showers quite a bit lately. I have been a resident here since 2018 and I have noticed some changes in staffing, but it's been okay. I would say the staff can be lazy and they could work a little harder. The showers are great if you could just get them to do it, they just don't seem like they want to do it. On 5/6/26 at 1:45 PM, V1 Administrator stated there are no shower sheets and the staff document showers in the electronic health record system. V1 provided a one-month shower history for R1. R1's Shower history showed from 4/6/26 through 5/6/26 showers were provided on 4/10/26, 4/27/26, and 5/4/26. The record showed a refusal on 4/19/26. (9 showers should have been provided during this time per the residents requested two showers per week.) On 5/7/26 at 5:15 AM, V3 Director of Nursing (DON) stated showers are once or twice per week depending on resident preferences. V3 said showers can be therapeutic and hygienic. V3 said it can feel good to have the water flow over you; it feels good both mentally and physically. The facility's Resident Shower policy (undated) showed, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice .Residents will be provided with showers as per request or as per facility schedule protocols and based up resident safety . 2. R2's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disorder (COPD, chronic lung disease), diabetes, and bipolar disorder. R2's 3/28/26 Quarterly Minimum Data Set (MDS) showed moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 11 out 15. The MDS showed she required substantial/maximal assistance for showering. On 5/6/26 at 11:49 AM, V12, V13, and V14 Certified Nursing Assistants stated they were unable to complete showers when only two CNAs were assigned to the first floor, which is the typical number of CNAs. V14 then stated R1 and R2 have not received their showers for a couple of weeks. On 5/6/26 at 12:50 PM, R2 was in her wheelchair in her room. R2's hair was combed; however, it appeared greasy and unwashed. On 5/6/26 at 12:50 PM, R2 stated I'm supposed to get a shower at least once a week, but I haven't gotten one in a couple of weeks. My shower day is Wednesday in the evening. Sometimes they tell me I'm not getting a shower, and they tell me the reason I'm not getting a shower is because they are short of help. I have gotten a bed bath, but I prefer the shower and when they do the bed bath, I don't get my hair washed. I prefer a shower. I like the water running over me; I feel more clean and my hair gets cleaned. This has been going off and on for quite a while now. On 5/6/26 at 1:45 PM, V1 Administrator stated there are no shower sheets and the staff document showers in the electronic health record system. V1 provided a one-month shower history for R1. R1's Shower history showed a refusal on 4/22/26 and a bed bath was provided no other showers were documented as being done/offered after this date. On 5/7/26 at 5:15 AM, V3 Director of Nursing (DON) stated showers are once or twice per week depending on resident preferences. V3 said showers can be therapeutic and hygienic. V3 said it can feel good to have the water flow over you; it feels good both mentally and physically. The facility's Resident Shower policy (undated) showed, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice .Residents will be provided with showers as per request or as per facility schedule protocols and based up resident safety .

Based on observation, interview, and record review, the facility failed to provide effective pain management to a resident with phantom pain in all 4 amputated extremities. This failure resulted in R1 having severe pain from 1/31/26 to 2/6/26 when he missed 11 doses of medication. This applies to 1 of 3 residents (R1) reviewed for pain management in the sample of four.The findings include:On 2/11/26 at 7:32 AM, R1 was in his room in bed on his back with head of his bed elevated. R1 had all 4 extremities amputated. R1 had a tray table in front of him with personal items on it. R1 stated he was without his pain medication for 4 days and was told that they couldn't get it from the pharmacy. R2 stated he was in a lot of pain. He stated his pain was a 10/10 on the pain scale. R1 stated his amputation sites (all 4 extremities) felt like they were on fire. R1 stated he was given Tylenol, but he was still very uncomfortable, and it was very unpleasant. R1 stated he has chronic pain but when the shooting pains start and he feels like he is on fire that is the worst. R1 stated he watches to see that the nurses give him his pain medication.The Medication Administration Record dated January 2026, and February 2026 showed the last dose of his Oxycodone 5 MG that was to be given twice a day was at bedtime on 1/31/26. The next dose he received was on 2/6/26. R1 missed 11 doses of pain medication.The February 2025 Medication Administration Record - MAR for R1 was reviewed and showed on 2/1, 2/3, 2/4 and 2/5 he did not receive Oxycodone 5 MG by mouth twice a day. The MAR showed on 2/2 that V8 RN (Registered Nurse) signed off that she gave the medication in the morning and V10 LPN (Licensed Practical Nurse) gave the medication at bedtime however the medication was not available.On 2/10/26 at 3:00 PM, R1's February 2025 MAR was reviewed with V8, and she stated she signed out his Oxycodone as given on 2/2/26 in error. It was not given; he did not have any available.On 2/11/26 V7 LPN stated she worked on 2/6/26 and R1 did not have Oxycodone. V7 stated the nurse before her documented a 9 on the MAR which meant R1 did not get the medication. V7 stated she thought R1 had run out of medication, so she went to the medication dispensing machine to get a dose of the medication. V7 stated the machine will prompt you to get a code from pharmacy. V7 stated she called the pharmacy and was asked if his Oxycodone order had changed. They went over his medication order and it wasn't changed and was the same as what was on file at the pharmacy. The pharmacist told her that R1 should have 16-20 pills left. V7 stated her access was denied by pharmacy until management was notified. V7 stated she notified the Director of Nursing. V5 - [NAME] President of Operations was contacted and she called pharmacy, and they told her on 1/17/26 there were two Oxycodone cards sent with 30 pills in each card, so they sent 60 pills.On 2/11/26 at 9:48 AM, V5 stated on 1/16/26 R1 had 2 cards of Oxycodone delivered and each card contained 30 tablets. V5 stated they are missing one of the Oxycodone cards. On 2/17/26 at 11:56 AM, V3 Director of Nursing - DON stated they use a numeric pain scale in the facility for residents that can rate their pain. The scale is from 0-10 with zero being no pain and 10 severe pain/crying etc. It is the worst pain on the scale. V3 stated for residents that cannot give a number they look at nonverbal s/s (signs and symptoms) such as facial grimaces, moaning, squinting etc. V3 stated it was a concern for R1 to receive his medication as ordered to manage his pain. V3 stated they don't want R1's pain to become out of control because it can affect his quality of life.On 2/17/26 at 1:01 PM, V17 Nurse Practitioner - NP stated R1 has phantom pain, neuropathy, and back pain and that is why he has pain medication. It is important for him to have the medication and to receive it as ordered because it can lead to other medical problems and can affect his quality of life. R1's Minimum Data Set - MDS dated [DATE] showed no impairment of memory and he is cognitively intact.The Care Plan dated 1/14/26 for R1 showed resident is at increased risk for alteration in pain/discomfort. Resident has scheduled and as needed medications ordered. Administer medications as ordered.The Face Sheet dated 2/10/26 for R1 showed diagnoses including chronic obstructive pulmonary disease, major depressive disorder, alcohol abuse, hypertension, hyperlipidemia, hypothermia, superficial frostbite, traumatic ischemia of muscle, homelessness, nicotine dependence, lower leg partial traumatic amputation below knee, reduced mobility, acute post hemorrhagic anemia, hypokalemia, disorders of phosphorus metabolism, type 2 diabetes mellitus, acute respiratory failure with hypoxia, mild protein calorie malnutrition, and traumatic amputation.The facility's Pain Management and Assessment policy and procedure (1/2026) showed it is the policy of the facility to assess the resident for the presence of pain in order to determine the appropriate interventions purpose - To develop a standardized method for assessing, monitoring, evaluating and documenting pain in both cognitively intact and impaired residents. Residents will receive necessary comfort, exercise greater independence, and enhance dignity through optimizing their ability to perform activities of daily living. If pain is not relieved, give further medication as the physician ordered. If there are no orders, notify the physician of assessment results and obtain an order.

Based on Observation, Interview, and Record Review the facility failed to prevent the misappropriation of resident's narcotic medication for three of three residents (R1, R2 & R3) reviewed for misappropriation of resident's property in the sample of four. The findings include:1. The Controlled Drug Receipt/Record/Disposition form dated 11/25/25 for R1 showed it was for Oxycodone 5 MG dose, 30 tablets, take 1 tablet by mouth daily as needed for pain. The form showed on 12/12/24 he had 4 tablets left. On 12/13/25 there were 2 tablets left with no documentation between the two dates to show administration. There was a note written on the sheet on 12/13/25 saying DON (Director of Nursing) aware and it was initialed by V7 Licensed Practical Nurse – LPN and V8 Registered Nurse – RN. On 2/11/26 V7 LPN stated in December 2025 there was an incident where she was coming in and switching with the night nurse, V10 LPN and the count for R1's Oxycodone was off. On the sheet there were 4 marked as being left and then they counted the medication and there were only two left instead of 4. The count went to 2 without showing where 2 pills went. V7 stated V10 couldn't come up with a reason as to why it was like that or where the pills went. V7 stated V10 then said she must have given him two pills which did not make sense. V7 stated she worked on 2/6/26 and R1 did not have Oxycodone. V7 stated the nurse before her documented a 9 on the MAR which meant R1 did not get the medication. V7 stated she thought R1 had run out of medication, so she went to the medication dispensing machine to get a dose of the medication. V7 stated the machine will prompt you to get a code from pharmacy. V7 stated she called the pharmacy and was asked if his Oxycodone order had changed. They went over his medication order and it wasn't changed and was the same as what was on file at the pharmacy. The pharmacist told her that R1 should have 16-20 pills left. V7 stated her access was denied by pharmacy until management was notified. V7 stated she notified the Director of Nursing. V5 - [NAME] President of Operations was contacted and she called pharmacy, and they told her on 1/17/26 there were two Oxycodone cards sent with 30 pills in each card, so they sent 60 pills. The February 2025 Medication Administration Record - MAR for R1 was reviewed and showed on 2/1, 2/3, 2/4 and 2/5 he did not receive Oxycodone 5 MG by mouth twice a day. The MAR showed on 2/2 that V8 RN signed off that she gave the medication in the morning and V10 LPN gave the medication at bedtime however the medication was not available. On 2/10/26 at 3:00 PM, R1's February 2025 MAR was reviewed with V8, and she stated she signed out his Oxycodone as given on 2/2/26 in error. It was not given; he did not have any available. On 2/10/26 at 1:14 PM, V5 [NAME] President of Operations stated last Friday (2/6/26) she was notified that R1 was missing oxycodone, so she started an investigation. V5 stated the missing oxycodone would be considered misappropriation of resident property. On 2/11/26 at 7:32 AM, R1 was in his room in bed on his back with head of bed elevated. R1 had all 4 extremities amputated. R1 had a tray table in front of him with personal items on it. R1 stated he was without his pain medication for 4 days and was told that they couldn't get it from the pharmacy. R2 stated he was in a lot of pain. He stated his pain was a 10/10 on the pain scale. R1 stated his amputation sites (all 4 extremities) felt like they were on fire. R1 stated he was given Tylenol, but he was still very uncomfortable, and it was very unpleasant. R1 stated he has chronic pain but when the shooting pains start and he feels like he is on fire that is the worst. R1 stated he watches to see that the nurses give him his pain medication. On 2/11/26 at 9:48 AM, V5 stated on 1/16/26 R1 had 2 cards of Oxycodone delivered and each card contained 30 tablets. V5 stated they are missing one of the Oxycodone cards. The Face Sheet dated 2/10/26 for R1 showed diagnoses including chronic obstructive pulmonary disease, major depressive disorder, alcohol abuse, hypertension, hyperlipidemia, hypothermia, superficial frostbite, traumatic ischemia of muscle, homelessness, nicotine dependence, lower leg partial traumatic amputation below knee, reduced mobility, acute post hemorrhagic anemia, hypokalemia, disorders of phosphorus metabolism, type 2 diabetes mellitus, acute respiratory failure with hypoxia, mild protein calorie malnutrition, and traumatic amputation. The facility's Abuse Prevention Program Facility Policy and Procedure (10/2023) showed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. The policy did not show the definition of misappropriation of resident property. 2. The January 2026 MAR for R2 showed on 1/1 at 7:37 AM, 1/3 at 6:58 AM, 1/4 at 11:53 PM and 1/13 at 7:15 AM he was given hydromorphone 4 MG by either V8 RN or V10 LPN. There wasn't a Controlled Drug Receipt/Record/Disposition Form for R2 for the administration and reconciliation of the hydromorphone 4 MG given in January 2026. The Proof of Delivery List Report (pharmacy manifest) for R2's controlled medication showed on 12/3/25 there were two cards (card 1 and 2) of hydromorphone 4mg of 30 tabs in each card were delivered. The Controlled Drug Receipt/Record/Disposition Form (narcotic count sheet) was missing for card 1. On 2/11/26 at 7:40 AM, R2 was in his room sitting up in bed and watching TV. R2 stated he tries to stay away for the oral narcotic pain medication because he doesn't like how it makes him feel. R2 stated he used to take the hydromorphone, but he stopped taking that in December 2025. R2 stated he takes Tylenol if he has more pain than usual. R2 stated he takes gabapentin, has a fentanyl patch, and lidocaine patch. R2 stated he has Ultram but doesn't use that either. On 2/11/26 at 9:48 AM, V5 [NAME] President of Operations stated she was not aware of any medication problems for R2. V5 reviewed the January 2026 MAR for R2 and confirmed V8 and V10 were the only nurses that gave R2 the hydromorphone. On 2/12/26 at 3:45 PM, R2 confirmed again that he did not receive Hydromorphone doses in January 2026. The Minimum Data Set, dated [DATE] for R2 showed he is alert, oriented, and cognitively intact. The Face Sheet dated 2/12/26 for R2 showed diagnoses including pathological fracture in neoplastic disease, tortuous aortic arch, acute kidney failure, degenerative disc disease, anemia, nicotine dependence, interstitial pulmonary disease, multiple myeloma, respiratory bronchiolitis interstitial lung disease, calculus of gallbladder, calculus of bile duct, sepsis, paroxysmal a fib, encounter for palliative care, anemia in chronic kidney disease, cardiomegaly, and morbid obesity. 3. R3's face sheet shows she was admitted to the facility on [DATE] with multiple diagnoses including pressure ulcer of sacral region, stage 4. R3's December 2025 MAR shows an order for Morphine Sulfate ER Extended Release 1 tablet by mouth twice daily for severe pain. The order was discontinued on 12/10/25. A new order for Morphine Sulfate ER 30 mg tablet three times a day was started on 12/30/25. R3's controlled drug receipt/record/disposition form for Morphine sulfate tablets 15 mg ER documents 30 tablets were dispensed on 11/16/25. The record shows on 12/31/25 at 9:00 AM, V8 signed out 2 tablets noting in parenthesis R3's order increased from 15 mg to 30 mg and marked error-not given. The entire line on the record is crossed off, leaving the count at 20. The next line shows V8 signing 1 tablet out for the same day, with an earlier time of 7:00 AM. The card was destroyed with 19 tablets. R3's Morphine Sulfate ER 30 mg tablet-controlled drug sheet shows on 12/31/25, V8 also signed out 1 tablet at 9:00 AM. On 2/13/26 at 3:00 PM, V5 said controlled medications should not be signed out after they have been discontinued. R3's manifest list of controlled medications, shows on 11/7/25, Hydrocodone/APAP 5-325 mg tablets, Rx number 11358133/001 and 002, each card with 30 tablets, 60 tablets in total. The controlled drug receipt record forms were requested, and the facility could not provide any documentation of receipt or destruction of the 60 tablets.

Based on interview and record review the facility failed to notify the Illinois Department of Public Health and local law enforcement immediately of misappropriation of resident property for 1 of 4 residents (R1) reviewed for misappropriation of resident property in the sample of four.The findings include:The facility's Initial Report to Illinois Department of Public Health (IDPH) Regional office was dated 2/10/26 and showed the facility noted a discrepancy in residents' hydrocodone (narcotic medication) on 2/6/26; investigation initiated.The facility's Investigation: Unaccounted for Controlled Medication 2/6/26 showed V1 Administrator was notified on 2/2/26 that R1's oxycodone could not be refilled by pharmacy because it would be refilled too soon. V1 began an investigation for a potentially missing card of oxycodone. V1 did not locate the card. On 2/10/26 IDPH began an investigation into controlled drug diversion. The local law enforcement was notified on 2/10/26.On 2/10/26 at 1:14 PM, V5 [NAME] President of Operations stated last Friday (2/6/26) she was notified that R1 was missing oxycodone, so she started an investigation. V5 stated the missing oxycodone would be considered misappropriation of resident property. V5 stated it was not reported to IDPH and should have been. V5 stated the police were not notified and should have been.On 2/11/26 at 9:48 AM, V5 stated that she has discovered that there is an entire card (30 pills) of Oxycodone 5 MG tablets for R1.On 2/17/26 at 11:45 AM, V1 Administrator stated they are to immediately report theft to IDPH and the police.The facility's Abuse Prevention Program Facility Policy and Procedure (10/2023) showed .Informing local law enforcement. The facility shall also contact local law enforcement authorities (i.e., telephone 911 where available or the non-emergency number) in the following situations: When there is reasonable suspicion that a crime has been committed in a facility by a person other than a resident.

Based on interview and record review the facility failed to ensure there was a system in place to assure accurate receipt, dispensing, administration, and reconciliation of controlled substances for 3 of 4 residents (R1, R2, & R3) reviewed for pharmacy services in the sample of 4.The findings include:1. The Proof of Delivery List Report (pharmacy manifest) for R1 showed Oxycontin 5 MG was ordered on 1/16/26 and delivered on 1/17/26. There were 2 cards delivered with 30 pills in each card. The cards were to have Controlled Drug Receipt/Record/Disposition Forms with each card. Card 1 had form 1 and card 2 had form 2. The facility had the Controlled Drug Receipt/Record/Disposition Form dated 1/16/26 form 1 with the Oxycontin 5 MG (milligram) card number 2. The Controlled Drug Receipt/Record/Disposition Form dated 2 dated 1/16/26 and the Oxycontin 5 MG card 1 were missing. On 2/11/26 at 9:48 AM, V5 [NAME] President of Operations stated what she found for R1 is that he had two cards of oxycontin 5 MG delivered on 1/16/26 with 30 tablets in each card. The cards are labeled card 1 and card 2; the narcotic sheet is labeled sheet 1 and sheet 2. The correct sheet is to go with the correct card. Staff pull a label and put it on the card, and everything should match. V5 stated they are missing sheet two and card one of the oxycontin. The right label and card should be with the right sheet. V5 stated it is not a policy; it is just what they are supposed to do. V5 stated there is a missing card of oxycontin. V5 stated she found out that extra medications from the medication cart were being put in the medication cupboard in the medication room and staff were told it is not good practice. V5 stated she told staff she knows they are not counting the medications in the cupboard in the medication room at shift change so those medications are not being accounted for as they should be. The Controlled Drug Receipt/Record/Disposition Forms dated 10/24 25 and 11/8/25 for R1's Oxycodone 5 MG tablets showed on 11/1 at 9:00 AM & 9:30 PM; 11/3 at 9:00 AM; 11/4 at 9:10 AM & 9:00 PM; 11/5 at 9:30 AM; 11/6 at 9:00 AM & 9:30 PM; 11/8 at 8:00 AM; 11/9 at 8:00 AM; 11/10 at 9:00 AM; 11/11 at 8:15 AM; 11/12 at 4:00 AM and 12:00 AM; 11/13 at 8:00 AM; 11/14 at 8:57 AM; 11/15 at 8:30 AM & 9:00 PM; 11/16 at 9:00 PM; 11/17 at 8:15 AM; 11/19 at 8:15 AM; 11/20 at 9:00 AM; 11/21 – no time documented; 11/22 at 9:00 AM; 11/23 at 9:00 AM; 11/24 at 8:50 AM; and 11/25 at 8:00 AM these doses were subtracted on the form but not documented as given on R1's November 2025 Medication Administration Record (MAR). The Face Sheet dated 2/10/26 for R1 showed diagnoses including chronic obstructive pulmonary disease, major depressive disorder, alcohol abuse, hypertension, hyperlipidemia, hypothermia, superficial frostbite, traumatic ischemia of muscle, homelessness, nicotine dependence, lower leg partial traumatic amputation below knee, reduced mobility, acute post hemorrhagic anemia, hypokalemia, disorders of phosphorus metabolism, type 2 diabetes mellitus, acute respiratory failure with hypoxia, mild protein calorie malnutrition, and traumatic amputation. The facility's Controlled Substance Storage policy (10/25/2014) showed the Director of Nursing in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses. Any discrepancy in controlled substance count is reported to the director of nursing and pharmacy immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator. Controlled substance inventory is regularly reconciled to the medication administration record and forms: Controlled Substance Count Record. Current controlled substance accountability records are kept in the MAR, or designated book. Completed accountability records are submitted to the director of nursing and kept on file for 5 years at the facility. 2. The November 2026 Controlled Drug Receipt/Record/Disposition Form for R2's hydromorphone HCL 4 MG tablet was reviewed. It showed to take 1 tablet by mouth, twice daily scheduled; take 1 tablet by mouth twice a day as needed. The form had a sticker on the side of it that showed this was for 2 of 2 cards that were received. The facility received 2 cards of the medication with 30 tablets in each card on 11/6/25. The form started on 11/8/25 at 9:30 PM and the last dose for this card was given on 11/18/25 at 5:20 AM. The form was compared to R2's November 2025 Medication Administration Record and showed the November 2025 Controlled Drug Receipt/Record/Disposition Form for R2 had 6 hydromorphone HCL tablets total signed out as given to the resident but R2's November 2025 MAR did not reflect the administration of the medication. The medication was signed out on 11/11 at 5:30 PM; 11/12 at 7:00 AM, 11:45 AM, and 5:30 PM; 11/13 at 8:15 AM, and 1:00 PM that were not documented as being given to the resident on the MAR. There wasn't a Controlled Drug Receipt/Record/Disposition Form for R2 for the other card hydromorphone HCL 4MG, 30 tablets that was delivered to the facility on [DATE]. The Controlled Drug Receipt/Record/Disposition Form for R2's hydromorphone HCL 4 MG tablet showed there were 2 cards delivered on 12/2/25 and this sheet was started on 12/10/25 and went through 12/29/25. The medication administered according to this form was compared to R2's December 2025 MAR and showed 9 pills were shown as being administered to R2 on the Controlled Drug Receipt/Record/Disposition form but were not signed out as being given to the resident on his December 2025 MAR. There wasn't a Controlled Drug Receipt/Record/Disposition Form for R2 for the other card of hydromorphone HCL 4MG, 30 tablets that was delivered to the facility on [DATE]. The January 2026 MAR for R2 showed on 1/1 at 7:37 AM, 1/3 at 6:58 AM, 1/4 at 11:53 PM and 1/13 at 7:15 AM he was given hydromorphone by two nurses. There wasn't a Controlled Drug Receipt/Record/Disposition Form for R2 for the administration and reconciliation of this medication. The delivery manifest from the pharmacy for R1's controlled medications showed Hydromorphone HCL 4 MG tablets were delivered on the following dates: on 11/6/25 one card of 30 pills and a second card with 30 pills; on 12/2/25 one card of 30 pills and a second card of 30 pills.; on 12/19/25 one card with 30 pills and a second card with 30 pills; 1/30/26 one card with 30 pills; and 2/7/26 one card with 30 pills. The Controlled Drug Receipt/Record/Disposition forms that the facility had for R1 were for the 11/6/25 second card; the 12/2/25 second card; and 2/7/26 current card of pills. The rest of the forms could not be located. On 2/13/26 at 2:20 PM, V5 [NAME] President of Operations stated pharmacy doesn't do reconciliation of narcotics. They look at current medications and narcotics but not previous medications. The clinical managers would do that. Typically, it would be the DON (Director of Nursing) and she is new. They typically do random audits and pick a sample of residents to review to look at the count sheets with the MAR and medications. This is typically done monthly. The pharmacy sends manifests every day. There isn't a policy for this, it is just what is preferred to be done. We also would do it if there was a concern about medications. On 2/17/26 at 11:52 AM V5 stated she spoke with V15 Registered Nurse/previous DON and she said that she was doing the audits (manifest, narcotic, sheets and MARS). V5 stated she told V15 if she had been doing them, she would have caught this problem and that is why that process was put in place. V5 said V15 would not commit one way or another on it during the interview. No records were available for the audits. 3. R3's face sheet shows she was admitted to the facility on [DATE] with multiple diagnoses including pressure ulcer of sacral region, stage 4. R3's December 2025 MAR shows an order for Morphine Sulfate ER Extended Release 1 tablet by mouth twice daily for severe pain. The order was discontinued on 12/10/25. A new order for Morphine Sulfate ER 30 mg tablet three times a day was started on 12/30/25. R3's controlled drug receipt/record/disposition form for Morphine sulfate tablets 15 mg ER documents 30 tablets were dispensed on 11/16/25. The record shows on 12/31/25 at 9:00 AM, V8 signed out 2 tablets noting in parenthesis R3's order increased from 15 mg to 30 mg and marked error-not given. The entire line on the record is crossed off, leaving the count at 20. The next line shows V8 signing 1 tablet out for the same day, with an earlier time of 7:00 AM. The card was destroyed with 19 tablets. R3's Morphine Sulfate ER 30 mg tablet-controlled drug sheet shows on 12/31/25, V8 also signed out 1 tablet at 9:00 AM. On 2/13/26 at 3:00 PM, V5 said controlled medications should not be signed out after they have been discontinued. R3's manifest list of controlled medications, shows on 11/7/25, Hydrocodone/APAP 5-325 mg tablets, Rx number 11358133/001 and 002, each card with 30 tablets, 60 tablets in total. The controlled drug receipt record forms were requested, and the facility could not provide any documentation of receipt or destruction of the 60 tablets.

Based on observation, interview and record review the facility failed to ensure social services assisted residents with discharge services. This applies to 2 of 3 residents (R1, R2) reviewed for social services in the sample of 3. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] with diagnoses including seizures, schizoaffective bipolar, post traumatic dress disorder, suicidal ideations, poisoning by unspecified drugs, medicaments and biological substances, intentional self-harm, unspecified mood (affective) disorder, and epilepsy.On 1/28/26 at 9:32 AM, R1 said she would like to be discharged to a place similar where she used to live. R1 said V4 (Social Services) was trying to find a place for me but has not told me what's going on. V4 said no one will accept me if I'm lying. On 1/28/26 at 12:05 PM, V4 said she has been at the facility for less than one year. R1 was admitted from the hospital and was living at residential group home setting. V4 said R1 lost her apartment since she has been at the facility. The previous home said they would not accept her back and did not give a reason. V4 said today she called developmental disability homes for placement and said they can take R1 when she is able to walk. V4 said R1 recently started walking. V4 said discharge planning should be initiated on admission and documentation should be in the resident's record. On 1/28/26 at 12:38 PM, V5 (RN-Registered Nurse) said R1 is a young resident with mental health needs. She needs to be placed where she can receive mental health services, be involved with groups and residents her own age. R1 is walking with her walker, she wants to use a wheelchair, but she is fully capable of ambulating. The staff are not trained for taking care of psych residents. On 1/28/26 at 10:51 AM, V1 (Administrator) said R1 has a history of mental health, substance abuse, and manipulative behaviors. R1 had been in a group home prior to admission and said they are trying to find placement for her. On 1/28/26 at 1:34 PM, V8 (Psych Nurse Practitioner) said due to R1's psych history she would benefit being in environment that specializes in psych services, providing group, individual therapy and being with residents around her age. R1's Social Services note dated 12/5/25 shows R1 would like to live in a place like she did before she got sick and went to the hospital and was admitted to the facility. R1 expressed she wanted to be placed in a group-like setting where she can have her own room, and staff would help with needs and go on trips. R1's Social Service notes from September 2025 to January 27,2026 show no documentation regarding discharge planning and there is no documentation showing group homes/facilities have been contacted for discharge placement.R1's current care plan shows discharge planning needs to be continually assessed but the IDT team placement continues to be temporary as (R1) verbalizes the desire to return to community/group setting. Interventions include social service will assist to find resident/group setting as requested. 2. R2's face sheet shows he was admitted on [DATE] from acute care hospital with diagnoses including unspecified cirrhosis of liver, alcohol abuse, restless leg, insomnia and major depressive disorders.On 1/28/26 at 9:30 AM, R2 was in his room. He said he came to the facility about a year ago from the hospital. R2 said he is independent with care and walks independently. R2 said there has been discussion about finding alternative placement for him. On 1/29/26 at 12:05 PM, V4 (Social Services) said R2's plan is for him to stay at the facility. He gets defensive when asking about discharge planning. R2 is not receiving therapy and confirmed he is independent with his needs. On 1/28/26 at 10:51 AM, V1 (Administrator) said R1 is young male resident, goes out on pass independently, he has reported he is at peace and complacent here. What can we do, R2 has nowhere to go. On 1/29/26 at 2:45 PM, V3 (Regional Nurse Consultant) said discharge planning should be started on the day of admission and updated/care planned in the resident's record. V3 confirmed there was no documentation of R1 and R2's discharge planning or attempts to find alternative placement. R2's Social Service note dated 11/9/25 documents, he is alert and oriented, able to communicate verbally his needs, ambulated independently using a walker, is a smoker, goes out of the facility has an independent community pass. R2's Social Service notes requested from November 2025 to January 2026 shows no documentation for discharge planning. R2's current care plan shows he is here for short term rehab; he makes his own decisions and is independent with activities. R2 discharge care plan shows he has extensive care needs and requires long term care setting. R2's preference is not to be asked about discharge planning. The facility's Discharge Planning dated January 2020, states, To identify appropriate candidates for inclusion in active discharge planning, to facilitate the transition to a less structured environment/or resident/decision-maker transfer requests to another facility of choice and to coordinate adequate supportive community care services.To assure the involvement of the Social Work staff in assessing discharge potential, transfer requests, documenting significant information related to discharge and coordinating community health care services.

Based on observation, interview and record review, the facility failed to prevent and supervise a resident from ingesting cannabis and failed to ensure a residents community pass privileges were re-assessed for safety. This applies to 2 of 3 residents (R1, R2) reviewed for safety in the sample of 3. The findings include: 1. On 1/28/26 at 8:25 AM, a sign posted at the reception desk Stated SAFETY AND SECURITY NOTICE To Protect the safety and well-being of all residents, personnel and visitors. To ensure the safety all reasonable inspections of personal items or property may be conducted when there is a reasonable cause or concern for the presence of prohibited or unsafe items such as weapons, illegal substances, alcohol and contraband.dated 12/2/25. R1's face sheet shows she has diagnoses including seizures, schizoaffective bipolar, post traumatic dress disorder, suicidal ideations, poisoning by unspecified drugs, medicaments and biological substances, intentional self-harm, unspecified mood (affective) disorder, and epilepsy.R1's hospital records dated 1/21/26 documents (R1) apparently seemed to be more confused and was slurring her words. She had problems with suspicious drug use in the past and has been caught using drugs at the facility within the facility on two separate occasions per report. (R1's) urine tox (toxicity) screen was positive for marijuana.(R1) says she may have taken some gummies or something which caused her mental status changes. On 1/28/26 at 9:32 AM, R1 was in her room, she said she was sent out to the hospital recently. R1 said she was getting gummies from R2. On 1/28/26 at 9:19 AM, V7 (Certified Nursing Assistant) said on 1/20/26, R1 was not acting herself, she was very lethargic and did not seem right. She notified V5 (RN) of R1's change of behavior. V7 said there are rumors of residents using illegal substances in the facility, but she hasn't seen any residents have illegal substances. V7 said management did not discuss why the sign was posted about substances or contraband in the facility. On 1/28/26 at 9:19 AM, V6 (CNA) said you hit the nail on the coffin when asked about substances in the facility. V6 said she's heard of rumors but has not seen it herself. On 1/28/26 at 10:23 AM, V2 (Director of Nursing-DON) said she was not aware of any residents using substances at the facility. V2 said R1 has history of substance abuse, she has tested positive for THC and she is not sure how she is getting the substance. R1 goes out on supervised visits. If we suspect a resident to be under the influence, we can get an order for urine drug screen. On 1/28/26 at 10:51 AM, V1 (Administrator) said R1 reported she had gotten gummies from another resident. R1 has manipulative behavior with a history of substance abuse. R2 denied giving the gummies to R1. On 1/28/26 at 12:38 PM, V5 (RN) said on 1/20/26 she was R1's nurse. R1 was not acting right, she was sent out to the hospital and tested positive for THC again. She is not sure how or who she is getting the substances from. R1 goes out on supervised visits with her mom. R1 has behaviors of manipulation and goes into R2's room. V5 said she re-directs R1 back to her room when she is trying to go into R2's room. R1 has no reason to go into R2's room. On 1/29/26 at 9:30 AM, R2 was in his room, he denied giving R1 gummies and said he goes out to the community independently. R1's Urine Drug Screen dated 1/14/25 shows she tested positive for cannabis. R1's current care plan does not include she has a history of substance abuse. R2's face sheet shows he has diagnoses including unspecified cirrhosis of liver, alcohol abuse, restless leg, insomnia, and major depressive disorders.R2's Physician Order Sheets dated January 2026 shows orders dated 12/1/25 for a urine drug screen. R2's nurses note dated 12/15/25 documents on multiple occasions (R2) was asked to provide a urine specimen for ordered urine drug screen. (R2) would either be out of the building or stated each time he was not able to urinate. R2's EHR (electronic health record) shows the urine drug screen was not collected. R2's Community Survival Skills assessment dated [DATE] shows he is capable of outside pass privileges. 2. On 1/29/26 at 9:30 AM, R2 was in his room; he said he goes out to the community independently. R2 admitted to consuming alcohol on occasion when he is out because he has problems sleeping. R2 said he can leave the facility when he pleases and denied using substances while at the facility. On 1/28/26 at 9:19 AM, V7 (Certified Nursing Assistant) said R2 does his own thing, he just does whatever he wants. R2 does not have any restrictions, he can leave the facility by himself. On 1/28/26 at 12:38 PM, V5 (RN) said R2 is young male resident, refuses some of his medications and leaves the facility when he wants. V5 said she has heard R2 goes out to the bars and drinks. On 1/28/26 at 1023 AM, V2 (DON) said R2 is independent, goes out on pass and does not need to be supervised. R2 does his own thing. Denies R2 having behaviors, she was not aware of R2 refusing medications or having any concerns with using substances at the facility. On 1/28/26 at 12:05 PM, V4 (Social Services) said she does the community assessment to determine if a resident is safe to go out on pass independently. If a resident violates the pass privileges, they should not be able to go out independently. R2 can leave the facility interpedently and she is not aware of R2 using substances while at the facility.On 1/29/26 at 1:34 PM, V8 (Psych Nurse Practitioner) said R2 has a history of alcohol abuse and confirmed he refused to be drug tested. V8 said she has shared her concerns with R2's use of substances with the facility. R2's Psychiatry Note dated 1/12/26 shows he is frustrated about insomnia. R2 is currently using illicit substances such as ETOH (Alcohol) and possibly cocaine. He has been refusing to provide a urine sample for drug screening.staff report he is exhibiting odd behaviors and been verbally aggressive towards staff. R2's Psychiatry Note dated 12/15/25 shows he is frustrated because he is still not sleeping well at night. R2 refusing his antipsychotic because he is not sure why it was ordered. The urine drug screen that was ordered since last visit due to refusal. It is possible that he has been using substances such as ETOH, cocaine and marijuana during community passes. R2's Community Survival Skills assessment dated [DATE] shows he is capable of outside pass privileges. The facility's Community Pass Policy states, A resident has the right to community overnight access with the consent of the facility and the resident's cooperation with the standards described within. If the resident refuses to adhere to the standards, he or she may be discharged from the facility in accordance with the Involuntary Discharge or Against Medical Advice Policy.Residents will be informed and educated about rules and expectations while in the community, including, but not limited to.Using alcohol or any illicit substance and/or bringing these items into the facility is prohibited and may result in forfeiture of pass privilege.Consenting to be checked at the discretion of supervisory personnel upon return if reasonable suspicion of contraband exists. Contraband is defined as any non-prescribed medication, substance or object that is not part of the treatment plan, is not ordered by the physician and has the likelihood of causing the individual or other persons direct or indirect harm.The facility reserves the right to revoke the community pass privilege of a person assessed by the IDT or physician or Social Services as a threat to him/herself or others to assure the safety of the individual resident and the neighboring community.

Based on interview and record review the facility failed to ensure final cooking temperatures were logged to ensure food was cooked to a food-safe temperature before serving. This failure has the potential to affect 64 residents residing in the facility. The findings include:The facility's Data Sheet dated January 20, 2025 shows 65 residents were residing in the facility. Per V9 Corporate staff, there is one resident who does not eat food from the facility kitchen.On January 20, 2026 at 8:40 AM, the kitchen food temperature logs were requested and reviewed. The food temperature logs showed no food temperatures were taken on January 8, 2026 for all three meals, January 9-11, 2026 for breakfast and lunch meals, January 12, 2026 for supper, January 13, 2026 for all three meals, January 14, 2026 for breakfast and lunch, January 15, 2026 for all three meals, and January 16,17, 2026 for breakfast and lunch. Both cooking temperatures and serving temperatures were missing and not documented. On January 20, 2026 at 8:40 AM, V4 Dietary Manager said that food temperatures should be taken when food is done cooking, and then the temperature should be taken again right before serving the food. V4 said temperatures should be logged as they are taken. The facility's Food Safety and Sanitation: General Preparation and Cooking Practices policy revise September 18, 2023 shows, Policy: The facility will follow sanitary practices in food preparation and cooking to keep food safe. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby prevent foodborne illness. Hot food prepped for serving will maintain a minimum temperature of greater than or equal to 135 degrees Fahrenheit when on the steam table and prior to being served to the residents. If the food is below 135 degrees Fahrenheit, the staff must reheat the food to 165 degrees Fahrenheit to assure time and temperature control.

Based on interview and record review the facility failed to ensure serving temperatures were logged to ensure food was served at a palatable temperature. This failure has the potential to affect 64 residents residing in the facility. The findings include:The facility's Data Sheet dated January 20, 2025 shows 65 residents were residing in the facility. Per V9 Corporate staff, there is one resident that does not eat food from the facility kitchen.On January 20, 2026 at 8:40 AM, the kitchen food temperature logs were requested and reviewed. The food temperature logs showed no food temperatures were taken on January 8, 2026 for all three meals, January 9-11, 2026 for breakfast and lunch meals, January 12, 2026 for supper, January 13, 2026 for all three meals, January 14, 2026 for breakfast and lunch, January 15, 2026 for all three meals, and January 16,17, 2026 for breakfast and lunch. Both cooking temperatures and serving temperatures were missing and not documented. On January 20, 2026 at 9:10 AM, R2 said that the food is always cold when it is served. At 10:40 AM, R4 said the food is not good. R4 says he orders out often because the food is bad. R4 says the food is cold most of the time. R4 says it depends on when he gets his food as to how hot or how cold it is. At 10:54 AM, R3 said there are some good meals and some meals not so good. R3 said his hot food is served cold at times. On January 20, 2026 at 8:40 AM, V4 Dietary Manager said food temperatures should be taken when they are cooked and then right before they are served to ensure they are at the right temperature. V4 said staff should log the temperatures as they are taken. V4 said that food trays are delivered via an opened metal cart with a cloth covering over it. V4 said the facility does not utilize heated place and no closed cart. V4 said the facility does not use any heating apparatus to keep food warm while they are being delivered to residents. V4 said those would be helpful to keep the food warm. The facility's Resident Council Minutes dated October 3, 2025 shows, Dietary old business: Resident Council members wanted to keep the old business regarding the cold food. They also stated the coffee is cold at times and they don't always get condiments on their meal trays. Resident Council Minutes dated December 3, 2025 shows, Dietary Old Business: Resident Council members wanted to keep the old business regarding the cold food. They also stated the coffee is cold at times and they don't always get condiments on their meal trays.

Based on observations, interviews, and record review, the facility failed to ensure resident equipment was maintained for two (R3, R4) of five residents reviewed for safe/clean/homelike in the sample of five.The findings include:1 R3's admission Record shows he was admitted to the facility on [DATE] with diagnoses including chronic respiratory failures, venous insufficiency, lymphedema, morbid obesity, fluid overload, cellulitis of right lower limb, bed confinement status, and stage 4 pressure injury of the sacral region.R3 Minimum Data Set (MDS) dated [DATE], shows that he is cognitively intact.On January 20, 2026 at 10:54 AM, R3 said the right siderail on his bed is loose. R3 moved the right siderail and it moved side to side. R3 said he let the facility know about it about a week ago, and they haven't fixed it yet. R3 said he needs to use his side rails in order to roll from side to side. On January 20, 2026 at 11:15 AM, V7 Maintenance Director said the facility does not use work orders. If a resident needs something fixed, receptionist or staff will get ahold of maintenance and tell them. V7 said the facility does not keep track of when something was requested and when it was repaired/completed. V7 said he was aware that R3's side rail was loose and said that R3's side rail was on the list of things to work on. V7 said he was told about the loose side rail late yesterday (January 19, 2026).2 R4's admission Record shows he was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, chronic kidney disease, anemia, restless legs syndrome, adjustment insomnia, glaucoma, and acquired absence of right leg blow knee.R4's MDS dated [DATE], shows he is cognitively intact.On January 20, 2026 at 10:40 AM, R4 said he has been waiting for maintenance to fix the right arm rest on his wheelchair. R4 said he was waiting for a shorter armrest. R4 said it is too long and R4 scratched his right forearm on the metal of the armrest because he uses his arms to propel the wheelchair. R4's right arm rest on his wheelchair had a cushioned piece. The cushioned piece was hanging off the back about 5-6 inches. There was metal underneath the cushioned piece. R4 had a scrape on his right forearm. The left armrest did not have the cushioned piece. R4 said he reported this concern a couple of weeks ago. On January 20, 2026 at 11:15 AM, V7 Maintenance Director said there was nothing wrong with R4's armrest. V7 said that R4 wanted a shorter arm rest to match the left armrest. V7 said he is waiting for a replacement arm rest. V7 said he received R4's concern about a week ago. The facility's Preventative Maintenance Program Policy dated January 2025 shows, Purpose: To conduct regular environmental tours/safety audits to identify areas of concern within the facility. Preventative Maintenance Program will review the following areas during random rounds: Resident equipment is in working order. Bed rails are in working condition.

Based on observation, interview, and record review the facility failed to ensure an allegation of misappropriation of resident property was reported immediately for 1 of 3 residents (R1) reviewed for theft in the sample of 5.The findings include: On 11/24/25 at 9:30 AM, R1 was sitting at the bedside in her room. R1 said she woke up one morning and her ring was missing. R1 pointed to her left hand, ring finger. R1's left hand ring finger had a visible indentation of where a ring had been worn. R1's skin in this area was lighter in color. R1 said it was a tight-fitting ring and just wouldn't slide off. R1 said she was very upset and told the first person that came in the room when she noticed. R1 said she never took the ring off. R1 said it was a large ring and went from her knuckle to the base of her finger. R1 said it had numerous diamonds with two large diamonds and it was yellow gold. R1 stated I miss it a lot. R2 (R1's roommate) said R1 always wore the ring and both herself and R3 sat with R1 at meals saw R1's ring. R1 said some staff had helped her look for it. R2 said R1 came to breakfast one day and told herself and R3 that the ring was missing. R2 said R1's ring fit snuggly and R1 always had it on. On 11/24/25 at 10:00 AM, R3 said R1 wore a wedding band on her left hand, that she always had on. R3 said R1 told them one morning at breakfast that she lost her ring. R3 said R1 was very upset and said V4 Housekeeping was looking for it.On 11/24/25 at 10:09 AM, V4 Housekeeping Manager said she was in R1's room one morning and R1 told her she was missing her ring and was very upset about it. V4 said she looked under R1's bed, in R1's wheelchair, and shook out R1's pajama pants. V4 said she told another housekeeper that when R1 got up for breakfast to strip R1's bed and look in the covers. V4 said R2 reported to her that R1's ring was missing, and she told R2 that she was looking for it. V4 said she did not report R1's missing ring to anyone, but she should have. V4 said this occurred when R1 was in a room on the south hall.On 11/24/25 at 12:43 PM, V12 Certified Nursing Assistant (CNA) said R1 told her about her ring missing awhile back when R1 was on the south hallway. V12 said she told the nurse on duty at that time and talked about it with V13 CNA. V12 said R1 was upset and had her things on her floor looking for the ring. V12 said she helped R1 look for her ring and put R1's things back in order. On 11/24/25 at 1:21 PM, V13 CNA said R1 told her that her ring was missing at breakfast one morning. V13 said V12 had reported it. On 11/24/25 at 12:01 PM, V1 Administrator said she became aware of R1's missing ring on 11/17/25 when R1's POA and nephew came into the facility and reported it to her. V1 said staff are to report a resident's missing item right away to the administrator of supervisor. R1's Census list shows R1 resided in the south hallway room (Room Number) from admission on [DATE] to 11/11/25, when she was moved to room (Room Number)The facility's Abuse Prevention Program Policy dated 1/24 shows Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator.

Based on observation, interview, and record review the facility failed to follow their Abuse Policy when a resident reported missing property for 1 of 3 residents (R1) reviewed for abuse in the sample of 5. The findings include:On 11/24/25 at 9:30 AM, R1 was sitting at the bedside in her room. R1 said she woke up one morning and her ring was missing. R1 pointed to her left hand, ring finger. R1's left hand ring finger had a visible indentation of where a ring had been worn. R1's skin in this area was lighter in color. R1 said it was a tight-fitting ring and just wouldn't slide off. R1 said she was very upset and told the first person that came in the room when she noticed. R1 said she never took the ring off. R1 said it was a large ring and went from her knuckle to the base of her finger. R1 said it had numerous diamonds with two large diamonds and it was yellow gold. R1 stated I miss it a lot. R2 (R1's roommate) said R1 always wore the ring and both herself and R3 sat with R1 at meals saw R1's ring. R1 said some staff had helped her look for it. R2 said R1 came to breakfast one day and told herself and R3 that the ring was missing. On 11/24/25 at 10:00 AM, R3 said R1 wore a wedding band on her left hand, that she always had on. R3 said R1 told them one morning at breakfast that she lost her ring. R3 said R1 was very upset and said V4 Housekeeping was looking for it.On 11/24/25 at 10:09 AM, V4 Housekeeping Manager said she was in R1's room one morning and R1 told her she was missing her ring and was very upset about it. V4 said she looked under R1's bed, in R1's wheelchair, and shook out R1's pajama pants. V4 said she told another housekeeper that when R1 got up for breakfast to strip R1's bed and look in the covers. V4 said R2 reported to her that R1's ring was missing, and she told R2 that she was looking for it. V4 said she did not report R1's missing ring to anyone, but she should have. On 11/24/25 at 12:43 PM, V12 Certified Nursing Assistant (CNA) said R1 told her about her ring missing awhile back when R1 was on the south hallway. V12 said she told the nurse on duty at that time and talked about it with V13 CNA. On 11/24/25 at 12:01 PM, V1 Administrator said she became aware of R1's missing ring on 11/17/25 when R1's POA and nephew came into the facility and reported it to her. V1 said staff are to report a resident's missing item right away to the administrator of supervisor according to their abuse policy.The facility's Abuse Prevention Program Policy dated 1/24 shows Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator.

Based on observation, interview, and record review the facility failed to ensure a resident was free from misappropriation for 1 of 3 residents (R1) reviewed for theft in the sample of 5. The findings include:On 11/24/25 at 9:30 AM, R1 was sitting at the bedside in her room. R1 said she woke up one morning and her ring was missing. R1 pointed to her left hand, ring finger. R1's left hand ring finger had a visible indentation of where a ring had been worn. R1's skin in this area was lighter in color. R1 said it was a tight-fitting ring and it just wouldn't slide off. R1 said she was very upset and told the first person that came in the room when she noticed. R1 said she never took the ring off. R1 said it was a large ring and went from her knuckle to the base of her finger. R1 said it had numerous diamonds with two large diamonds and it was yellow gold. R1 stated I miss it a lot. R2 (R1's room mate) said R1 always wore the ring and both herself and R3 sat with R1 at meals saw R1's ring. R2 said R1 came to breakfast one day and told herself and R3 that the ring was missing. R2 said R1's ring fit snuggly. On 11/24/25 at 10:00 AM, R3 said R1 wore a wedding band on her left hand that she always had on. R3 said R1 told them one morning at breakfast that she lost her ring. R3 said R1 was very upset and said V4 Housekeeping was looking for it.On 11/24/25 at 11:25 AM, V9 (R1's Power of Attorney/sister) said R1 had a ring when she came to the facility from the hospital. V9 said R1's daughter visited R1 at the facility on 10/13/25 and confirmed that R1 had her ring on her finger.R1's Inventory of Personal Effects dated 9/25/25 shows Jewelry-1 ring.R2's Minimum Data Set, dated [DATE] shows R2 is cognitively intact.R3's MDS dated [DATE] shows R3 is cognitively intact.The facility's Abuse Prevention Policy dated 1/24 shows Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment.

Based on observation, interview, and record review the facility failed to ensure a resident 's walkway path in her room was free from accidental hazards this applies to 1 of 18 residents (R8) in the sample of 18. This failure resulted in R8 tripping in her cluttered room and sustaining a left ankle and foot fracture. The findings include: On 11/17/25 at 9:40 AM, R8 was in her room sitting in her wheelchair. An immobilizer boot was in place to her left lower leg. R8 said about a month ago, she was in her room and her roommate had four visitors in the room. The visitors were sitting in chairs across her roommate's bed and she was trying to walk through the small space with her walker tripped and fell. R8 said there was not enough walk space causing her to trip and fall. R8 said she had a left ankle fracture and is non-weight bearing to her left leg. On 11/18/25 at 10:44 AM, V10 (Licensed Practical Nurse-LPN) said she was R8's nurse when she fell on [DATE]. R8 was in her room walking with her walker. Her roommate had several visitors visiting and the visitors were sitting across R8's roommate's bed. R8 was walking with her walker trying to get through the space and she tripped and fell. The room was overcrowded and there was not enough walk space for R8 to get through. On 11/19/25 at 8:39 AM, V2 (Director of Nursing) said R8 tripped and fell in her room due to safety hazards. R8's walk space was limited and there were several visitors in the room at that time. Walkways should be free of clutter and have enough space for a resident to walk. V2 said R8 sustained a left ankle fracture but did not require surgical intervention. R8's Fall Risk Review dated 9/20/25 shows she is at moderate risk for falls due to history of falls in the last three months, balance problems when walking and use of assistive device. R8's Fall Incident Report dated 10/5/25 shows (R8) tripped in her room trying walk past visitors .predisposing environmental factors include crowding people crowded in room, several chairs in room (R8) was sent to out to the local hospital and diagnosed with a fracture R8's Hospital Discharge report dated 10/6/25 shows fracture of distal fibula and fracture of third metatarsal bone of left foot. R8's current care plan shows she is at risk for falls with interventions including proper footwear, use of walker, call light within reach and encourage her to use of assistance. R8's care plan does include ensuring her room is free from safety hazards and clutter. The facility's Safety and Supervision of Residents Policy revised 2025 states, Our facility strives to make the environment as free from accidental hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities.

Based on observation, interview and record review the facility failed to provide assistance with ADL's (Activities of Daily Living). This failure resulted in R1 being left on the bed pan unattended leading to feelings of pain, frustration, panic and embarrassment. This applies to 1 of 3 residents reviewed for assistance with ADL's in a sample of 6 residents. The findings include: R1 Face sheet shows his diagnoses to include acute respiratory failure with double lung transplant, protein-calorie malnutrition, pneumonia, and type 2 diabetes mellitus. R1's 3/18/24 MDS (Minimum Data Set) shows, he is fully cognitively intact, and needs substantial/maximal assistance rolling left and right. R1's 3/12/24 POS (Physician Order Sheets) shows Physical and Occupational therapy is to evaluate and treat as indicated 3-5 times a week. R1's 3/13/24 Care Plan shows he has a self care deficit and is dependent with ADL care. The facility must provide total assistance in all aspects of hygiene/dressing. R1's 3/21/24 Progress Note, by V10 (Nurse Practitioner) shows R1 was referred to skilled therapy related to a noted functional decline. R1 has a decrease in strength, balance, transfers, mobility, and the ability to perform self-care ADL's. The same progress note shows R1 is alert and oriented to person, place, and time. On 4/2/24 at 10:00 AM, R1 said, on 3/29/24 at 11:00 AM he was placed on the bed pan, and when he was finished having a bowel movement pressed his call light to be taken off. R1 said, staff kept coming in and shutting off the call light and telling him (R1) they would be right back and never returned. R1 said, the bed pan was starting to hurt his bottom and he was feeling frustrated, R1 said, it was like he didn't matter. R1 said, he finally called 911 because he couldn't take it anymore and was starting to panic. R1 became emotional and started to weep when relaying this event. R1 said, it's embarrassing to have to use a bed pan but to be on it for 3 hours and then have a room full of EMS and staff to take him off caused more embarrassment. On 4/2/24 at 1:00 PM, V7 CNA said, she was R1's CNA on 3/29/24, the day R1 called 911. V7 said, her normal shift is 10:00 AM to 10:00 PM but she was late that day. V7 said, she put R1 on the bed pan, but she couldn't remember what time. V7 said, it was before lunch because she remembers R1 was still on the bed pan when she delivered his lunch tray. V7 said, she didn't take him off the bed pan because she got busy and thought someone else would do it. V7 said, she doesn't know what time he (R1) was taken off the bed pan. On 4/2/24 at 9:45 AM, V2 DON (Director of Nursing) said, we have video of staff going in R1's room several times, so V2 thinks R1 was put on the bed pan at 1:00 PM and taken off at 2:40 PM. V2 said, she assessed R1's bottom at 2:40 PM when EMS (Emergency Medical Service) arrived. V2 said the staff should answer the call light as soon as possible because the resident may be in distress. On 4/2/24 at 1:00 PM, V4 CNA said, R1 is alert and oriented. V4 said, staying on the bed pan for longer than 1/2 an hour is too long. V4 said the resident should come off the bed pan and try again later, because staying on the bed pan too long could cause skin break down. On 4/2/24 at 1:00 PM, V5 CNA said, R1 is alert and oriented. V5 said, staying on the bed pan for longer than 1/2 an hour is too long. V5 said, the resident should come off the bed pan and try again later, because staying on the bed pan too long could cause skin break down. On 4/2/24 at 10:15 AM, V3 (Wound Nurse) said, a 1/2 hour to 1 hour on the bed pan is too long because it might cause skin breakdown. The CNA should take the resident off the bed pan and the resident should try later to use the bed pan. A Policy and Procedure for Bed Pan use and for assistance with ADL's was requested, however V1 (Administrator) said, they did not have one.

Based on observation, interview, and record review the facility failed to ensure a resident received pain medication as scheduled for 1 of 1 resident (R9) reviewed for pain in the sample of 20. This failure has resulted in R9 requesting further pain control on 7/18/23 while reporting pain at a level 10 on the pain scale and on 10/18/23 while reporting pain at a level of 8 on the pain scale. The findings include: R9's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, palliative care, cerebrovascular disease, Type 2 diabetes, rheumatoid arthritis, major depressive disorder, age related osteoporosis without current pathological fracture, and anxiety disorder. R9's facility assessment dated [DATE] showed she has moderate cognitive impairment. R9's care plan initiated 5/3/21 showed, Resident and family have opted for hospice via [hospice company] for diagnosis of weight loss and failure to thrive . Resident will be enabled to live to the limit of potential in physical, mental, emotional, and spiritual health and will be kept as comfortable and as pain free as possible . Keep resident comfortable and as pain free as possible. Monitor for symptoms of pain and/or distress (i.e. restlessness, grimaces, etc.) and anticipate and meet needs throughout the day. Provide medication as ordered for comfort . R9's care plan initiated on 2/11/21 showed, Resident is at increased risk for alteration in pain/discomfort related to compression fractures and Rheumatoid Arthritis. The resident will notify staff with onset of pain through next review . Notify MD for any new resident complaints of pain and or signs and symptoms of pain to obtain new order for medication regimen or break through pain management . R9's care plan initiated 2/21/23 showed, [R9] on hospice care related to terminal illness - alteration in comfort . Resident will have no observable indications of physical discomfort (moaning, restlessness, grimacing) . Provide cares per resident and/or family wishes to achieve acceptable level of comfort . Assess for pain and discomfort PRN. See Pain Care Plan . R9's December 2023 POS (Physician Order Sheet) showed an order for Norco (Opioid Pain Medication) 5-325 mg, Give 1 tablet by mouth every 8 hours related to Rheumatoid Arthritis. The same POS showed an order for Fentanyl Transdermal Patch, Apply 1 patch transdermally every 72 hours . R9's July 2023 eMAR (electronic Medication Administration Record) showed she did not receive any of her scheduled opioid pain medication on 7/26/23 (3 doses) and 7/27/23 (3 doses). R9 did not receive her 5:00 AM dose of Norco on 7/28/23. R9's eMAR notes showed the Norco was not available to be administered. This same eMAR showed R9 also did not receive her scheduled Fentanyl pain patch on 7/15/23, 7/18/23, and 7/24/23. R9's eMAR notes showed on 7/15/23 they were waiting for the physician to send the prescription to the pharmacy and the medication was not available for administration. R9's eMAR showed she received a dose of Morphine on 7/18/23 for pain she rated at a 10 out of 10 on the pain scale. R9's August 2023 eMAR showed she missed 2 doses of her Norco on 8/29/23. R9's eMAR notes showed the missed doses were due to the medication being on order and not available for administration. R9's September 2023 eMAR and Norco count sheet were reconciled to determine the number of doses R9 did not receive. The narcotic count sheet showed R9 ran out of Norco on 9/19/23 causing her to miss her scheduled dose at 9:00 PM. R9 missed all doses of her Norco from 9/20/23 through 9/23/23. (13 missed doses) R9's eMAR notes showed the Norco was not available. R9's October 2023 eMAR and Norco count sheets were reconciled to determine the number of doses R9 did not receive. The narcotic count sheet showed R9 ran out of Norco on 10/13/23. R9 missed all doses of her Norco from 10/14/23 through 10/19/23 (24 missed doses). R9's eMAR notes showed the Norco was on order. R9's same eMAR showed R9 did not receive her Fentanyl pain patch on 10/16/23, 10/19/23, 10/22/23, and 10/25/23. R9's narcotic count sheet for Fentanyl showed her last patch had been applied 10/13/23. R9's eMAR note showed her Fentanyl pain patch was not available. R9's 10/18/23 eMAR note showed she requested Morphine for generalized pain. R9's eMAR showed she received a dose of Morphine on 10/18/23 when she reported pain at a level 8 out of 10 on the pain scale. Additionally, a 10/18/23 Mood/Behavior note was added for R9 that showed, CNA (Certified Nursing Assistant) reported that patient was changed 14 times throughout the night. Patient repeatedly taking off brief without it being wet/soiled asking to be changed . R9's December 2023 eMAR and Norco count sheets were reconciled to determine the number of doses R9 did not receive. The narcotic count sheet showed R9 ran out of Norco on 12/11/23. R9 missed all doses of her Norco from 12/12/23 through 12/13/23 (6 missed doses). R9's eMAR notes show a new prescription was needed. On 12/14/23 at 9:41 AM, V16 CNA said R9 complains about pain all the time. V16 said R9 has been complaining more recently and the aides report this to the nurses. On 12/14/23 at 12:45 PM, V12 RN (Registered Nurse) said, I'm assuming it is [R9's] Rheumatoid Arthritis that is causing her pain. She has Norco and Fentanyl patches for pain treatment. The Norco came in today. Norco is given every 8 hours scheduled. It is not PRN (as needed). If I see that a medication is not here I call the pharmacy to find out if they need a new prescription, if they do need a new prescription, I call the doctor and ask them to send to the pharmacy. I let them know if we have none because I write NONE so they know that we don't have any. The pharmacy comes in one time a day early in the morning or you can STAT (rush) it if needed. There is a convenience box but if its a prescription issue we still can't get it. On 12/14/23 at 2:14 PM, V2 DON (Director of Nursing) said, There was an order the other day that they changed it because we needed a prescription. So we had to go through hospice for that for the refills. We would have to reach out to see if there is something available that is comparable if we run out of medications. I haven't heard anything in terms of her complaining of pain. The nurse yesterday said she was reaching out to hospice to see if they could switch her Norco to PRN . If they are out, the nurses should reach out to hospice because hospice fills the scripts . On 12/19/23 at 5:02 PM, V19 (Medical Director) said R9 could start experiencing withdrawal signs and symptoms within 6-12 hours of her missed dose of Norco or Fentanyl. V19 said R9 would present with agitation, restlessness, and increased pain. V16 said he would expect the facility to request refills and new prescriptions timely to ensure the resident does not run out of medications. V16 said if the facility nurses have difficulty getting the hospice physician to ensure prescriptions are called in and a resident is without their pain medications they would be able to contact him to call in a prescription. The facility's policy and procedure with review date of 11/2022 showed, Pain Management and Assessment . Purpose: To develop a standardized method for assessing, monitoring, evaluating, and documenting pain in both cognitively intact and impaired residents. Resident will receive necessary comfort, exercise greater independence, and enhance dignity through optimizing their ability to perform activities of daily living . 2. Assess and document pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms . 3. Evaluate for behavioral responses to pain: . crying or moaning . increase in body movements . irritability/mental confusion . 7. Evaluation of the effectiveness of analgesic pain medication will be conducted post administration . 9. If pain is not relieved, give further medication as the physician ordered. If there are no orders, notify the physician of assessment results and obtain an order. 10. The resident's care plan will reflect the individualized pain management plan, including both pharmacological and non-pharmacological interventions.

Based on observation, interview, and record review the facility failed to ensure a resident (R14) with congestive heart failure was weighed daily to monitor for fluid overload. The facility also failed to ensure a resident (R57) received wound care as ordered. The facility also failed to identify a wound to the foot for (R24). These failures affect 3 of 7 residents (R14, R24, R57) reviewed for quality of care in the sample of 21. This failure resulted in R14's increased weights not being reported to the physician and R14 requiring hospitalization from [DATE] through 11/24/23. Findings include: 1. R14's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease with acute exacerbation, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, acute on chronic diastolic (congestive) heart failure, acute and chronic respiratory failure with hypoxia, chronic kidney disease, secondary hyperparathyroidism, morbid obesity, Type 2 Diabetes, anemia in chronic kidney disease, acquired absence of right leg below knee, acquired absence of left leg above knee, major depressive disorder, and anxiety disorder. R14's facility assessment dated [DATE] showed he has no cognitive impairment. On 12/11/23 at 9:45 AM, R14 was in his room and sitting in his wheelchair. R14 stated he does not get the care he needs at the facility. R14 said, I am supposed to be weighed daily for congestive heart failure and kidney failure because I retain fluid. I end up in the hospital about once a month almost. Today they took me down to weigh me and the batteries in the scale were dead so I was sitting there waiting for them to find the batteries and I had to have them bring me back to my room because it was taking too long for me to do down there without my oxygen on. I keep my own list of my weights so you can see I wasn't weighed 12/5-12/9 and I was not weighed 12/10 or 12/11 and today now I'm still waiting. I don't know what they are writing down but these are my weights. I'm getting myself up and into bed and I get really really winded, that is when I know that I need to go to the hospital. I've been in the hospital probably 6 or more times this year. R14's care plan initiated 10/24/23 showed, The resident demonstrates a potential for fluid overload related to: . Daily weight . Administer medication per physician's orders, Assess for signs and symptoms of fluid overload and notify the physician if signs and symptoms of fluid overload are present: edema . adventitious lung sounds . Observe, assess and record signs of edema. Report changes, new edema to physician . R14's care plan initiated 10/24/23 showed, The resident presents with altered respiratory function secondary to: . Observe and report signs of congestions, lethargy, labored breathing, wheezing, etc . Notify the physician as needed . R14's October and November 2023 eMAR (electronic Medication Administration Record) showed an order for Lasix Oral Tablet 40 mg (milligrams) Give one tablet by mouth every 24 hours as needed for weight gain greater than 3 lbs (pounds) in a 24 hour period . R14's 10/26/23 weight was 277 lbs and his 10/27/23 weight was 282 lbs showing a 5 lb weight gain in 24 hours. R14's October 2023 eMAR showed no dose of Lasix 40 mg administered as a result of that 5 lb weight gain. R14's October and November 2023 eMAR (electronic Medication Administration Record) showed an order for CHF (congestive heart failure) - weight daily - if weight gain of 2 lbs or more notify MD (physician) . R14's documented weights showed his 11/8 weight was 269.9 and his 11/9 weight was 272 (2.1 lb weight gain). R14's 11/9/23 nursing progress note showed, . stated he feels like he is gaining, refuses 911 transport for evaluation, resident alert and orientated x 4 . This note does not show physician notification made of resident 2.1 lb weight gain and report of feeling like he is gaining weight. R14's 11/9/23 Skin/Wound Note showed, . swelling of hands noted. Floor nurse notified. R14's eMAR showed R14's 11/10 weight was 267.2 and his 11/11 weight was 273.2. (6 lb weight gain) R14's medical record showed no evidence of notification to the physician regarding the 6 lb weight gain identified on 11/11/23. R14's November 2023 eMAR showed no evidence of Lasix given in response to this 6 lb weight gain. R14's 11/17 weight was 258 lbs and his 11/18 weight was 274 lbs (16 lb weight gain). R14's medical record showed no evidence of notification to the physician regarding the 16 lb weight gain identified on 11/18/23. R14's November 2023 eMAR showed no evidence of Lasix given in response to his 16 lb weight gain. R14's 11/20/23 nursing progress note entered at 9:16 PM showed, Patient requested to be sent to ER (emergency room ) for SOB (shortness of breath). Doctor and POA (power of attorney) was notified. [Ambulance Service] was provided for transport to [acute care hospital] . R14's 11/24/23 nursing progress note entered at 3:36 PM showed R14 was readmitted from the acute care hospital. R14's Nurse Practitioner Note dated 12/1/23 showed, . His most recent hospitalization was from 11/20/23 through 11/24/23. He presented to the emergency department with worsening shortness of breath x 2 days. Also reported a cough with increased congestion and sputum production O2 sat (saturation) 78. He was started on IV furosemide (diuretic), scheduled nebulizer treatments, prednisone (steroid), doxycycline (antibiotic). Nephrology was consulted and recommended continued diuresis without need for dialysis at that time. His weight at the time of discharge was 272 pounds . He was discharged back to the SNF (Skilled Nursing Facility) . Weight 11/28/23 263.7 lbs On 12/14/23 at 12:55 PM, V12 RN (Registered Nurse) said weights are documented on the eMAR and those flow over to the weights and vitals in each resident record. V12 said once entered they have to verify if he has had a two lb weight gain. If he has had 2 lb or more weight gain, we contact the doctor for his congestive heart failure. Physician notification gets documented in the progress notes. If [R14] has an increase in weight he could be having too much fluid building up on him. We monitor his weights to monitor his CHF. On 12/14/23 at 1:13 PM, V2 DON (Director of Nursing) said R14 is a daily weight to monitor his congestive heart failure. V2 said, In fact, he had came back to us not too long ago from a hospitalization . He still is a daily weight, came back 11/25. Monitoring for weight gain for fluid. He builds up with edema, he has been educated often to elevate extremities, and he does not lay down during the day, he sits up in his chair during the day. If there is a weight gain of 2 lbs or more the nurses contact the physician. Notification to the physician should be documented in the progress notes and also depending on if faxed over or called. If faxed it is under the misc scanned in. On 12/19/23 at 5:02 PM, V16 (Medical Director) said he is not very familiar with R14 but that he would expect daily weights to be completed as ordered for CHF (congestive heart failure) residents. V16 said the physician should be notified of weight of changes as ordered as well. V16 said increased weight would be an indicator of increased fluid. A policy and procedure for care of a resident with congestive heart failure and daily weights was requested. On 12/14/23 at 11:30 AM, V1 (Administrator) stated the facility has no policies addressing either congestive heart failure or daily weights but that the nurses are to follow physician orders as written. 39543 2. R57's Admission Record showed and original admitted [DATE] with diagnoses to include cellulitis (skin infection) of left lower limb, sepsis (blood infection), diabetes, and obesity. R57's 9/29/23 Admission Minimum Data Set showed moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. On 12/12/23 at 2:24 PM, R57 was alert and oriented to person, place, time, and medical condition. R57 stated he had sepsis from right leg wound. R57 stated he had a wound to his left leg that requires daily treatment. R57 stated the facility is known to not perform the dressing changes daily. R57 stated the dressing had not been changed on 12/11/23 or 12/10/23. R57's November and December 2023 Treatment Administration Record (TAR) showed an order for daily left knee wound care to include an antibacterial wound treatment. The treatment began on 11/8/23 and was discontinued on 12/13/23. During this time, 8 treatments to the left knee were not documented as being completed out of a total possible 36 treatments (22 percent of R57's treatments were not documented as being done; 12/11/23 treatment was not documented as being done.) On 12/13/23 at 4:29 PM, V2 Director of Nursing stated the purpose of wound care is to promote healing, treat the condition, and it can help prevent infection. When a nurse does a treatment it should be documented in the treatment record or a progress note. It's possible that it wasn't done if it's not documented. You could also talk to the patient and see if the treatment had been done. He should be having daily dressing changes. The facility's Dressing Non-Sterile policy (revised 2/17/20) showed the purpose of wound care is To protect open wounds from contamination and to absorb drainage. The policy states, following wound care, to Initial Treatment Administration Record electronically . 3. R24's Face Sheet shows his diagnoses to include, lymphedema, type 2 diabetes mellitus, a history of pressure and non-pressure injuries, venous insufficiency, developmental disorder of scholastic skills, and morbid obesity. R24 is alert and oriented. On 12/14/23 at 3:03 PM, during a dressing change performed by V12 RN (Registered Nurse), R24 had a unstageable pressure injury on the inside edge of his left foot, below his big toe. The sore was on a bony prominence. The pressure injury was 1 cm (centimeter) round with a scab on the top of the wound. The wound bed could not be seen because of the scab on top. On 12/14/23 at 3:03 PM, R24 said, the wound on the side of his left foot is new and he must be wearing his shoes too tight. R24 said he is to receive new shoes soon. 12/15/23 02:42 PM, V18 ( R24's wound care Physician) said, a pressure ulcer will form on a bony prominence. V18 said, if the wound bed is not visible then the wound is classified as unstageable. On 12/14/23 at 3:03 PM, V12 RN said, she wouldn't classify R24's new wound as an unstageable pressure injury. V12 said she thinks it's just a scab. V12 said she called the Physician and is waiting to get orders for what to do about it. On 12/15/23 at 12:15 PM, V17 (RN at the wound clinic) said, R24 did not come to his appointment today. On 12/15/23 at 11:52 AM, V11 (Clinical Executive Director) said, she did R24's dressing the night (12/13/23) before the new pressure injuries was found and could not recall for sure if she saw anything, V11 said it may have been a callous. V11 said, R24 did not go to his scheduled appointment at the wound care clinic today, and she was not sure why. V11 said, in order to determine if a wound is partial or full thickness the wound bed needs to be visible, if not, the wound can't be staged. V11 said, wounds should be found on a resident before reaching a unstageable level. R24's care plan (revision on 12/06/2023) shows, The resident is at increased risk for alteration in skin integrity related to venous insufficiency. R24's goal is to not develop any skin integrity issues through the next review. The interventions in place includes: Skin will be checked during routine care on a daily basis and during the weekly bath or shower schedule per resident preference. and reposition resident frequently, and off load heels as needed. R24's 12/13/23 (8:20 PM) Progress Notes, shows V11 did R24's dressing the night before the wound was discovered. There is no mention of a new wound in that progress note. The local wound care clinic notes dated 12/8/23 (the latest one available) does not mention a new wound on the left metatarsophalangeal joint. R24's Shower Sheets and the Physician Order Sheets fail to mention a new wound on his left foot between 12/12/23 and 12/14/23. The 10/2020 Pressure Ulcer and Skin Condition Assessment Policy shows, the purpose is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure, and other ulcers and assuring intervention are implemented. Each resident will be observed for skin breakdown daily during care and .the CNA (Certified Nursing Assistant) will promptly report it to a licensed Nurse who will perform the initial assessment.

Based on interview and record review, the facility failed to timely respond to a report of an unresponsive resident, failed to ensure a resident was monitored and not left unattended once found unresponsive, failed to thoroughly assess a resident to identify the source of hemorrhagic blood loss and provide immediate treatment in attempt to control blood loss and failed to contact Emergency Medical Systems (EMS) in a timely manner. These failures resulted in R1 sustaining hemorrhagic blood loss leading to R1's cardiac arrest. R1 required initiation of cardiopulmonary resuscitation (CPR) initiated by EMS staff upon their arrival to the facility, intubation for mechanical/artificial breathing support and transport to the local hospital emergency department. R1 required multiple rounds of CPR while in the emergency room , expiring on [DATE] at the local hospital. These failures affect one of five residents (R1) reviewed for neglect on the sample list of five. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R1's wound vac became disconnected and he began experiencing hemorrhagic blood loss. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:00AM. While the immediacy was removed on [DATE], noncompliance remains at a Level Two due to additional time needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's electronic face sheet printed on [DATE] showed R1 has diagnoses including but not limited to aneurysm of artery of lower extremity, hypertensive heart disease, ischemic cardiomyopathy, acute post hemorrhagic anemia, and atherosclerotic heart disease. R1's nursing progress notes written by V3 (Assistant Director of Nursing) dated [DATE] showed, Notified by nursing staff that resident was slumped over and unresponsive, blood noted to be on bed and floor due to his wound vac being dropped and broken, sternal rub initiated. Respirations noted to be at 12. Oxygen applied. Unable to obtain blood pressure at this time .Resident left facility via ambulance . The EMS (emergency medical services) report documents on [DATE] at 7:50am, EMS arrived at the facility in response to R1 was found unresponsive and not breathing. Upon arrival, EMS staff arrived to (R1) at 7:51am and noted R1 sitting upright in a wheelchair in R1's room, with multiple staff members present. Staff states (R1) was fine 5 minutes ago. EMT staff noted large amount of blood to R1's right side of his pelvic area and on the floor under the R1's wheelchair. (Facility) staff states R1 pulled out his wound vac (vacuum). No patient care provided by staff and no further information on R1 was passed on to EMS staff. EMS moved R1 in the wheelchair to the hall and placed R1 supine on the stretcher in the hall. Baseline vitals were assessed with agonal respirations noted and no pulses present. EMS initiated CPR via manual compressions. R1's shirt and pants were cut by EMS staff and a large wound with exsanguinating hemorrhage with a large blood clot noted to R1's right pelvic area. 4X4 gauze and direct pressure applied to wound area, AED (automated external defibrillator) pads placed on R1's chest and pulse check showed no palpable pulses and PEA (pulseless electrical activity) on the cardiac monitor. EMS applied 15 liters/minute via bag valve mask ventilation and CPR continued. R1 moved outside via stretcher and loaded into ambulance without incident. EMS staff attempted to place an intravenous line but was unsuccessful. EMS was able to obtain Intraosseous (IO) line successfully in left leg upon first attempt and EMS administered a normal saline fluid bolus and 1 mg (milligram) of epinephrine via IO site. Pressure bag placed over fluid bag; EMS staff intubated R1. Reassessment of wound area showed continued bleeding. EMS staff continued direct pressure of wound area. EMS administered 1mg of Epinephrine and pulse check showed no palpable pulses present and PEA on the cardiac monitor- CPR continued and cardiac monitor continued to show PEA. This report documents EMS gave a total of three doses of Epinephrine with continued CPR while enroute to the emergency room , and that EMS notified the emergency room R1 was due for a 4th round of Epinephrine. R1's local emergency room records dated [DATE] showed, .Per EMS, the patient had a wound vac to his right groin area which was removed at some point and there was a significant amount of blood on the patient's clothes and he was actively bleeding from his right wound .There is an open wound in the right inguinal area with blood clots present not actively bleeding. EMS actively putting pressure on this wound .Patient intubated upon arrival. We continued with CPR (Cardiopulmonary Resuscitation) per ACLS (Advanced Cardiac Life Support) protocol with massive transfusion protocol. Patient had ROSC (Return of Spontaneous Circulation) at 8:29AM .Patient lost pulse at 8:51AM and CPR was re-initiated .patient expired at 9:11AM .clinical impression: Cardiac arrest. On [DATE] at 9:55AM, V5 (Certified Nursing Assistant-CNA) stated, I found (R1) around 7:11AM when I was delivering his breakfast tray. He was in his wheelchair and when I set his tray down, I called his name and he didn't answer. Then I saw a big pool of blood on the bed & floor and ran and got the nurse. He wasn't responding at all. After I let her know, I just moved on with the rest of my day because she didn't tell me to do anything with (R1) and I assumed she was heading to his room. On [DATE] at 9:59AM, V6 (LPN) stated, (V5-CNA) came and told me that there was blood on (R1's) floor a little after 7. I went down to his room and he was in his wheelchair. I asked him where the blood came from and he didn't respond verbally but just looked at me. I was trying to figure out if he had a wound vac or dialysis or what was going on. I asked (V3-Assistant Director of Nursing) to come down and she came down and had (V8-CNA) call 911 after she saw all of the blood. I don't work there that often so I don't know him that well. I didn't get information in nursing report from (V3) that he had a wound vac. I saw blood on the floor and I think there was some on his bed. His clothes were saturated with blood and I was trying to feel through his clothes where the blood was coming from. I didn't see his wound vac anywhere near him at the time but I wasn't really paying attention to that. I would have had to cut his clothes off to see where the blood was coming from. I told the paramedics to be careful when they moved him because we were unsure of where the blood was coming from. Looking back, I wouldn't have handled this situation any differently. (V3) told me she would document everything we did and not to document anything in (R1's) chart so I didn't. (Facility) is very particular in these situations how they want things documented and I'm not getting in trouble for anything so I did what (V3) told me to do. (R1's electronic medical record showed 1 nursing progress note regarding R1's change in condition on [DATE] that was documented by V3-ADON. No records were present in R1's medical record that were documented by V6). On [DATE] at 9:46AM, V3 (Assistant Director of Nursing) stated, I worked from 6am-7am on [DATE]. (V6-Licensed Practical Nurse-LPN) arrived at 7am and I gave her report and went to my office. (V6) sent me a text message at 7:38am and said something was wrong with (R1's) wound vac. I went into his room, said hi to him and the wound vac was on the floor with blood spilling out of it. I asked (R1) what happened and he said UGH and slumped over. I went to the doorway to get (V6) to help me and she came in and got a pulse and said he was breathing. I told her to stay with (R1) and not to leave him so I could go get the paperwork ready .I saw a little bit of blood on the edge of the bed but I was more concerned about (R1). I just assumed since the wound vac had fallen on the floor that was where the blood was coming from. Neither I nor (V6) checked to see if there was any other source of the blood. It all happened pretty fast and we didn't really have time to do much. On [DATE] at 12:45PM, V2 (Director of Nursing) stated, I was not in the facility when (R1's) change in condition occurred. All I really know is that I was told they had to call 911, paramedics got here and ended up coding him and doing CPR. I would assume that the nurse's would know to identify where the bleeding is coming from and apply pressure to a site that is actively bleeding. That is common sense but I guess they were worried about his vitals too because they had a hard time with them. On [DATE] at 2:31PM, V3 stated, I saw a little bit of blood on the bed and there was blood on the floor in (R1's) room in front of his wheelchair next to the wound vac. I can't remember if I saw the actual machine or not or just the canister for the wound vac. I told (V6) to document everything she did so I don't know why she didn't document anything. On [DATE] at 9:19AM, V10 (R1's physician) stated, (R1) was up in a wheelchair and was fine and sought me out and introduced himself when I saw him for the first time. He had the wound vac for a wound in his groin area from a surgery. If staff found him in the condition he was in, I would expect them to see where the bleeding is coming from and control the bleeding. Yes, overall blood loss is probably related to his death and can definitely contribute to cardiac arrest. What I have kind of read of the reports here at the hospital is the large amount of blood loss occurred at some point but we can't be sure when all of the blood loss occurred. When a resident is experiencing a rapid decline in condition I would expect the staff to respond immediately and assess the resident's vital signs, lung sounds, and any other emergency management they feel is reasonable at the time. The facility's policy titled, Abuse Prevention Program Facility Policy and Procedure dated [DATE] showed, .Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident secure environment. The facility's policy titled, Cardio-Pulmonary Resuscitation dated 2023 showed, Upon discovery of an unresponsive resident that is a Full Code status: 1. Determine unresponsiveness by shouting Are you okay and gently shake or tap on the resident. 2. If no response, call for help of other staff members. 3. Instruct other staff responding to the scene to obtain emergency supplies and notify 911 or emergency personnel. DO NOT leave the resident .5. determine if resident is breathing by opening airway with the head tilt chin lift method and check for breathing using your ear and face next to the residents' nose and mouth for no more than 10 seconds. 6. If resident is not breathing, give 2 rescue breaths using a mouth shield/barrier; preferably ambu-bag .8. Determine if unresponsive resident has a pulse or heartbeat by checking carotid artery pulse or use a stethoscope to listen to heart tones. If none, then begin chest compressions .9. Continue the cycle of 30 chest compressions followed by 2 breaths until resident shows signs of life or help arrives and takes over or physician gives order to cease. 10. Document events in medical record. The facility's policy titled, Emergency Care dated ,d+[DATE] showed, Emergency medical care refers to the care given to residents with urgent and critical needs. The circumstances under which the care given may or not be optimal; whatever facilities are at hand are used in the most effective manner .Principles of Emergency Management: To preserve life, to restore the resident to useful living, and to prevent deterioration before a more definite treatment can be given. 1. Maintain a patent airway, employing resuscitation measures, if necessary. 2. Stop bleeding .5. Protect wounds with sterile dressings or with dressings that are as clean as possible . The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: The facility failed to ensure staff were aware R1 had a wound vacuum device. Facility staff identified R1 was experiencing hemorrhagic blood loss and left him unattended. Facility failed to perform a full body assessment for R1 to determine the source of R1's bleeding. R1 was subjected to cardiac arrest requiring CPR and expired on 11.20.23. * All licensed nurses will be re-educated on emergency management of residents, nursing shift to shift report, and all staff on responding to a resident emergency including assessing residents with wound vacuums. -education initiated 11.22.2023; education will be completed 11.23.2023 -the administrator/DON/Minimum Data Set (MDS) nurse will complete the education. All licensed nurses will be educated via phone prior to the beginning of the next shift worked and will sign education sheets. -new hires will be educated during orientation *All staff will be re-educated on abuse, neglect by the administrator/DON/MDS nurse -all staff will be educated via phone prior to the beginning of the next shift worked and will sign education sheets -on the spot education is completed to ensure compliance System: Education to be completed by the start of scheduled shift A weekly audit of all will continue for two months on all emergent situations involving residents A weekly audit of shift to shift report between nurses changing shifts will continue for two months A weekly audit of all wound vacuums will continue for two months to ensure compliance Audits will be completed by DON or designee and an analysis presented through QAPI (Quality Assurance Performance Improvement) *A root cause analysis was conducted to identify barriers and further education needed. (Completed 11.22.2023) *ADON (Assistant Director of Nursing) will be educated on emergency management of residents, nursing shift to shift report and all staff on responding to a resident emergency; including assessing residents with wound vacuums. All audits will be analyzed and reviewed in monthly QAPI. This is overseen by the medical director and administrator. QAPI will determine if the audits will continue at that time. On [DATE], a review of the facility's in-service documentation showed 63% of the facility's total staff received education regarding abuse & neglect and 54% of the facility's nursing staff received education on emergency management of resident's. The remainder of staff and any new staff will be educated prior to the start of their next shift. Interviews with staff working on [DATE] showed staff have received the education and were able to verbalize the education they had received that aligned with the facility's abatement plan.

Based on interview and record review, the facility failed to provide care needs details to staff that R1 had a wound vacuum device, failed to provide monitoring and remain with/supervise R1 while he was experiencing hemorrhagic blood loss. The facility also failed to perform a full body assessment for R1 to determine the source of R1's bleeding to provide proper first aid to attempt to control the bleeding. These failures resulted in R1 sustaining hemorrhagic blood loss leading to R1's cardiac arrest. R1 required initiation of cardiopulmonary resuscitation (CPR) initiated by EMS staff upon their arrival to the facility, intubation for mechanical/artificial breathing support and transport to the local hospital emergency department. R1 required multiple rounds of CPR while in the emergency room , expiring on [DATE] at the local hospital. These failures affect one of five residents (R1) reviewed for neglect on the sample list of five. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R1's wound vac became disconnected and he began experiencing hemorrhagic blood loss. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:00AM. While the immediacy was removed on [DATE], noncompliance remains at a Level Two due to additional time needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's electronic face sheet printed on [DATE] showed R1 has diagnoses including but not limited to aneurysm of artery of lower extremity, hypertensive heart disease, ischemic cardiomyopathy, acute post hemorrhagic anemia, and atherosclerotic heart disease. R1's nursing progress notes written by V3 (Assistant Director of Nursing) dated [DATE] showed, Notified by nursing staff that resident was slumped over and unresponsive, blood noted to be on bed and floor due to his wound vac being dropped and broken, sternal rub initiated. Respirations noted to be at 12. Oxygen applied. Unable to obtain blood pressure at this time .Resident left facility via ambulance . The EMS (emergency medical services) report documents on [DATE] at 7:50am, EMS arrived at the facility in response to R1 was found unresponsive and not breathing. Upon arrival, EMS staff arrived to (R1) at 7:51am and noted R1 sitting upright in a wheelchair in R1's room, with multiple staff members present. Staff states (R1) was fine 5 minutes ago. EMT staff noted large amount of blood to R1's right side of his pelvic area and on the floor under the R1's wheelchair. (Facility) staff states R1 pulled out his wound vac (vacuum). No patient care provided by staff and no further information on R1 was passed on to EMS staff. EMS moved R1 in the wheelchair to the hall and placed R1 supine on the stretcher in the hall. Baseline vitals were assessed with agonal respirations noted and no pulses present. EMS initiated CPR via manual compressions. R1's shirt and pants were cut by EMS staff and a large wound with exsanguinating hemorrhage with a large blood clot noted to R1's right pelvic area. 4X4 gauze and direct pressure applied to wound area, AED (automated external defibrillator) pads placed on R1's chest and pulse check showed no palpable pulses and PEA (pulseless electrical activity) on the cardiac monitor. EMS applied 15 liters/minute via bag valve mask ventilation and CPR continued. R1 moved outside via stretcher and loaded into ambulance without incident. EMS staff attempted to place an intravenous line but was unsuccessful. EMS was able to obtain Intraosseous (IO) line successfully in left leg upon first attempt and EMS administered a normal saline fluid bolus and 1 mg (milligram) of epinephrine via IO site. Pressure bag placed over fluid bag; EMS staff intubated R1. Reassessment of wound area showed continued bleeding. EMS staff continued direct pressure of wound area. EMS administered 1mg of Epinephrine and pulse check showed no palpable pulses present and PEA on the cardiac monitor- CPR continued and cardiac monitor continued to show PEA. This report documents EMS gave a total of three doses of Epinephrine with continued CPR while enroute to the emergency room , and that EMS notified the emergency room R1 was due for a 4th round of Epinephrine. R1's local emergency room records dated [DATE] showed, .Per EMS, the patient had a wound vac to his right groin area which was removed at some point and there was a significant amount of blood on the patient's clothes and he was actively bleeding from his right wound .There is an open wound in the right inguinal area with blood clots present not actively bleeding. EMS actively putting pressure on this wound .Patient intubated upon arrival. We continued with CPR per ACLS (Advanced Cardiac Life Support) protocol with massive transfusion protocol. Patient had ROSC (Return of Spontaneous Circulation) at 8:29AM .Patient lost pulse at 8:51AM and CPR was re-initiated .patient expired at 9:11AM .clinical impression: Cardiac arrest. On [DATE] at 9:55AM, V5 (Certified Nursing Assistant-CNA) stated, I found (R1) around 7:11AM when I was delivering his breakfast tray. He was in his wheelchair and when I set his tray down, I called his name and he didn't answer. Then I saw a big pool of blood on the bed & floor and ran and got the nurse. He wasn't responding at all. After I let her know, I just moved on with the rest of my day because she didn't tell me to do anything with (R1) and I assumed she was heading to his room. On [DATE] at 9:59AM, V6 (LPN) stated, (V5-CNA) came and told me that there was blood on (R1's) floor a little after 7. I went down to his room and he was in his wheelchair. I asked him where the blood came from and he didn't respond verbally but just looked at me. I was trying to figure out if he had a wound vac or dialysis or what was going on. I asked (V3-Assistant Director of Nursing) to come down and she came down and had (V8-CNA) call 911 after she saw all of the blood. I don't work there that often so I don't know him that well. I didn't get information in nursing report from (V3) that he had a wound vac. I saw blood on the floor and I think there was some on his bed. His clothes were saturated with blood and I was trying to feel through his clothes where the blood was coming from. I didn't see his wound vac anywhere near him at the time but I wasn't really paying attention to that. I would have had to cut his clothes off to see where the blood was coming from. I told the paramedics to be careful when they moved him because we were unsure of where the blood was coming from. Looking back, I wouldn't have handled this situation any differently. (V3) told me she would document everything we did and not to document anything in (R1's) chart so I didn't. (Facility) is very particular in these situations how they want things documented and I'm not getting in trouble for anything so I did what (V3) told me to do. (R1's electronic medical record showed 1 nursing progress note regarding R1's change in condition on [DATE] that was documented by V3-ADON. No records were present in R1's medical record that were documented by V6). On [DATE] at 9:46AM, V3 (Assistant Director of Nursing) stated, I worked from 6am-7am on [DATE]. (V6-Licensed Practical Nurse-LPN) arrived at 7am and I gave her report and went to my office. (V6) sent me a text message at 7:38am and said something was wrong with (R1's) wound vac. I went into his room, said hi to him and the wound vac was on the floor with blood spilling out of it. I asked (R1) what happened and he said UGH and slumped over. I went to the doorway to get (V6) to help me and she came in and got a pulse and said he was breathing. I told her to stay with (R1) and not to leave him so I could go get the paperwork ready .I saw a little bit of blood on the edge of the bed but I was more concerned about (R1). I just assumed since the wound vac had fallen on the floor that was where the blood was coming from. Neither I nor (V6) checked to see if there was any other source of the blood. It all happened pretty fast and we didn't really have time to do much. On [DATE] at 12:45PM, V2 (Director of Nursing) stated, I was not in the facility when (R1's) change in condition occurred. All I really know is that I was told they had to call 911, paramedics got here and ended up coding him and doing CPR. I would assume that the nurse's would know to identify where the bleeding is coming from and apply pressure to a site that is actively bleeding. That is common sense but I guess they were worried about his vitals too because they had a hard time with them. On [DATE] at 2:31PM, V3 stated, I saw a little bit of blood on the bed and there was blood on the floor in (R1's) room in front of his wheelchair next to the wound vac. I can't remember if I saw the actual machine or not or just the canister for the wound vac. I told (V6) to document everything she did so I don't know why she didn't document anything. On [DATE] at 9:19AM, V10 (R1's physician) stated, (R1) was up in a wheelchair and was fine and sought me out and introduced himself when I saw him for the first time. He had the wound vac for a wound in his groin area from a surgery. If staff found him in the condition he was in, I would expect them to see where the bleeding is coming from and control the bleeding. Yes, overall blood loss is probably related to his death and can definitely contribute to cardiac arrest. What I have kind of read of the reports here at the hospital is the large amount of blood loss occurred at some point but we can't be sure when all of the blood loss occurred. When a resident is experiencing a rapid decline in condition I would expect the staff to respond immediately and assess the resident's vital signs, lung sounds, and any other emergency management they feel is reasonable at the time. The facility's policy titled, Abuse Prevention Program Facility Policy and Procedure dated [DATE] showed, .Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident secure environment. The facility's policy titled, Cardio-Pulmonary Resuscitation dated 2023 showed, Upon discovery of an unresponsive resident that is a Full Code status: 1. Determine unresponsiveness by shouting Are you okay and gently shake or tap on the resident. 2. If no response, call for help of other staff members. 3. Instruct other staff responding to the scene to obtain emergency supplies and notify 911 or emergency personnel. DO NOT leave the resident .5. determine if resident is breathing by opening airway with the head tilt chin lift method and check for breathing using your ear and face next to the residents' nose and mouth for no more than 10 seconds. 6. If resident is not breathing, give 2 rescue breaths using a mouth shield/barrier; preferably ambu-bag .8. Determine if unresponsive resident has a pulse or heart beat by checking carotid artery pulse or use a stethoscope to listen to heart tones. If none, then begin chest compressions .9. Continue the cycle of 30 chest compressions followed by 2 breaths until resident shows signs of life, or help arrives and takes over or physician gives order to cease. 10. Document events in medical record. The facility's policy titled, Emergency Care dated ,d+[DATE] showed, Emergency medical care refers to the care given to residents with urgent and critical needs. The circumstances under which the care given may or not be optimal; whatever facilities are at hand are used in the most effective manner .Principles of Emergency Management: To preserve life, to restore the resident to useful living, and to prevent deterioration before a more definite treatment can be given. 1. Maintain a patent airway, employing resuscitation measures, if necessary. 2. Stop bleeding .5. Protect wounds with sterile dressings or with dressings that are as clean as possible . The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: The facility failed to identify that R1 had a wound vacuum device. Facility staff identified R1 was experiencing blood loss and left him unattended. Facility failed to perform a full body assessment for R1 to determine the source of R1's bleeding. R1 was subjected to cardiac arrest requiring CPR and expired on 11.20.23. * All licensed nurses will be re-educated on emergency management of residents, nursing shift to shift report, and all staff on responding to a resident emergency including assessing residents with wound vacuums. -education initiated 11.22.2023; education will be completed 11.23.2023 -the administrator/DON/Minimum Data Set (MDS) nurse will complete the education. All licensed nurses will be educated via phone prior to the beginning of the next shift worked and will sign education sheets. -new hires will be educated during orientation *All staff will be re-educated on abuse, neglect by the administrator/DON/MDS nurse -all staff will be educated via phone prior to the beginning of the next shift worked and will sign education sheets -on the spot education is completed to ensure compliance System: Education to be completed by the start of scheduled shift A weekly audit of all will continue for two months on all emergent situations involving residents A weekly audit of shift to shift report between nurses changing shifts will continue for two months A weekly audit of all wound vacuums will continue for two months to ensure compliance Audits will be completed by DON or designee and an analysis presented through QAPI (Quality Assurance Performance Improvement) *A root cause analysis was conducted to identify barriers and further education needed. (Completed 11.22.2023) *ADON (Assistant Director of Nursing) will be educated on emergency management of residents, nursing shift to shift report and all staff on responding to a resident emergency; including assessing residents with wound vacuums. All audits will be analyzed and reviewed in monthly QAPI. This is overseen by the medical director and administrator. QAPI will determine if the audits will continue at that time. On [DATE], a review of the facility's in-service documentation showed 63% of the facility's total staff received education regarding abuse & neglect and 54% of the facility's nursing staff received education on emergency management of resident's. The remainder of staff and any new staff will be educated prior to the start of their next shift. Interviews with staff working on [DATE] showed staff have received the education and were able to verbalize the education they had received that aligned with the facility's abatement plan.

Based on interview and record review the facility failed to follow facility policy and failed to notify a resident's provider and provide emergency services for a resident with a change in condition, and the facility failed to follow-up with a resident's physician regarding signs and symptoms relating to a urinary tract infection. This applies to 1 of 3 residents (R1) reviewed for change in condition in the sample of 7. This failure resulted in R1 developing septic shock (Serious Condition that occurs when a body-wide infection leads to dangerously low blood pressure) and requiring hospitalization . The findings include: 1. R1's Admission Record showed an original admitted [DATE] with diagnoses to include major depression; nausea, and acid reflux disease. R1's 5/29/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 14 out 15. The MDS showed she was able to make herself understood, she was able to understand others, and she had clear speech. The MDS showed R1 was totally dependent upon two staff for bed mobility (turning in bed); transferring from bed to chair; dressing; personal hygiene; and toilet use. The MDS showed she was frequently incontinent of urine and she was always incontinent of bowel. The MDS showed she had a stage II pressure sore. R1's Care Plan showed she was a Full Code (In the event her heart or lung function would cease; resuscitation interventions should be initiated). R1's 5/20/23 Admission Note from 7:50 PM showed R1 was admitted from a hospital approximately 45 minutes from the facility. R1 was alert and she was oriented to person, place, time and curent condition. R1's note showed R1 stated R1 was not able to walk due to a pinched nerved and R1 required surgery. The note showed R1 was unable to move or straighten R1's left leg. (Note was authored by V18 Licensed Practical Nurse, LPN) R1's Hospital Records (obtained from the facility) showed R1 is a [AGE] year old female admitted on [DATE]. Patient active problem list: Urinary Tract infection without hematuria (no bleeding) .and Sepsis, due to unspecified organism . The records also showed diagnoses to include Failure to thrive in adult; malnutrition; and low blood pressure. R1's 6/1/23 psychiatry note showed .there are no symptoms of mania, paranoia, or delusional thoughts elicited this visit .Appearance/Behaviors: Calm, cooperative, Good eye contact, Well groomed. Speech: Clear, normal rate, tone, and volume .Mood: Depressed; Attention: Good; Insight: Fair; Judgment: Fair. The note showed she was awake; alert; and oriented to person, place, and time. R1's Physician Notification from V22 Registered Nurse sent to V4 Medical Director/Physician on 6/1/23 showed, R1 was complaining of burning with urination, urinary urgency, and bloody discharge. V22 requested a urine analysis (Urinalysis, UA) and, if needed, catheterize the resident to obtain the sample. V4 responded on 6/1/23 to do urine analysis (UA) and catheterize the resident if needed. The same fax sheet showed, Update 6/6/23 - resident refuses straight cath (catheter that is inserted for sample then immediately removed), says she has a fear of catheters, has been refusing. R1's Fax sheet sent to V4 showed R1 had blood tinged urine and her vaginal area was swollen and she was experiencing vaginal discharge. The note showed a request for catheterization for urine analysis and to culture the urine if indicated. V4 responded, via fax, on 6/4/23 stating Ok to do above. (The nurse's signature who authored the fax was not legible; V18 LPN confirmed she sent the fax. The date box on the fax is blank; however, the fax was stamped with a date of 6/2/23. Staff schedules showed V18 worked the evening of 6/1/23 to the morning of 6/2/23.) R1's 6/4/23 Nurse's Note from 8:02 PM, showed, R1 refused straight catheterization for a UA and that she would do a bed pan for the UA. (Note authored by V18) R1's 6/6/23 Nurse's Note from 3:18 AM, showed Resident refused to be straight cathed, stated that she has a fear of catheters. R1's 6/11/23 Nurse's Note from 4:57 PM, showed R1 was experiencing a change in condition. The note showed, Altered mental status, lethargy, slow to respond. Unable to get blood pressure reading. Oxygen saturation ranging from 79 percent to 86 percent. Oxygen started at 3 liters per nasal cannula . The note showed she had a low heart rate of 38 beats per minute (Normal range is 60 to 100 beats per minute, BPM) and 911 was called. The note showed V4 was notified of the transfer. R1's Hospital records from the evening of 6/11/23 showed R1 was in septic shock, she had bladder inflammation, and a urinary tract infection. The records showed a physician note on 6/11/23 at 9:13 PM, . It is difficult to obtain history from patient but patient's mother is at bedside and stated that 2 to 3 days ago the patient started not looking so well. Patient's face appeared pale and she was having increasing her jerking movements. Patient's mother states the patient was treated for UTI 2 weeks ago . The note continued .Septic shock with acute (recent onset) organ dysfunction present on admission .Source of infection is urinary and respiratory . On 6/14/23 at 1:00 PM, V18 LPN stated she works 6:00 PM to 6:00 AM mainly on the first floor of the facility. (R1 was a first floor resident of the facility.) V18 stated, on admission, R1 was alert, oriented, and conversational. V18 said R1 was .very 'spot on' and deliberate with her statements, she could make her needs known . V18 said she worked the evening of 6/11/23. V18 said the day nurse on 6/11/23, V19 Registered Nurse, had a one hour and 45 minute drive home, therefore, she came in early so V19 could start her long drive home. V18 said she arrived at the facility between 4:30 PM and 5:00 PM. V18 said the report she received from V19 regarding her shift that day was uneventful. V18 said while she was receiving report, V20 Certified Nursing Assistant stated R1 was talking crazy .she was talking about asparagus and how the CNA had blue eyes and pretty pale skin but she (V20) is dark skinned and has dark eyes. I asked the CNA, was she saying this stuff with her eyes open and the CNA said no . V18 said the CNA reported R1 had not eaten breakfast or lunch and she had not drank any fluids that day. V18 said R1 not eating breakfast or lunch was normal for R1. V18 said, So I said send her out, she has altered mental status. If she is seeing stuff with her eyes closed, that is weird and not normal for her . V18 said V19 went to do vitals while she called for transportation. V18 said when she entered the room the staff were not able to get a blood pressure with the machine. V18 said she attempted a manual blood pressure and she could not hear anything. V18 said she attempted to feel for a pulse in R1's wrist and she was unsuccessful. V18 said R1 appeared pale; almost grey. V18 said, A week and a half ago Monday, or Sunday, I went to straight cath her for a UA because her urine was nasty smelling and blood tinged .I asked [V4] for UA and culture if indicated. She (R1) said she can't use a bed pan because of what happened at [previous long-term care facility]; then she would start crying. Then I went to straight cath her and she said no. I told her she can't use bed pan but I told her to press the call light next time she had to go and we would do the bed pan. She was not willing to do the bed pan for the UA then [V22 Registered Nurse] tried (straight catheter) and she said No again. The night they sent her to the ER, I told them (R1's family that was in the room that night) she is in bad shape; I think she has Sepsis .I think she was septic from the UTI. She had nasty foul smelling urine for 1 to 2 weeks and you don't let anyone get a UA; these UTI's don't go away on their own. I think [V22] sent him (V4) something or faxed him something that she refused straight cath or UA. I don't remember getting a fax back that he (V4) respond. If we fax and there is no response, we sometimes have to send a couple faxes . V18 said providers will not order antibiotics without a UA. V18 said the foul smelling urine was reported to her by the CNA staff. V18 said, If someone told me something is not right with her (R1), I would go down and see for myself. I don't know why [V20] didn't tell her (V19) what she told us [during report] earlier on in the shift. If I was told she was not right, I would go down there with the vitals machine and talk to her and do an assessment and see what's up and do vitals. On 6/15/23 at 10:05 AM, V18 stated she knew R1 needed to be sent out without seeing the resident. V18 said, What they were describing was a change in her mental condition and she needed to be sent out. On 6/14/23 at 9:43 AM, V20 CNA said she was scheduled to work 6:00 AM to 6:00 PM on 6/10/23 (Saturday) and 6/11/23 (Sunday.) V20 said, in regards to R1 on Saturday, She was a lot more with it, at least more than Sunday .Saturday she was not even talking in a normal conversation but she could at least talk. She asked to talk to her mom. She was trying to help us turn her on Saturday but you could tell something was going but it was not as bad as Sunday. She could say she was hurting and she really did not like to reposition. The weekend before I only saw her a little but she was a lot more alert and conversational (The weekend prior to 6/10/23 and 6/11/23) . it was a big change to the next weekend . It was painful for her when I would provide incontinence care .I even told the night CNA, if she doesn't get sent out, that he needed to check on her every hour and don't go longer than that. V20 said, in regards to R1 on Sunday 6/11/23, She was a lot worse. She was totally out of it. I tried to wake her up for breakfast and she wouldn't wake up at all, she mumbled a few things but that was it. I told her I would leave her breakfast and I would come back. I asked if she needed help, but she didn't say anything. I tried to get her a drink with a straw and the water just ran out of her mouth . Then at lunch she did nothing again. I told the nurse that she has gotten way worse; it was around lunch time. I don't know the exact time, but it was right around lunch time. Then, sometime between 3:00 PM and 5:00 PM, [V19 RN] went down there to check her (R1) vitals and they couldn't get vitals on her. I did see [V19] go down and check on her at lunch time. I don't know if she did a set a vitals on her at lunch time but, I did tell [V19] I would do a set of vitals and with everything going on I forgot to do them. (R1's Electronic Charting showed no vital signs on or about 12:00 PM on 6/11/23) When [V19] saw her at lunch time, [R1] would not have been alert and oriented. She was not alert for me at all; the entire shift. I would say her condition from Saturday to Sunday, she had a change in condition. Even on Sunday morning she already had a change in condition. I even asked what meds she was on Sunday morning because she appeared snowed (sedated) to me, and she was on Seroquel so I thought that was the cause of it but she never came around. I don't think [V19] had ever taken care of her before so I don't think she knew if this was a change in condition. [V19] would not have known this was change. The family came in later in the afternoon, they came in right before, as everybody decided she (R1) needed to be sent out The way [R1] was when she was sent out she was not in any different condition than she was in the morning. [R1] was talking about asparagus and she said I had pretty pale skin, but I am super dark and tan and I have brownish green eyes but she said I have beautiful blue eyes. She said that around lunch time, and that was when I told [V19] that she was not really waking up at all. V20 said, It wasn't until the full time employee came in on Sunday night; she came in early around 4:30 PM or so, and we told her how [R1] was acting .It was the night nurse (V18) that prompted us to send her out. I think if [V19] knew she (R1) was alert and oriented prior to Sunday, she (V19) would have sent her (R1) out earlier that day. But no one knew how she was normally and it wasn't until [V18] came in that we were aware how she was acting was not normal. [V19] didn't work Saturday either. V20 said, R1 had yellow drainage that was not urine. V20 said, in regards to the drainage, I've never seen anything like that before and I have [AGE] years of experience .The yellow discharge smelled like, it's hard to explain, I've never smelled anything like that before, it was not normal. I don't think it was a yeast infection, It seemed like it was vaginal discharge but I did not think it was a yeast infection. I've had residents with yeast infections and it didn't look like any of those that I have seen before. V20 said, Oh god yes, most definitely with UTI's and infections, there is a big change in cognition. I remember, I think [V18] said, they were trying to get a UA on her but she wouldn't let them straight cath her. I don't know how long they had been trying to get one. On 6/13/23 at 3:49 PM, V16 CNA stated she worked the day shift on Sunday 6/11/23. V16 said, Sunday was my first time meeting [R1]. She was really out of it. She had her eyes closed and she could not form a sentence. That was how she was at the beginning and the end of the shift .She did have a brief (incontinence brief) I didn't notice any blood but I did notice some yellow pus like discharge. The yellow pus was mixed with the urine. I didn't see any yeast like discharge when I cleaned her up. My understanding that was her normal condition .the nurse [V19] said she was out of it as well. [V19] did not say this was abnormal for her. My shift that day was 6:00 PM to 2:00 PM that day. She was definitely not alert, oriented, and answering questions when I saw her. She was the same my entire shift. If I had cared for her previously and she was alert and oriented at that time, I would have told the nurse she needed to be evaluated because the way I saw her on Sunday that would have been a change .She (R1) was just gibberish nothing that she said was understandable. I did not do the vital signs on her that day the nurses will sometimes give us a list of residents that need vitals but they did not give us a list that day. I did try talk to her and I tried to feed her both meals but she pushed them away both times. On 6/14/23 at 8:15 AM, V19 stated, prior to 6/11/23, she had never cared for R1. V19 said she saw R1 for morning medication pass, then again shortly after medication pass. V19 stated she saw R1 for less than 10 minutes during the day. V19 said during morning medication pass R1 stopped V19 from giving her medications water and she wanted to take them with soda; however, she did not really speak with R1. V19 returned to apply a cream to R1's vaginal area and R1 did not say anything. V19 stated she believed R1 was alert and oriented in the morning of 6/11/23. On 6/15/23 at 11:24 AM, V19 denied being told at lunch time on 6/11/23 of a declining condition. V19 denied requesting a CNA do vitals for R1 and denied being aware of the CNA stating she would perform vitals on R1. V19 said, I would have gone down and done an evaluation, if I had known there was a change, but that was my first time taking care of her and I know she has a history of behaviors. I told [V18] maybe she (R1) was having behaviors that afternoon. I would say when I went in in the morning she was awake and alert. I would say that not being able to make her needs known, not opening eyes, and being out of it would be a change in condition. If I had been told that, I would have gone down and done an assessment. I would expect the CNA's to tell me if the resident was having a change in condition . A change in cognition is not uncommon for residents with a UTI . On 6/14/23 at 3:01 PM, V22 RN stated he sent the fax on 6/1/23 to R1's physician. V22 said, said R1 was incontinent; alert and oriented; and she could make her needs known. V22 stated, R1 reported to him the symptoms listed on the fax sheet. V22 said the symptoms he reported are consistent with the symptoms of a UTI. V22 stated he notified the physician of R1's refusal for catheterization and he was not aware if V4 responded. V22 stated an untreated UTI can lead to sepsis. V22 said if resident is unable to provide a urine sample for UA but the resident has symptoms of a UTI, he would encourage fluids and contact the resident's physician to see if we can get an antibiotic due to the signs and symptoms of a UTI. On 6/14/23 at 12:25 PM, V3 Assistant Director of Nursing stated if a resident refuses straight catheterization the nurse should attempt alternatives such as a bedside commode or bed pan if needed. V3 said the doctor should be notified if the staff are unable to obtain a UA. V3 said there should be follow up if nursing does not hear back from the doctor and the resident continues to have symptoms. V3 said she did not interact extensively with R1; however, [R1] could respond appropriately. On 6/15/23 at 12:48 PM, V4 Medical Director/Physician stated signs and symptoms of a urinary tract infections in females are discomfort with urination and urinary frequency. V4 said UTI's are typically diagnosed based on UA results. V4 said UTI's left untreated, can resolve on their own but the infection could get worse, it could spread. A person can become septic from a UTI. It's variable but it takes longer than a day to become septic from a UTI. V4 stated he was R1's physician; however, he had not yet met her in person for an examination. V4 said he did not recall the fax messages regarding R1. V4 stated he did not recall being notified of R1 refusing to be catheterized or the facility being unable to obtain a UA for R1. V4 said the symptoms described on the fax message sent on 6/1/23 of burning with urination, urinary urgency, and bloody discharge are symptoms consistent with a UTI. V4 said he does not recall the facility notifying him of foul smelling urine and pus like discharge, which V4 stated are symptoms of a UTI. V4 said, If the staff are not able to get a UA and the resident is having symptoms, if I don't respond to the fax, I would expect the staff to do some sort of a follow up with me. V4 stated, if he had been notified of urgency with urination, burning with urination, blood tinged urine, yellow discharge, and foul smelling urine, refusal of catheterization, and staff were not able to do a hat (a hat is a urine catch device placed in a toilet) then V4 would have said lets go ahead and treat it with an antibiotic. If I had been called and she was treated with an antibiotic, it's possible that she would not have become septic. V4 said that based on the quick diagnosis of a UTI at the hospital (within a few hours of arriving at the hospital) and based on the symptoms she had at the facility; R1 had the UTI while she was living at the facility. V4 said a change in cognition is not an uncommon symptom of a UTI. V4 stated, prompt care of a UTI can be important. It is better to treat it sooner rather than later. It's not the best case scenario to let it go a week or two. V4 stated he does not recall being notified of a change in cognition for R1and he would expect to be notified of such a change. V4 stated nurses may use their best judgement and send a resident out for evaluation without notifying him. R1's Physician Order Sheet showed no orders for antibiotics during her stay at the facility. R1's Progress notes from 6/1/23 through 6/11/23 (with the exception R1's note on 6/11/23 when she was sent out for evaluation) showed no communication with R1's physician regarding an inability to obtain a UA or notification of a change in cognition. On 6/14/23 Documentation of R1's UA results, if done, was requested and not provided The facility's Change in Condition Physician Notification Overview Guidelines policy (Reviewed 4/22) showed, Theses guidelines were developed to ensure that: All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and is to be documented in the medical record .medical care emergency problems are communicated to attending physician and family as soon as possible. The policy continued, The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgement requires immediate medical intervention .Any calls to or from the physician will be documented in the nurse's notes indicating information conveyed and received.

Based on observation, interview, and record review the facility failed to monitor a resident's weight who had congestive heart failure; failed to provide wound care in a manner to prevent cross contamination; and failed to provide ongoing assessments for a resident readmitted following a pulmonary embolism. This applies to 4 of 5 residents (R11, R29, R54, R1) reviewed for quality of care in the sample of 23 and 1 resident (R20) outside of the sample. This failure resulted in R11 being hospitalized for an exacerbation of congestive heart failure and chronic obstructive pulmonary disease. The findings include: 1. R11's Face Sheet showed an original admitted [DATE] with numerous diagnoses to include: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, and morbid obesity. R11's 12/21/22 Minimum Data Set (MDS) showed he was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. R11's MDS showed he required limited assistance of one person for transfers and dressing as well as extensive assistance of one person for toilet use and personal hygiene. On 3/06/23 at 7:42 PM, R11 was in his room, in his wheelchair, and self-propelling in his room. R11 was using supplemental oxygen via nasal cannula set to 5 liters per minute. R11 stated, I just got back from hospital today. I was there for five days. I have CHF and I was having trouble breathing for several weeks and I just couldn't take it anymore. They (hospital) took 14 liters [of fluid] off of me. I can breathe better now. They (facility) never weigh me. I've only been weighed a few times since I've been here .I don't think the staff recognized what the problem was .Everyone knew I was having breathing difficulties. I told everybody that. I even told the activity lady. The activity lady took my oxygen saturation. It's just that no one was pushing me to go to the hospital except myself. R11's hospital discharge summary from 3/6/23 showed during his hospital stay Continue bumex (diuretic) gtt (intravenous drip) and albumin (intravenous protein) for exacerbation of CHF. The summary showed he was down 7 liters of fluid. R11's electronic health record showed he was sent to the hospital on 3/1/23. R11's progress notes showed no entries on 3/1/23. R11's electronic health record showed no documented assessment on 3/1/23. R11's 3/6/23 Nursing Progress Notes from 2:25 PM showed he readmitted to the facility at 1:45 PM (5 day hospital admission). R11's Weights and Vitals Summary from 11/1/22 through 2/31/23 showed the following (only 4 weights): on 11/30/22 he weighed 232.4 pounds; on 12/1/22 he weighed 248 pounds; on 1/26/23 (nearly two months between weights) he weighed 249.4 pounds; on 2/1/23 he weighed 250 pounds (This was the final documented weight prior to R11's hospital admission.) R11's documented weight on 3/7/23 was 271 (21 more pounds than the previous weight) pounds. (This weight is following a hospital stay in which 7 liters of fluid, or 15.4 pounds was removed.) R11's 2/26/23 Dietary progress note for 10:57 PM showed his chart was reviewed and he triggered for significant weight gain of 17.6 pounds or 7.6 percent over 3 months (From his weight of 232.4 pounds on 11/30/22 to his weight of 250 pounds on 2/1/23) The note showed R11 had a diagnosis of CHF and he was on diuretic therapy, which may be attributing to his weight fluctuations. (The note did not indicate R11's provider was notified of the weight gain. This note was documented 25 days after he was weighed on 2/1/23. Note was authored by V28 Registered Dietitian.) On 3/08/23 at 11:19 AM, V28 stated she did not recall R11. V28 stated CHF resident are .at risk for fluid gain or fluid loss from week to week typically they are weighed weekly; depending on doctor orders. I would expect the doctor to be notified [of weight gain] because they might need an increase in their diuretics. I think it's possible that maybe he (R11) would not have needed to be admitted [to the hospital] if the MD was notified and the diuretic was increased. On 3/08/23 at 3:38 PM, V2 Director of Nursing stated, she could not find any assessment or documentation regarding why R11 was sent to the hospital. V2 stated she would expect a head-to-toe assessment if a resident is complaining of shortness of breath. V2 said, They (the hospital) ended up keeping him for 5 days which, means it was fairly significant. CHF patients can get fluid around their lungs and that can cause shortness of breath. Weighing should be done weekly for CHF to monitor for fluid increase. They should have seen the weight increase way before (2/26/23). The second they (resident) put on the weight it should have been identified. V2 said if weight gain is identified, They should call the doctor as soon as it notified and assess the resident. V2 said, if weekly weights were done and the doctor was notified of R11's weight gain, she would anticipate an increase in R11's diuretic dosing or a new diuretic medication. V2 said these interventions could have prevented R11 from experiencing shortness of breath and a subsequent 5 day hospital admission. The National Library of Medicine published study titled Information Needs of Skilled Nursing Facility (SNF) Staff to Support Heart Failure Disease Management (published 1/25/21) showed, monitoring body weight, administering medication, and sodium restricted diets Improved outcomes of patient with HF (heart failure) in skilled nursing facilities .Evidence shows that performing heart failure disease management (HF-DM) practices as described by clinical guidelines can decrease mortality rates, decrease hospital admission rates, and improve quality of life for HF patients by relieving symptoms. However, within the SNF, quality of HF care is highly variable and HF-DM practices are applied inconsistently .Clinical practice guidelines recommend monitoring for changes in body weight and changes in symptoms because these early warning signs can alert staff and physicians to worsening HF, prompt early intervention, and may help patients avoid hospitalization s . 2. R29's Face Sheet showed an original admitted [DATE] with diagnoses to include: chronic ulcer of right heel and midfoot; diabetic foot ulcer; and type 2 diabetes. On 3/07/23 at 1:45 PM R29's was supine in bed with an elastic bandage and wound vacuum to his right foot. On 3/7/23 at 1:45 PM, V15 wound care nurse removed R29's dressing to his right heel by cutting the elastic bandage as well as the underlying dressings and then removed his negative pressure wound therapy NPWT (commonly referred to as a wound vac) tubing. V15 set the scissors in R29's bed. V15 then cleaned the wound and applied the NPWT dressing; during this time V15 did not change her gloves until after R29's drape dressing was applied. V15 did not sanitize her scissors prior cutting the new NPWT drape and foam dressing components (same scissors used to cut the old dressing then set in R29's bed.) On 3/08/23 at 4:09 PM, V2 Director of Nursing stated V15's gloves should have been changed after R29's dressing was removed and before the wound was cleaned. V2 said this is done to prevent cross-contamination of the wound. V2 said V15's scissors should have been disinfected prior to cutting R29's clean NPWT drape and foam. V2 said her scissors could have been contaminated from cutting the old dressing and/or setting them down in the resident's bed. 34491 3. R54's Admission Record, printed by the facility on 3/8/23, showed diagnoses including cellulitis of left and right lower limbs, morbid obesity, dyspnea and arthropathies (diseases of the joints i.e. arthritis). R54's most recent facility assessment showed she is cognitively intact (BIMS score of 15) and is independent with activities of daily living. The assessment showed R54 does require supervision for dressing and personal hygiene. R54's Admission/Readmission Screener dated 11/19/22 showed Skin Integrity: 1. Current ski integrity issues: Venous or arterial ulcers. The screening document also showed R54 had +1 pitting edema to her bilateral lower extremities. R54's 11/19/22 Discharge Summary, from a local hospital, lists self neglect as one of her discharge diagnoses. On 3/6/23 at 6:08 PM, R54 was sitting in her room, in her wheelchair. Both of R54's lower legs were covered in bandages. Both of R54's feet were swollen and her right foot was very red. R54 said she has infections in both legs. R54 said she changes the bandages on her legs herself. R54 opened the drawer to her night stand and it was filled with supplies to do the dressing changes. On 3/8/23 at 11:08 AM, R54 was sitting in her wheelchair in her room, doing needlepoint. R54 put the needlepoint down and got the supplies out of the bottom drawer of her night stand to do the dressing change. R54 cut the gauze that was wrapped around her right leg and removed the gauze. R54 did not perform hand hygiene or wear gloves at any point during the wound care. R54 had oil emulsion dressings around her right lower leg. R54 said she put them on that morning so she was not going to change them as she already had and they were to be changed daily. R54 put saline on gauze and patted the oil emulsion dressing with the gauze. Then R54 put a little more saline on another piece of gauze and wiped all over the top of her right foot, going over intact skin and then the 2 open areas on her right foot (one near the arch of her foot and the other at the top by her first and second digits). R54 said I know I should use gloves, but I can't feel my fingers with them on. R54 dropped the rolled gauze onto the floor and it rolled about 8 inches from her wheelchair. R54 used a reacher bar to scoot the gauze close enough back toward her to where she could pick it up. R54 placed the rolled gauze back on her table with the other wound supplies. R54 grabbed three abdominal pads from the bedside table and placed them on her abdominal area of her shirt, with the blue line facing out. R54 taped the three abdominal pads together and then wrapped them around her right leg, with the sides of the abdominal pads that had been in contact with her shirt directly over the oil emulsion dressings. R54 grabbed the rolled gauze that had recently been on the floor and wrapped the rolled gauze around the abdominal pads on her right lower leg. R54 grabbed scissors and cut a section of the rolled gauze to tie together in order to secure the gauze to her right leg. After wound care R54 put the supplies back in the bottom drawer. R54 did not perform hand hygiene after wound care. R54's Nursing Progress Note dated 3/1/23 at 3:08 PM, showed, Late Entry: (entered on 3/3/23) Note Text: I talked to this resident about doing her legs. She stated that she can do her own legs. I told her that I could do them. She said you don't do them right anyway. I asked if the way you do your leg is how you want them done. She said yes. I reached out to the Wound Doctor, she stated that the resident will be discharged from the Wound Center because she has refused or don't want to do any of the treatment they have offered for her. I told the doctor that she stated that she likes the way that she does her own legs. She told me to get in contact with the MD. I sent him a note and told him about what was going on with the resident and how she has started doing her own legs, because she refuses a lot. The Physician gave the order to let her do her own legs if she prefers. I will monitor the legs for signs or symptoms of infection or edema. Resident told about the order. R54's Order Summary Report, listing the active orders as of 3/9/23, showed an order on 3/3/23 Resident to do her own wound dressing because of continuous (refusals). Nurse will monitor the lower legs for signs and symptoms of infection or edema one time a day, every 6 days for wound care. the report showed an active order dated 2/9/23 for right and left leg and right heel: Apply a thin layer of betamethasone valerate 0.1% over the adaptic dressing (a dressing with a specially formulated petrolatum emulsion to help protect the wound while preventing the dressing from adhering to the wound) and apply to the entire open wound from heel up on the right lower leg. Cover with a 4 x 4 gauze, Qwik (an absorbent and wicking dressing) and ABD (abdominal) pad. Secure with (rolled gauze), paper tape and a 6 inch ace wrap three times a day for wound care. The Order Summary Report also showed an order for Ciprofloxacin HCl 500 mg (milligram) tablet twice daily for leg infection until 4/9/23. R54's Unit Nurse Skin Review dated 3/7/23 showed she has open ulcers and cellulitis. R54's Skin/Wound note dated 3/2/23 showed The resident has a venous ulcer on the right and left leg. Both of the lower legs are macerated (moisture associated skin damage). The right leg venous ulcer measures 12.5 x 44.5 x 0.1 cm (centimeters) with large serous (thin, watery fluid that is produced in response to local inflammation) drainage. This wound is a full-thickness wound. The left venous ulcer measures 12.0 x 15.8 x 0.1 cm. This venous ulcer is full thickness with moderate drainage . On 3/8/23 at 1:30 PM, an assessment of R54's abilities to perform wound care on her own was requested. On 3/9/23 at 10:23 AM, V2 (Director of Nursing) said she did not see an assessment in R54's medical record to determine her ability to perform self-wound care. This surveyor's observation of R54 performing wound care to her right leg was described to V2. At 10:30 AM, V2 stated, Based on the information you just provided, it is obvious that we should be doing her wound care and she should not be doing her own wound care. 41639 4. R1's electronic face sheet printed on 3/9/23 showed R1 has diagnoses including but not limited to chronic respiratory failure, chronic obstructive pulmonary disease, pneumonia, congestive heart failure, acute kidney failure, fluid overload, and hypertension. R1's facility assessment dated [DATE] showed R1 has no cognitive impairment. On 3/7/23 at 7:53AM, R1 stated, I go to the hospital quite often, usually for my congestive heart failure. They used to weigh me every day but for some reason they don't anymore. They hardly ever weigh me and the doctors always tell me I need to monitor my weight to see if I'm retaining fluid. R1's weight record showed for February and March 2023 showed R1 is weighed 3-4 times per month. R1's weight record showed on 2/24/23 R1's weight was 344.8lbs (pounds) and on 3/6/23 R1's weight was 349.8lbs (5 lb. weight gain in 1 month). R1's nursing progress notes dated 2/19/23 showed, Patient complaining of shortness breath and difficulty catching his breath. Patient oxygen 89% with 4 liters per nasal cannula, desaturating ranging from 84-86%. Not able to titrate levels above 90%. Patient stated that he would like to go to the hospital to be evaluated. Patient note with elevated Blood pressure 129/102 heart rate: 110. Call placed to (local ambulance) .Patient admitted with bilateral pneumonia per (local hospital). R1's nursing care plan dated 12/18/22 showed, The resident demonstrates a potential for fluid overload related to: noncompliance. Education provided on risks of fluid overload, patient states, I do not care about diet or fluid restriction, it makes me happy and I will die happy. Physician notified of non-compliance, assess for signs and symptoms of fluid overload & notify the physician if signs and symptoms of fluid overload are present: adventitious lung sounds, observe, assess & record signs of edema. R1's local hospital discharge records dated 2/24/23 showed, Weigh yourself daily before breakfast. Notify physician if 3lb weight gain in 24 hours or 5lb weight gain in 1 week. R1's physician's orders showed an order for daily weights was discontinued in November 2022 when resident was sent to the local hospital. R1's daily weight physician's order was not reinstated when he returned back to the facility in November 2022. On 3/9/23 at 9:05AM, V4 (Certified Nursing Assistant) stated, All residents are weighed per orders and the nurse gives us a list of who needs to be weighed. If the nurse notices a discrepancy then she will have us reweigh them. (R1) is weighed monthly as far as I know. We haven't been asked to weigh him more often. He would even go down and weigh himself if we asked him to. On 3/9/23 at 9:53AM, V2 (Director of Nursing) stated, Weights should be obtained per physician's orders. Best practice for a resident with congestive heart failure is to weigh them every day to keep an eye on their fluid status and be aware of any concerns with fluid overload. 31615 5. R20's nursing progress notes for 3/4/23 at 5:20 PM document she had complaints of flank pain and shortness of breath. Her vital signs included a blood pressure of 144/91 and pulse oximetry level of 86% on room air. R20's daughter who was present at the time requested R20 be sent to the hospital for evaluation. The notes show R20 was sent out and admitted to the hospital for a pulmonary embolism (blood clot in the lung). R20's progress note of 3/8/23 at 1:51 PM shows she returned from the hospital via stretcher at 12:46 PM, she was alert and oriented x 2. No complaints of pain and her call light was in reach. The nursing note did not include any assessment or vital signs upon her return. The assessments were reviewed for 3/8/23 and show no assessment until 10:06 PM. That assessment showed vital signs taken on 3/4/23 at 10:00 AM, before R20 was sent out to the hospital. No current vital signs are documented in the computer charting program. On 3/9/23 at 11:58 AM, V29 LPN said R20 just came back from hospital and is on a 72 hour monitor status, so the nurses document her condition and pain level every shift. Vitals are done every shift and are documented in the computer under assessments and vital signs tabs. V29 said when a resident returns from hospital the nurse should do an assessment, get vial signs notify the family and physician of their return. She said when vital signs are posted in the record, they will transfer over to the vital signs tab. V29 said she had not obtained R20's vital signs yet for her shift. On 3/9/23 at 12:24 PM, V2 said when a resident returns to the facility, they are a re-admit and should follow the same procedures as a new resident. The nurse should do a physical assessment including a set of vital signs. V2 said the manager V15 (Registered Nurse) was on duty and should have either obtained a fresh set of vitals or had an aide get them for her. V2 checked R20's record and said the last set of vital signs she sees are from 3/4/23. V2 said there is no excuse for not having the assessment and vital signs completed. The facility's 11/2022 policy for admission of a resident shows the purpose of the policy is to facilitate smooth transition into a health care environment and to gather comprehensive information as a basis for planning individualized therapeutic care. Procedure: 9. Conduct head to toe nursing assessment of body systems, parts, and surfaces identifying functional status abilities, needs, or problems. Be sure to measure any areas of redness or skin breakdown on extremities or other skin surfaces. 18. complete admission record, charting, T.P.R (Temperature/Pulse/Respirations), Blood pressure, height and weight. 20. Record in detail on nurses' notes all other pertinent information such as: a. Findings from the assessment-required to meet the residents needs, which can in turn be conveyed to the physician so the admission orders cover all aspects of required treatment.

Based on observation, interview, and record review the facility failed to implement interventions to promote wound healing; failed to assess a pressure injuries upon readmission; and failed to implement treatment for a pressure injury upon readmission. The facility also failed to provide care in a manner to prevent pressure injury cross- contamination. This applies to 3 of 7 residents (R51, R23, R10) reviewed for pressure ulcers in the sample of 23. This failure resulted in R51's pressure ulcers not being assessed or treated upon readmission leading to a worsening of R51's pressure injury. The findings include: 1. R51's Face Sheet showed an original admitted [DATE] with diagnoses to include: Right pubic fracture (onset 12/27/22); Non-Pressure chronic ulcer of right and left lower leg; heart failure. R51's 1/8/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. R51's MDS showed she required extensive assistance of two staff for bed mobility, transferring, dressing, and toileting. R51's Pressure Injury Report showed she had an unstageable pressure injury to her left heal measuring 1.1 centimeters (cm) by 1.3 cm by 0.1 cm. The report showed the right heel was also unstageable measuring 0.9 cm by 1.1 cm by 0 cm. The pressure injury report showed it was identified in this condition on 2/23/23 and the last assessment was 2/23/23. (Document was provided on 3/9/23 at 11:23 AM.) R51's Skin/Wound Note from 2/23/23 at 8:26 PM showed she has blisters to the left lower leg that burst open and Eschar (dead tissue) to both heels. The note showed the same measurements as the pressure injury report from 2/23/23. The note showed she applied a betadine (antiseptic) moistened 4 inch by 4 inch gauze pad, an absorbent pad (ABD), and a gauze wrap. The note showed, I put pillows under her feet to help relieve pressure. R51's Skin/Wound note from 2/16/23 showed no heel injuries. R51's 2/27/23 Progress note from 2:24 PM showed she was sent to the local emergency department for increased confusion and swelling to her legs. R51's 3/3/23 Social Service note from 2:02 PM showed she returned to the facility. On 3/7/23 at 2:20 PM, R51 had signage on her door indicating she was in contact and droplet isolation. R51 was supine in bed. R51 had gauze wrap to her lower leg extending to the middle of her foot. The gauze wrap was covered with an elastic support bandage. R51 had a blanket folded under her ankles; however, R51's heels were touching the bed. R51's March 2023 TAR (provided 3/9/23) showed her heel treatment was discontinued on 3/2/23. R51's TAR showed no heel treatment was documented as being provided. On 3/8/23 at 11:48 AM, R51 was supine in bed. Heels in full contact with the mattress; no blanket under her ankles. On 3/9/23 at 8:34 AM, R51was supine in bed and her heels were in full contact with the mattress. On 3/9/23 at 8:34 AM, R51 stated she has not been out of bed since she returned from the hospital. R51 said, I guess I'm lucky I have water. They don't care about me here. On 3/9/23 at 9:51 AM, V7 Licensed Practical Nurse (LPN) stated if there are not orders for wound care she wouldn't know that the treatment needed to be done. On 3/9/23 at 9:55 AM, R51's heels remained in full contact with her mattress. Her room was as it was at 8:34 AM; over bed table to the side, no breakfast tray in the room. On 3/9/32 at 9:55 AM, R51 stated, I never got my breakfast. I'm starving please just get me a cracker or something. On 3/9/23 at 10:10 AM, V1 Administrator stated there is a camera on R51's hallway. (Requested V1 review video showing staff provided R51 a breakfast tray; no video proof was provided.) 03/08/23 11:19 AM, V28 Registered Dietician said proper nutrition and protein is important for wound healing. On 3/9/23 at 10:49 AM, V7 and V14 Certified Nursing Assistant (CNA, providing assistance for V7) entered R51's room for wound care. V7 removed the bandage to R51's right lower leg and stated there is no wound to the right heel. The dressing removed from R51's left heel did not include a betadine moistened gauze or an absorbent pad (ABD.) V7 removed the wrap to R51's left lower leg and said there is a heel wound and she has no orders to treat this wound. R51 refused to have her legs wrapped again. R51 stated she wanted to leave them off for a while because they make her legs hot. V7 did not provided education or encouragement to R51 regarding the importance of wound care and protecting her wounds. V7 also did not offer alternative options to protect R51's wound. At 11:03 AM V7 and V14 completed their care and left the room. R51's left heel draining pressure injury was in full contact with the bed; her heels were not off-loaded. On 3/09/23 at 10:49 AM, R51's left heel was approximately 3 inches by 2 inches (7.6 cm by 5 cm; wound is considerably larger compared to 2/23/23 assessment.) On 3/09/23 at 11:03 AM, R51 stated, If they had a pillow, I would let them get my heels off the bed. That would probably feel good. I think they are supposed to have my heels not touching the bed anyways. On 3/09/23 at 11:20 AM, V2 Director of Nursing stated, (while reviewing R51's electronic record) she could not find any treatment orders for R51's left heel. V2 stated, It (R51's left heel pressure injury) was first identified to left heel on 2/23/23 per the wound report. It was found as an unstageable pressure wound. I would expect her wound to be found prior to it having eschar, which is dead tissue. I don't see any other assessment other than 2/23/23. V2 said R51's wound should have been assessed upon her return from the hospital on 3/3/23. (R51's wound had not been assessed by the facility as of 3/9/23 at 11:20 am; 6 days later.) V2 said R51's heels should be off-loaded to promote wound healing. V2 said an indicator of a wound declining is increasing in size, smell, or pain. V2 said wound orders are important to ensure the best wound care to promote healing is put in place; ensures the physician is aware of the resident's current status; and it ensures the wound treatment is being done. V2 said the importance of wound assessments is to track the wound to determine if the wound is declining, which may warrant a change in wound care. V2 said the only location R51's wound treatment would be documented is in the wound report and/or her treatment administration record. R51's Care Plan showed, Skin will be checked during routine care on a daily basis and during the weekly bath or shower schedule per resident preference. R51's care plan showed no interventions to off-load her heels. R51's February 2023 Treatment Administration Record (TAR) showed both heels should be cleaned and dried; betadine moistened gauze applied; and then covered with gauze and an ABD pad. The TAR showed this treatment was not initiated until 2/26/23 (3 days after wound was identified.) R51's Wound Policy (Revised 2/2023) showed finding from the weekly skin assessment should be completed by the wound nurse or designee and should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues . The policy showed, Nursing staff should keep the attending physician aware of the progress of all ulcers, especially those in higher risk residents, those that do not heal as anticipated, and those that develop complications . 38488 2. R23's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include acute on chronic congestive heart failure, chronic atrial fibrillation, difficulty in walking, unsteadiness on feet, essential hypertension, gall bladder disease, Type 2 Diabetes, and major depressive disorder. R23's facility assessment dated [DATE] showed he has severe cognitive impairment and requires extensive assistance from staff for all cares. R23's nursing note dated 11/30/22 showed, I was called to resident room. CNA was cleaning resident's toes and there is an area between great and 2nd toe. It appears to be a stage 2. Right foot. It was cleansed and protocol initiated. Wound nurse was notified. R23's Skin/Wound note dated 11/30/22 entered at 6:36 PM showed, . Resident has an opening on the top of the toe. The third toe is rubbing the skin off. Wound measures 0.9 x 1.6 x 0.1 cm . R23's November 2022 TAR (Treatment Administration Record) showed no orders for wound care to R23's 2nd toe. R23's December 2022 TAR showed an order for treatment to R23's 2nd toe on his right foot was not started until 12/6/22 (6 days after identification). On 3/8/23 at 2:33 PM, V15 (Wound Care Nurse) entered R23's room to provide wound care to the pressure sore on R23's right foot. V15 entered the room and went directly to R23's bed. V15 did not perform hand hygiene prior to starting R23's wound care. V15 applied gloves, sprayed the wound with wound cleanser, cleaned the wound with gauze, removed her gloves (did not perform hand hygiene), put on a new pair of gloves and put the new dressing on. V15 then removed her gloves, picked up the wound supplies, exited R23's room and went to the clean utility room where she washed her hands. V15's heels were not floated prior to V15 leaving the room. On 3/09/23 at 11:57 AM, V2 DON (Director of Nursing) said hands should be washed after entering the room and before touching the resident. V2 said gloves should be put on and changed after the wound is cleaned and before putting the new dressing on. V2 said gloves should be changed during the wound care but no hand hygiene is necessary due to time restrictions while performing dressing changes. V2 said V15 should have washed her hands before leaving R23's room. The facility's policy and procedure revised 11/8/22 showed, Hand Hygiene; Purpose: Provide guidelines on proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infection . Procedure: . 3. The use of gloves does not replace hand hygiene. 4. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE) . Staff will perform hand hygiene by washing hands for at least twenty seconds with antimicrobial or non-antimicrobial soap and water under the following conditions: . c. Before applying gloves and after removing gloves or other PPE; d. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; e. After handling items potentially contaminated with blood, body fluids, or secretions; .g. After providing direct resident care . Surveyor: Gross, Patricia 3. R10's Admission Record, printed by the facility on 3/8/23, showed diagnoses including encephalopathy (a term for any brain disease that alters brain function or structure), other specified disorders of the brain, convulsions, bipolar disorder, autistic disorder, disorders of psychological development and altered mental status. R10's ADL (activities of daily living) care plan, with a revision date of 3/10/22. showed she had a self-care deficit and required total assistance of staff in all aspects of hygiene and dressing. R10's facility assessment dated [DATE] showed she had severe cognitive impairment and was dependent on staff for personal hygiene. The assessment showed R10 was always incontinent of bowel and bladder. R10's incontinence care plan, with a revision date of 1/4/21, showed she had incontinence of bowel and/or bladder. The care plan showed Administer appropriate cleansing and peri-care after each incontinent episode. Observe for signs of skin irritation and/or breakdown . R10's skin integrity care plan, with a revision date of 10/12/21, showed she is at increased risk for alteration in skin integrity and skin will be checked during routine care on a daily basis . R10's Order Summary Report, showing active orders as of 3/8/23, showed Cleanse coccyx with normal saline, pat dry. Apply foam dressing twice weekly. R10's 2/20/23 Skin/Wound note showed Resident has an open stage II to the left inner buttock cheek. The wound has a red outer edge. Full thickness wound with no drainage. Area measures 0.4 x 0.8 x 0.1 cm (centimeters) . 03/06/23 at 7:43 PM V17 and V18 (Certified Nursing Assistants-CNAs) were providing incontinence care during the bedtime care for R10. V17 cleaned R10's front, periarea, then rinsed and dried. V17 and V18 rolled R10 onto her right side. R10 had a couple small pieces of stool in her brief. V17 used the same wash cloths that she used to clean R10's periarea to wipe and rinse both of R10's buttock cheeks, then the rectal area, then wiped over the open wound on R10's left inner buttocks. V15 (Wound Nurse) came into R10's room and placed a dry dressing over the open area on R10's left inner buttocks. V15 did not clean the wound before placing the dressing on. On 3/09/23 at 9:03 AM, V29 (Licensed Practical Nurse-LPN) said it is not okay to clean a resident during pericare and then wipe over the open wound bed, it is cross-contamination. V29 said the staff should use a clean cloth to clean the wound bed. On 3/9/23 at 10:12 AM, V2 (Director of Nursing-DON) said she would expect the CNAs to use a clean wash cloth for each area during incontinence care. At 10:20 AM, V2 said staff should not clean stool and then go over any wound bed with the same cloth. V2 said staff should not use the same wash cloth to clean the front and back areas of the resident during incontinence care and then go over a wound bed because it would introduce bacteria into the wound bed. The facility's Wound Policy, with a revision date of 2/2023, showed Purpose . To promote healing of existing pressure and non-pressure ulcers. The policy showed 5. The goals of wound treatment are to; a. Keep the ulcer bed moist and the surrounding skin dry. b. Protect the ulcer from contamination, and c. Promote healing. 34491

Based on observation, interview, and record review the facility failed to ensure a resident on an enteral feeding did not experience severe weight loss, failed to provide enteral feeding per facility policy and procedure, and failed to follow the physician's order for enteral feeding for 1 of 2 residents (R9) reviewed for enteral feedings. This failure resulted in R9 experiencing a severe weight loss of 28 lbs in three months which is a 13% weight loss. The findings include: R9's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include cellulitis of bilateral lower extremities, major depressive disorder, and pressure ulcer of right buttock stage 3. R9's facility assessment dated [DATE] showed he has no cognitive impairment and is totally dependent on staff for all cares. R9's care plan initiated 1/10/23 showed, The resident is receiving a tube feeding and it has been determined to be medically necessary and the resident is at risk for complications: . inadequate calorie or protein intake, altered hydration . Goal: The resident will tolerate the tube feeding without complications thru the next review . Interventions: . The feeding tube will be utilized in compliance with current clinical standards of practice and services provided to prevent complications to the extent possible for the resident . Report the following to the MD (physician) for further medical evaluation: . changes in medical condition . weight loss . On 3/06/23 at 6:09 PM, R9 said he has lost a lot of weight since being at the facility. R9 said his pants are falling off of him. R9's record showed the first time the Registered Dietitian assessed R9 was on 1/21/23. This assessment showed, . Chart reviewed for new admission, skin review, and tube feeding follow up- noted that resident does not have orders for free water flush to meet hydration needs. RD (Registered Dietitian) to provide recommendations to clarify orders and increase protein to aid in wound healing. Tolerating TF (tube feeding), however, some noted refusals due to feeling full. Will encourage staff to notify RD if resident is not tolerating . PLAN: Continue to monitor with RD available as needed. Recommendations: 1) update TF orders to read: Jevity 1.2 bolus feed of 480 mls four times per day to Total Volume 1920 ml/24 hours; 2) Provide Free Water Flush: 200 ml four times per day to total volume 800 ml/24 hours; 3) Provide via PEG: Prostat 30 mls BID to aid in wound healing . R9's Dietary Progress note dated 2/10/23 showed, . Resident triggered for significant weight loss x 1 month [-11%, -23.6 pounds] - per nursing notes, resident has been reported to skip bedtime bolus feed resulting in decreased caloric intakes. Staff encourage resident to take bolus, however he will refuse Chart reviewed for skin review and tube feeding follow up and significant weight loss review . Plan: Continue to monitor with RD available as needed . R9's January 2023 MAR (Medication Administration Record) showed R9 refused 9 of 24 of his enteral feedings scheduled to be given at 9:00 PM. R9's February 2023 MAR showed R9 refused 20 of 28 of his feedings scheduled for 9:00 PM. R9's March 2023 MAR showed R9 refused 4 of 7 of his feedings scheduled at 9:00 PM. R9's weight record was reviewed and showed on 1/6/23 he weighed 213 pounds, on 2/6/23 he weighed 190 pounds, and on 3/8/23 he weighed 185 pounds. (This is a 13% weight loss in three months.) R9's Physician Order Sheet showed an order started 1/6/23, Enteral Feed Order, four times a day 16 ounce bolus feeding plus 21 grams protein and probiotic. The same Physician Order Sheet showed, Jevity 1.2 bolus feed of 480 mls four times a day to Total Volume 1920/ml over 24 hours. R9's physician order sheet did not include the addition of the free water flush recommended by the Registered Dietitian to meet R9's hydration needs. The same Physician Order Sheet showed an order started 1/29/23 for ProStat (protein supplement) twice daily. On 3/7/23 at 8:36 AM, V15 WCN (Wound Care Nurse) prepared R9's medications and placed them in a small drinking cup and poured water over them. V15 did not include Pro-Stat (protein supplement) with R9's medications. V15 mixed them with a spoon and entered R9's room. V15 did not wash her hands after she entered R9's room, filled a graduated cylinder with water from the bathroom and went to R9's bedside. V15 went into R9's closet and brought out a enteral feeding syringe. No hand hygiene was performed. V15 asked R9 if he wanted some protein today to which he answered yes. V15 took a scoop of protein powder from the large container of protein powder at bedside and placed a full scoop into the same cup with R9's medications and water. V15 stirred the mixture for several minutes to try and get the protein powder dissolved. The cup was full all to the top edge. V15 filled the enteral feeding syringe from the cup, opened the valve on R9's enteral tube and pushed the contents into his tube without checking placement. V15 repeated this for 15 syringe's full of medications, water, and his carton of tube feeding formula. V15 was adding water and formula to the cup to try and get all the medications and protein from the cup. No hand hygiene was performed before leaving R9's room. R9's complete medical record showed no evidence of notification to R9's physician regarding significant weight loss. On 3/09/23 at 11:57 AM, V2 DON (Director of Nursing) said in order for R9 to receive protein powder he should have an order for protein powder. V2 said ProStat is a protein supplement and since he has an order for the ProStat he should have received the ProStat. V2 said the facility has been trying with his comorbidities but he has declining rapidly. V2 said the facility has received recommendations for a continuous feeding but the family refuses. V2 said she was not aware of R9's continuous refusals for his nightly enteral feeding. V2 said she has told the nursing staff to do R9's feeding first thing in the morning because he is very hungry in the morning. V2 said R9's physician and nurse practitioner have been coming in every week for the previous month. V2 said the Nurse Practitioner and the Physician both document in the electronic record when they see a resident. V2 was unable to provide documentation to show R9 was seen by the Nurse Practitioner or the Physician since his admission to the facility. V2 said R9 goes to many physicians and all have recommended the same continuous feeding. The only documentation provided to show R9's physician visits was emergency room visit documentation. V2 said V15 (Wound Care Nurse) should have washed her hands upon entered R9's room and upon exiting after providing care. V2 said V15 should have checked placement prior to pushing the medications and tube feeding formula to ensure proper placement of the tube. V2 said R9's orders should reflect the free water flush to avoid dehydration. On 3/9/23 at 2:06 PM, V28 (Registered Dietitian) said residents who have enteral feeds are assessed monthly. V28 said they were aware of R9 refusing some of his nightly feedings but that they were not aware that he was refusing almost all of his nightly feedings. V28 said if they knew he was refusing these feedings so frequently they would have considered adjusting the other three scheduled feedings to increase his caloric intakes. The facility's policy reviewed 4/2022 showed, Tube Feeding; Purpose: To define infection control measures for the resident receiving tube feedings. Standards: 2. Wash hands before and after the procedure . 10. After each tube placement check, before and after medications and feedings, the tube is flushed with clear water (patency check) to completely clear the tube to remove all residues . The facility's policy reviewed 11/22 showed, Change in Resident's Condition . General: It is the policy of the facility, except in a medical emergency to alert the resident, resident's physician/Nurse Practitioner and resident's responsible part of a change in condition Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: . b. There is a significant change in the resident's physical, mental, or emotional status. c. There is a pattern of refusing treatment or medication. The facility's policy reviewed 11/22 showed, Weighing Residents; Purpose: To monitor weight gain or loss 1. Ease resident is weighed on admission and monthly thereafter, or in accordance with physician orders or plan of care. 5. A licensed nurse evaluates weight changes and determines if there is a 3 pound or greater weight loss/gain in one week and notified physician of unanticipated or undesired weight gain or loss. 7. Monthly weights shall be measured and recorded according to schedule. Undesired or unanticipated weight gains/loss of 5% in 30 days, 7.5% in three months, 10% in six months shall be reported to the physician, Dietary Manager and or Registered Dietitian .

Based on observation, interview, and record review the facility failed to monitor blood glucose levels for residents receiving diabetic medications to avoid adverse diabetic reactions, for 3 of 3 residents (R2, R4, R5) reviewed for [DIAGNOSES REDACTED]. R2 was hospitalized due to critical low blood glucose levels. There was no evidence of blood glucose monitoring found in R2's chart from 1/20/21 at 11:00 AM through 2/10/21 when R2 was transferred to the hospital. This failure contributed to R2 being transferred to an acute care hospital with a critically low blood glucose level on 12/31/20 and again on 2/10/21. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 1/20/21 when the facility failed to continue R2's blood glucose monitoring before meals and at bedtime. V1 (Administrator) was informed of the Immediate Jeopardy on 3/3/2021 at 11:00 AM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on March 3, 2021, however the facility remains out of compliance at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's admission documents dated 12/28/20 showed R2 to have a [DIAGNOSES REDACTED]. R2's electronic medical record showed her blood sugar was not checked at the facility between her first admission on 12/29/20 and her readmission to the acute care hospital for [DIAGNOSES REDACTED] (low blood sugar) on 12/31/20. R2's electronic medical record showed she was discharged to the acute care hospital on [DATE] and readmitted to the facility on [DATE]. R2's acute care hospital discharge summary dated 1/4/21 showed R2 was admitted to the hospital on [DATE] for low blood sugar. The same discharge summary showed, SNF (Skilled Nursing Facility) orders: . BGM (Blood Glucose Monitoring) AC (before meals) and HS (bedtime) . Follow up with (Referring Provider) 7-10 days . follow up regarding [DIAGNOSES REDACTED] (please consider reducing dose of [MEDICATION NAME] and/or [MEDICATION NAME]). The acute care hospital's hospitalist note dated 1/1/21 (during R2's hospital stay) showed, . Assessment and Plan, (1) [DIAGNOSES REDACTED] . Patient continue to receive [MEDICATION NAME] at NH (nursing home), despite little appetite, not eating. Home dosing of [MEDICATION NAME] and [MEDICATION NAME] held, Accuchecks ACHS (before meals and at bedtime) . patient admitted to the hospital, from local nursing home, with report of lethargy r/t [DIAGNOSES REDACTED] (blood sugar reportedly 30 at the NH). My sense here is that, even though the patient was not eating much lately, the NH continued to give her [MEDICATION NAME] XL 10 mg q day as well as [MEDICATION NAME] I find her (R2) to be very much A & O X 4 (Alert and Oriented to person, place, time, and situation); the patient has expressed some concerns regarding gaps in care at the NH that she came from . R2's eMAR (electronic medication administration record) for January 2021 showed R2's blood glucose level was checked from January 6, 2021 through 11:00 AM on January 20, 2021. No documentation of R2's blood glucose checks was found from January 20, 2021 at 4:00 PM through 2/10/21 when R2 was transferred to the acute care hospital for the second time for [DIAGNOSES REDACTED]. R2's physician order [REDACTED]. On 1/6/21, V5 (Nurse) sent a physician notification which showed, Resident has decreased appetite and intakes - may we have an order for [REDACTED].) R2's readmission paperwork from the acute care hospital dated 2/11/21 showed, Assessment and Plan H&P (History and Physical) . Home dosing regimen of [MEDICATION NAME] and [MEDICATION NAME] held as inpatient. Consideration reducing dose of [MEDICATION NAME] and/or [MEDICATION NAME] as outpatient. Accuchecks ACHS (before meals and at bedtime) . BMP (lab results) demonstrated blood sugars to be 34. Underlying etiology is likely due to poor oral intake and continue use of sulfonylurea (blood sugar reducing agents) . Based on documentation considering patients repeat hospitalization with the last 90 days, patient is not a good candidate for sulfonylurea. Would recommend discontinuing medication Patient has had previous hospitalization with similar symptoms; unresponsiveness and altered mental status. During last hospitalization , patient was found to have [DIAGNOSES REDACTED] and similarly during this hospital stay on 2/11/21, blood work was collected, the patient was found to have low blood sugars. Based on documentation from previous hospitalization , recommendation was to reduce sulfonylurea doses for diabetes management however medications have been continued the same level. R2's Medication Administration Records for January, and February 2021 show that R2 continued to be given [MEDICATION NAME] 1000mg twice a day, and Glypizide 10mg daily. (Both diabetic medications) R2's complete care plan initiated on 12/30/20 with most recent revision date of 1/14/21 included no care plan for [DIAGNOSES REDACTED]. On 2/26/21 at 3:15 PM, V2 DON (Director of Nursing) said she was unsure why R2's blood sugars were not monitored as ordered and does not understand why the nursing staff stopped checking R2's blood sugars from 1/20/21 until she was transferred to the acute care hospital a second time on 2/12/21 with [DIAGNOSES REDACTED]. On 3/2/21 at 3:07 PM, V5 RN (Registered Nurse) said she remembered caring for R2. V5 said when R2 came back from her first hospitalization she requested an order to monitor blood sugars for 2 weeks because of the hospitalization . V5 said she did not know there was an order to be monitoring R2's blood sugars before that. On 3/3/21 at 1:55 PM, V10 (Nurse Practitioner) said she would expect the nursing staff to be communicating with her regarding needing blood glucose monitoring for a resident with diabetes. V10 said she would absolutely expect communication with her from the nursing staff regarding the need for blood glucose monitoring for a resident who has experienced hypoglycemic episodes requiring hospitalization . V10 said she is available by phone at all times for the nursing staff. V10 said when a new admission or readmission from the hospital come into the facility she reviewed the hospital documentation and the discharge orders, however, at this particular facility she is having a very hard time getting the admission paperwork located and at times it has taken several weeks for the hospital packet to be provided to her for review. On 3/2/21 at 2:52 PM, V1 Administrator said if someone would be admitted to the facility with a [DIAGNOSES REDACTED]. V1 said she would expect the nurses to contact the nurse practitioner as well. V1 said she would expect physician orders [REDACTED]. V1 said ancillary orders require no documentation. V1 said entering these orders as ancillary orders makes the order basically pointless because the order is just out there without any way to document that it is being done. The facility's undated policy titled Diabetes Mellitus - Routine Care showed, Purpose: To provide nursing staff with guidelines for implementing care for the person with Diabetes Mellitus .2. A focused assessment is performed by a licensed nurse within 24 hours of admission or at the time the [DIAGNOSES REDACTED]. The facility's policy with revision date of 9/2020 titled Admission of Resident showed, Purpose: To facilitate smooth transition into a health care environment. To gather comprehensive information as a basis for planning individualized therapeutic care . Equipment: Transfer documents . Admissions Nurse's Record, .history and physical information (if available) . Procedure: 11. Using information obtained, contact the physician (attending), ensuring that admission orders [REDACTED]. Inform physician of allergies and diet requests or needs .20. Record in detail on nurses' notes all other pertinent information such as: a. Findings from the assessment - required to meet the residents needs which can in turn be conveyed to the physician so the admission orders [REDACTED] 2. R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4's initial admission orders [REDACTED]. DM type 2 (Type 2 Diabetes Mellitus) . BG (blood glucose) better after decreasing [MEDICATION NAME] due to decreased appetite, SSI (sliding scale insulin) ordered. There was no order received in the discharge packet for blood glucose monitoring or for sliding scale insulin. R4's 2/5/21 facility assessment showed R4 has no cognitive impairments. R4's Medication Administration Record [REDACTED]. This order does not indicate what is being checked and there was no documentation found to show what was being checked. R4's nursing progress note dated 2/5/21 at 3:34 PM showed, Resident being admitted to (acute care hospital) for [MEDICAL CONDITION] (slow heart rate), [MEDICAL CONDITION], and [MEDICAL CONDITION] (high potassium level). R4's acute care hospital discharge instructions dated 2/8/21 showed R4 was readmitted to the facility with an order to check blood sugar before meals and at bedtime. R4's physician order [REDACTED]. R4's physician order [REDACTED]. R4's electronic medical record showed under vital signs there was 1 blood sugar documented on 2/21/21. There were no other blood sugar readings documented in the vital signs record for R4. R4's complete care plans were reviewed on 2/26/21 and did not include a care plan for diabetes management. On March 2, 2021 at 1056 AM, R4 said she was in the facility for about 3 weeks. R4 said the nursing staff did not check her blood sugar until she would tell them they needed to before they would give her insulin. R4 said her blood sugar will bottom out if it is already too low when she gets insulin. On 3/2/21 at 9:37 AM, V6 (Registered Nurse-RN) said it is important to check blood sugar levels prior to giving insulin. If the resident is already low, you don't want to bottom them out. When blood sugar levels get too low, the resident may experience lethargy, have cool, clammy skin, be diaphoretic, maybe confusion. V6 said it is pretty dangerous when a resident's blood sugar level gets too low. V6 said blood sugar levels are documented in the residents' Medication Administration Record [REDACTED]. V6 said it would be documented in the electronic MAR indicated [REDACTED]. On 2/26/21 at 3:40 PM, V2 (Director of Nursing) said blood sugar levels should always be checked prior to administering insulin. V2 stated, If the resident's blood sugar level is low and you give them insulin, you could bottom the resident out. 3. R5's electronic [DIAGNOSES REDACTED]. R5's minimum data set assessment dated [DATE] shows she is cognitively intact. On 2/26/21 at 2:20 PM, R5 was lying in bed in her room. R5 was alert and oriented. R5 said there are only a few nurses that actually check her blood glucose levels. R5 said Sometimes they gave me insulin without checking my blood sugar level. R5 said this occurs usually on the night shift. R5's 1/18/21 facility assessment shows she is cognitively intact. R5's physician's orders [REDACTED]. The physician's orders [REDACTED]. On 3/2/21 at 12:15 PM, V1 (Administrator) said she figured out what the problem was. V1 said when the new orders were put in on 1/8/21, whoever entered the order into the system listed the order as ancillary. V1 said because it was listed as ancillary, it did not go onto R5's MAR. R5's January 2021 Medication Administration Record [REDACTED]. No further orders for monitoring of blood glucose levels was on R5's January 2021 MAR. R5's February 2021 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R5's complete care plans were reviewed on 2/26/21 and did not include a care plan for diabetes management. Plan to Remove Immediacy: Re-education on Systems: Dates education completed 3.03.2021. All staff was re-educated on monitoring blood glucose levels for residents receiving anti-diabetic medications to avoid adverse Diabetic reactions. This training included, Blood Glucose monitoring documentation, hypoglycemic episodes, refusals, and ordering entry and notifying POA and Physician's. o Education initiated 02.26.2021 and completed 3.3.2021 by the Administrator and DON to all licensed Nursing Staff. o All Licensed Nursing staff were educated on Hospital admission Paper work with Triple checks in place o All staff educated via phone were educated with the same training as the staff educated in person, however, the staff who received training over the phone were notified that they will also be required to attend an in-person training prior to the beginning of the next shift worked additionally. Upon completion of this in-person training, staff will sign education sheets. Evidence for education that took place over the phone is provided by specifying the name of the employee educated, the time the employee educated was called, and who conducted the training. o New hires will be educated during orientation. o A baseline house audit was completed on 3.3.2021 to ensure compliance with monitoring blood glucose levels for residents receiving anti-diabetic medications to avoid adverse Diabetic reactions. The audit included that the facility needs to take immediate action to ensure resident's with diabetes are managed and monitored to avoid adverse outcomes. o A QA tool was developed and 5 audits a week will be completed by the Director of Nursing or designee to ensure compliance with monitoring blood glucose levels for residents receiving anti-diabetic medications to avoid adverse Diabetic reactions. The QA tool also includes residents review of MAR indicated [REDACTED] o All audits will be analyzed and reviewed in monthly QAPI. This is overseen by the medical director and administrator. Audits will continue for no less than 4 months. The QAPI committee will determine if the audits continue at that time.

Based on interview and record review the facility failed to implement policy and procedure for necessary medical services for a resident with s significant change in condition and a history of [MEDICAL CONDITION] embolism. This failure began at 6:30 AM on [DATE] when V4 was aware R1 was cold/clammy and having difficulty breathing. R1's condition continued to deteriorate; R1 was found not breathing and without a pulse. This applies to 1 of 3 residents (R1) reviewed for neglect in the sample of 3. The findings include. R1's Face Sheet showed an original admitted (MONTH) 22, 2019 with [DIAGNOSES REDACTED]. R1's Face Sheet showed him to be a Full Code. R1's [DATE] hospital records which were sent to the facility on [DATE] at 11:20 AM (the day prior to R1's admission to the facility) showed a physician note at 11:02 PM, .diagnosed with [REDACTED]. The physician note showed he was admitted to the hospital due to an acute kidney injury and a large [MEDICAL CONDITION] embolism. The physician note continued, No lower extremity [MEDICAL CONDITION] (swelling) and no calf tenderness . R1's State of Illinois Certificate of Death Worksheet which was certified on [DATE] showed his date of death to be [DATE] and the Immediate Cause of death to be [MEDICAL CONDITION] Embolism. The facility's Emergency Management policy dated [DATE] showed, Emergency guidelines refer to actions given to residents with urgent and critical needs. When an emergency situation arises, emergency procedures are initiated which include sending the resident to the closest emergency room . The policy continued, Have someone immediately call the physician and 911 . R1's [DATE] Narrative Note documented by V9 (Licensed Practical Nurse/LPN) at 4:56 AM showed, Resident denies pain this shift .reports appetite as fair .Pleasant and cooperative with staff . R1's 72 Hour Charting done by V9 at 4:21 AM showed a Regular Pulse at 92 beats per minute (BPM) and a respiratory rate of 16 breaths per minute. On [DATE] at 9:10 AM, V4 (Certified Nursing Assistant/CNA) stated she visited R1 on the morning of [DATE] from approximately 6:15 AM to 6:30 AM. V4 stated R1 was sweaty, clammy, and not feeling good and he wanted me to ask the nurse to check his blood sugar. V4 stated, R1 said 'I can't seem to catch my breath.' V4 said she told V3 (LPN) that R1 was not feeling well and he seems to have a hard time breathing. V4 stated, When I went back in to do his vitals he was cold and clammy to the touch and he had ripped his hoodie (sweatshirt) off and unbuckled his belt because he said he had to use the bathroom. His breathing was rapid, labored, and you could tell he was having a very hard time breathing. He said his legs were killing him. V4 stated R1 had put his call light on at approximately 7:50 AM that morning and V4 told V3 that R1 wanted to see V3. V3 replied, If he's well enough to turn his call light on, he can wait till I'm done up here to see him. V4 stated at approximately 8:00 AM she followed V3 to R1's room. V4 stated he was complaining of leg pain at a ten out of ten and R1 said I can't take this anymore and he wanted to be sent to the hospital. On [DATE] at 3:30 PM V3 said nothing was done for R1 from approximately 8:00, when the second blood sugar was done, until the EMS (Emergency Medical Services) was called at 9:22 AM. V3 said V10 (R1's Physician) was first notified about R1's condition about the time she called EMS (9:22 AM). R1's [DATE] Emergency Department (ED) physician note showed, when EMS arrived R1 was unresponsive, CPR in progress, and he was in asystole. R1 developed PEA (Pulseless Electrical Activity) without return of spontaneous circulation. R1's Downtime was slightly greater than 25 minutes upon arrival. On [DATE] at 9:42 AM, V10 stated if he was notified of R1 having an increased heart rate, shortness of breath, being cold and clammy, and having leg pain, I would have told them to call 911 immediately and get him to the emergency room right away. He is at an increased risk for blood clots given his history of clots and his clotting disorder. I did tell them when I saw him ([DATE]) that he has a history of blood clots. V10 stated he has no record or recollection of a phone call from the facility on [DATE] regarding R1. V10 said, If there was a problem they can call the on call doc (doctor) or just send out to the ED (Emergency Department). On [DATE] at 2:40 PM, V11 (ED Medical Director/Physician) stated, with symptoms of increased heart rate, significant rise in blood sugar, shortness of breath, being cold/clammy certainly with those symptoms you would worry that he had a clotting issue. Given those symptoms and his history, I would have expected he be sent in right away, especially given his history. We see people come in for a lot less. V11 said, in regards to treatment for [REDACTED]. The facility's Emergency Management policy dated [DATE] also showed, Have someone stay with the resident at all times .Take vital signs and provide reassurance to the resident. Vital signs should be taken every ,[DATE] minutes based on resident need until the resident is stable or transferred. The facility's Change in Condition Physician Notification Overview Guidelines policy reviewed on ,[DATE] showed, All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings. On [DATE] at 2:10 PM, V4 stated, Right before breakfast is when I noticed he was really having difficulty breathing; he just told me he couldn't catch his breath, he was breathing faster. I don't know what his respiratory rate was at that time. I did tell (V3) at that time that he was having difficulty breathing; she didn't really say anything to that when I told her. On [DATE] at 9:10 AM, V4 stated she did not measure R1's oxygen level when she took his vital signs. On [DATE] at 1:28 PM, V2 (Director of Nursing/DON) provided an approximate timeline of events with one set of vital signs. (These vital signs were not a part of R1's medical record and did not include oxygen saturation.) The timeline showed at approximately 7:30 AM R1 was short of breath, nauseated, pain in his legs, and he refused breakfast. Vital signs included pulse of 123, respiratory rate of 26, and blood sugar of 106, blood pressure ,[DATE], and temperature 98.7. (No other subsequent vital signs or head to toe assessment mentioned.) At approximately 7:45 AM V3 re-took R1's blood sugar and it was 343 and he was still hurting and he was breathing heavily. At 9:28 AM resident was found unresponsive and CPR was started. On [DATE] at 2:35 PM V2 stated, if a resident has a change in condition the nurse should do an assessment and depending on that assessment notify the physician. On [DATE] at 1:28 PM V2 stated, If it's not documented, it's not done. R1's 72 Hour shift charting, progress notes, vital sign record, Medication Administration Record, [REDACTED]. The (MONTH) (YEAR) facility policy titled Abuse Prevention Program states Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The Immediate Jeopardy was found to have begun on [DATE] when R1 notified V4 of shortness of breath, [MEDICATION NAME] and leg pain, and R1's condition was allowed to deteriorate. E1 (Administrator) was informed of the Immediate Jeopardy on (MONTH) 8, 2019. The Immediate Jeopardy was removed on (MONTH) 10, 2019. While the Immediacy was removed, the facility remains out of compliance at a level two as the facility needs to complete training. Though observation, interview, and record review on (MONTH) 13, 2019, the surveyor confirmed the facility took the following steps to remove the immediacy: 1. On (MONTH) 10, 2019 the facility provided education, 1:1 and by telephone, to 100% of the facility staff on change in condition, when to notify Emergency Services and the physician, and Abuse/Neglect. 2. On (MONTH) 10, 2019 the administrator reviewed with facility staff the policies and procedures for: Change in Condition, Emergency Response, Emergency Management, Charting and Documentation to included assessment, and Abuse/Neglect. 3. On (MONTH) 10, 2019 the facility provided a question and answer assessment following the training provided on Change in Condition, Emergency response, Emergency Management, Charting and Documentation and Assessment, and Abuse/Neglect. 4. On (MONTH) 4, 2019 the Medical Director was notified of the concerns identified during the survey, Policy and procedures were reviewed for Change of Condition, Abuse, Resident Documentation, and Medical Emergency Response. 5. On (MONTH) 10, 2019 the administrator trained facility staff on signs/symptoms of [MEDICAL CONDITION] embolism and other emergency situations. 6. Re-education will be provided on a monthly basis and presented in QAPI for 4 months. QAPI will determine the need for further audits or expanding audits. 7. The DON will monitor on-going compliance of 10% of the facility population through weekly audits. Audits will cover change in condition and decline in condition to ensure documentation, notification and the use of resident transport vs. calling emergency services. Residents selected for the audit: a. Noted change in condition b. [MEDICAL TREATMENT] c. Return from the hospital d. Ambulance transport 8. Administration will perform targeted rounds of 5 residents a day for 4 months, as an additional method of resident oversight to monitor for compliance related to abuse/neglect with a Resident Questionnaire. The resident Questionnaire will be shared through the monthly QAPI. 9. The administrator and DON will meet weekly to analyze audit results for 4 months. The analysis will be provided to QAPI, overseen by the Administrator and Medical Director.

Based on interview and record review the facility failed to provide emergency treatment and services for a resident exhibiting signs and symptoms of a [MEDICAL CONDITION] embolism. This failure resulted in R1 expiring from a [MEDICAL CONDITION] embolism. The facility failed to assess a resident on admission to the facility. This applies to 2 of 3 (R1,R7) residents reviewed for improper nursing care in the sample of 3. The findings include. 1. R1's Face Sheet showed an original admitted (MONTH) 22, 2019 with [DIAGNOSES REDACTED]. R1's Face Sheet showed him to be a Full Code. R1's [DATE] hospital records which were sent to the facility on [DATE] at 11:20 AM, (the day prior to R1's admission to the facility) showed a physician note at 11:02 PM, .diagnosed with [REDACTED]. The physician note showed R1 was admitted to the hospital due to an acute kidney injury and a large [MEDICAL CONDITION] embolism. The physician note continued, No lower extremity [MEDICAL CONDITION] (swelling) and no calf tenderness . R1's State of Illinois Certificate of Death Worksheet which was Certified on [DATE] showed his date of death to be [DATE] and the Immediate Cause of death to be [MEDICAL CONDITION] Embolism. On [DATE] at 2:50 PM, V9 (Licensed Practical Nurse/LPN) stated she recalled her evening shift from [DATE] to the morning of [DATE]. V9 stated, I remember (R1); he was a younger gentleman, very talkative, and nice. He had no complaints of shortness of breath, no pain. He had no complaints of not feeling well; he wasn't cold or clammy. V9 stated R1 told her that when he does have pain it is in his chest and thigh; however, he did not complain of any pain during her shift. V9 said, I did a set of vitals and they were fine. R1's [DATE] Narrative Note documented by V9 at 4:56 AM showed, Resident denies pain this shift .reports appetite as fair .Pleasant and cooperative with staff . R1's 72 Hour Charting done by V9 at 4:21 AM showed a Regular Pulse at 92 beats per minute (BPM) and a respiratory rate of 16 breaths per minute. On [DATE] at 9:10 AM, V4 (Certified Nursing Assistant/CNA) stated she visited R1 on the morning of [DATE] from approximately 6:15 AM to 6:30 AM. V4 stated R1 was sweaty, clammy, and not feeling good and he wanted me to ask the nurse to check his blood sugar. V4 stated, R1 said 'I can't seem to catch my breath.' V4 said she told V3 (Licensed Practical Nurse/LPN) that R1 was not feeling well and he seems to have a hard time breathing. V4 said V3 instructed her to do vital signs at around 7:00 AM. V4 stated, When I went back in to do his vitals he was cold and clammy to the touch and he had ripped his hoodie (sweatshirt) off and unbuckled his belt because he said he had to use the bathroom. His breathing was rapid, labored, and you could tell he was having a very hard time breathing. He said his legs were killing him. V4 stated she did not check R1's oxygen level. V4 stated R1 had put his call light on at approximately 7:50 AM that morning and V4 told V3 that R1 wanted to see V3. V3 replied, If he's well enough to turn his call light on, he can wait till I'm done up here to see him. V4 stated at approximately 8:00 AM she followed V3 to R1's room. V4 stated R1 was complaining of leg pain at a ten out of ten and R1 said I can't take this anymore and he wanted to be sent to the hospital. V4 stated, His breathing was the same; very labored, he wouldn't even open his eyes to talk to us . Based on his condition at that time and how he was behaving, I could tell he needed to be sent out. V4 stated at 9:28 AM she was handed an oxygen saturation monitor and she was instructed to measure R1's oxygen saturation (no documentation this had been done prior to this point). V4 stated when she entered R1's room, He was just lying there, pale, and yellow. I checked his pulse and there was none. V4 stated she notified staff and then she (V4) went back to his room and began CPR. On [DATE] at 2:10 PM, V4 stated, I was in the kitchen finishing breakfast around 8:15 AM or 8:20 AM and I was in there for maybe 15 mins. I asked (V3) right after I got out of the kitchen if she was going to send him out? She said 'I'm figuring that part out.' So I went down and told him that. He was still the same; he was huffing and puffing and swearing. The room smelled different. It could have been a fruity smell. V4 stated she believed R1's first blood sugar to be 102 or 107. V4 stated V3 rechecked his blood sugar at approximately 7:30 AM and it was at least 320. V4 stated, Right before breakfast is when I noticed he was really having difficulty breathing; he just told me he couldn't catch his breath, he was breathing faster. I don't know what his respiratory rate was at that time. I did tell (V3) at that time, that he was having difficulty breathing; she didn't really say anything to that when I told her. On [DATE] at 10:52 AM, V3 stated, (V4) did approach me and tell me that he (R1) had his call light on and he wanted to see me. I did go see him at that time. I would have to say it was after the 7:00 AM blood sugar check .he said he didn't feel good. V3 said she asked R1 to elaborate and he said I don't know my legs hurt. V3 said, I asked him, 'Do you need to go to the hospital?' He said yes. I asked him for the leg pain or something else and he said 'I'm not sure.' V3 said, He was not having difficulty breathing. To me, he was hyperventilating. His breathing was rapid at the time and if he could just slow down and tell me what was going on. R1's charting showed no progress notes from V3 on [DATE]. On [DATE] at 3:30 PM V3 stated she rechecked R1's blood sugar and there was a significant jump up in the value. V3 said nothing was done for R1 from approximately 8:00, when the second blood sugar was done, until the EMS (Emergency Medical Services) was called at 9:22 AM. V3 said V10 (R1's Physician) was first notified about R1's condition about the time she called EMS (9:22 AM). On [DATE] at 12:16 PM, V6 (Local ambulance dispatcher) stated, I was working that day ([DATE]). The first and only call we received was at 9:22 AM and our crew was dispatched right away and was on the scene at 9:28 AM. V6 stated they were called to transport a person who was a full code to the Emergency Department for leg pain. V6 stated her crew arrived on the scene just as the facility was dialing 911 (R1 was found unresponsive by V4 at 9:28 AM). V6 stated the municipal fire department/EMS crew responded to the 911 call. On [DATE] at 1:39 PM, V8 (R1's Healthcare Power of Attorney/Sister) stated (while reviewing her cell phone call log), (R1) called me on (MONTH) 25, (2019) at 7:07 AM and he asked me to call (the facility). He said his one leg was hurting him real bad. I knew he was short of breath, because he was scared and worked up. I could tell he was out of breath on the phone. At 7:10 AM, I called (R1) back because I couldn't get anyone at (the facility) and he couldn't really talk because he was in so much pain. V8 stated she spoke with the facility through R1's phone at 9:11 AM and they asked if that was normal for him to have pain. On [DATE] at 1:28 PM, V2 (Director of Nursing/DON) stated the timeline provided was done on [DATE] at approximately 10:00 AM or 11:00 AM and the times provided could be off. The timeline is as follows: I held a debrief with myself (V2), (V3), (V5 CNA), and (V4) for the code that happened this morning. Here is a timeline of events: Around (7:30 AM) Resident stated he didn't feel good, nauseated and refused breakfast. Stated he had pain in his legs and was SOB (Short of Breath). (V3) informed me and I told her to call the physician and POA (phone calls were not made until approximately 9:20 AM; no documentation in R1's medical record of these phone calls) to determine next steps as he was A & O (Alert and Oriented) at baseline and vitals were (blood pressure ,[DATE]; Temperature 98.7; Pulse 123 (31 BPM higher than last time documented); Respiratory Rate 26 (10 higher than last documented); Blood Sugar 106. Around (7:45 AM) (V3) re-took (blood sugar) and it was at 343, resident stated his legs were still hurting .and was breathing heavily. Around (9:00 AM) resident and (V3) called (V8 POA) from resident's cell phone. (V8) explained to (V3) that last time the resident presented to the ER (emergency room ) he was diagnosed with [REDACTED]. (V3) informed me of this and I instructed her to call an ambulance and send him to the ER and to get a PO2 (oxygen saturation). On [DATE] at 2:35 PM V2 stated, No one told me about (R1's) condition when I came in; I do rounds when I first get here and I hadn't heard. I don't recall the exact time but (V3) told me that he (R1) stated he wasn't feeling well .it was around 8:30 AM or 9:00 AM. She (V3) said he was having some leg pain and some shortness of breath. V2 stated a [MEDICAL CONDITION] Embolism is a medical emergency and signs and symptoms include: shortness of breath, pain, weakness, sweating, restlessness, anxiety, and increased heart rate. R1's [DATE] Emergency Department (ED) physician note showed when EMS arrived R1 was unresponsive, CPR in progress, and he was in asystole. R1 developed PEA (Pulseless Electrical Activity) without return of spontaneous circulation. R1's downtime was slightly greater than 25 minutes upon arrival. The note continued, Apparently the patient was complaining of some pain and numbness of his right lower extremity earlier today and his blood sugar was quite elevated. R1's ED records showed a blood sugar of 465. On [DATE] at 9:42 AM, V10 stated if he was notified of R1 having an increased heart rate, shortness of breath, being cold and clammy, and having leg pain, I would have told them to call 911 immediately and get him to the emergency room right away. I would suspect blood clots with him given that information. V10 said, He has poor health and very little reserves; if he did have a blood clot, that is big deal. His reserve capacity to compensate is very low, compared to a healthy adult, so anything like response time is a factor for him. A heart rate of 123 is a significant jump for him. A blood sugar jump, without food, is his body's reaction to a stressor; it was trying to fix something. V10 said a blood clot induces the flight or fight response which triggers [MEDICATION NAME] and causes blood sugar to go up. He is at an increased risk for blood clots given his history of clots and his clotting disorder. I did tell them when I saw him ([DATE]) that he has a history of blood clots. V10 stated he has no record or recollection of a phone call from the facility on [DATE] regarding R1. V10 said, If there was a problem they can call the on call doc (doctor) or just send out to the ED (Emergency Department). On [DATE] at 2:40 PM, V11 (ED Medical Director/Physician) stated, He (R1) was one of those patients who was dead when he got here. He had no brainstem reflexes. V11 said with symptoms of increased heart rate, significant rise in blood sugar, shortness of breath, being cold/clammy certainly with those symptoms you would worry that he had a clotting issue. Given those symptoms and his history, I would have expected he be sent in right away, especially given his history. We see people come in for a lot less. V11 said, in regards to treatment for [REDACTED]. The Immediate Jeopardy was found to have begun on [DATE] when R1 notified V4 of shortness of breath, clamminess and leg pain, and R1's condition was allowed to deteriorate. E1 (Administrator) was informed of the Immediate Jeopardy on (MONTH) 8, 2019. The Immediate Jeopardy was removed on (MONTH) 10, 2019. While the immediacy was removed, the facility remains out of compliance at a level two as the facility needs to complete training. Though observation, interview, and record review on (MONTH) 13, 2019, the surveyor confirmed the facility took the following steps to remove the immediacy: 1. On (MONTH) 10, 2019 the facility provided education, 1:1 and by telephone, to 100% of the facility staff on change in condition, when to notify Emergency Services and the physician, and Abuse/Neglect. 2. On (MONTH) 10, 2019 the administrator reviewed with facility staff the policies and procedures for: Change in Condition, Emergency Response, Emergency Management, Charting and Documentation to included assessment, and Abuse/Neglect. 3. On (MONTH) 10, 2019 the facility provided a question and answer assessment following the training provided on Change in Condition, Emergency response, Emergency Management, Charting and Documentation and Assessment, and Abuse/Neglect. 4. On (MONTH) 4, 2019 the Medical Director was notified of the concerns identified during the survey, Policy and procedures were reviewed for Change of Condition, Abuse, Resident Documentation, and Medical Emergency Response. 5. On (MONTH) 10, 2019 the administrator trained facility staff on signs/symptoms of [MEDICAL CONDITION] embolism and other emergency situations. 6. Re-education will be provided on a monthly basis and presented in QAPI for 4 months. QAPI will determine the need for further audits or expanding audits. 7. The DON will monitor on-going compliance of 10% of the facility population through weekly audits. Audits will cover change in condition and decline in condition to ensure documentation, notification and the use of resident transport vs. calling emergency services. Residents selected for the audit: a. Noted change in condition b. [MEDICAL TREATMENT] c. Return from the hospital d. Ambulance transport 8. Administration will perform targeted rounds of 5 residents a day for 4 months, as an additional method of resident oversight to monitor for compliance related to abuse/neglect with a Resident Questionnaire. The resident Questionnaire will be shared through the monthly QAPI. 9. The administrator and DON will meet weekly to analyze audit results for 4 months. The analysis will be provided to QAPI, overseen by the Administrator and Medical Director. 2. R7's electronic Admission Record shows [DIAGNOSES REDACTED]. The Minimum Data Set of (MONTH) 9, 2019 shows R7 was cognitively intact and required assistance of 1 staff with bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. This assessment shows R7 had a history of [REDACTED]. R7's Admission Record shows she was admitted on (MONTH) 2, 2019. R7's Nurse Notes dated [DATE] at 2:13 AM shows Resident sent to ED due to low oxygen saturation at 0000 (midnight). Resident was resting in bed with [MEDICAL CONDITION] machine on and notified staff of 74% oxygen level. Removed [MEDICAL CONDITION] and replaced with oxygen via nasal cannula @ 3L .@ 0015 (12:15AM) resident oxygen level was 69%. Resident requested to go to the hospital. The nurse note dated [DATE] at 2:54PM shows Resident returned to the facility today at 1400 (2:00PM). Upon doing the skin assessment resident oxygen was 45% on pulse ox. 911 was called and DON was informed. Resident was picked up at 1420 by the ambulance and taken back o the hospital. Resident was admitted to the hospital with [REDACTED]. The next nurse note was documented on (MONTH) 28, 2019 at 11:35PM. The note shows patient was placed on trilogy mask with 4L of oxygen, call light in place. Bed in low position. At 2335 while attending to another patient this nurse heard patient yelling for help. Patient was found on floor lying face down bleeding from forehead. Pressure was placed on wound. Patient states, I was trying to go to the bathroom.EMS arrived at 2350 patient was sent to hospital . There was no nurse note documenting when (date or time) R7 readmitted to the facility from the hospital stay starting (MONTH) 22, 2019. There are no assessments for R7's condition, vital signs, etc. when R7 returned from the hospital and readmitted to the hospital on (MONTH) 28, 2019. On [DATE] at 11:13 AM, V2 (Director of Nursing/DON) said she was unsure when R7 returned to the facility on [DATE]. V2 said the nurse should have assessed the resident when she readmitted to the facility and checked her vitals. V2 said there is an admission screener that should be completed and an assessment of the resident is done at that time. At Approximately 4:00PM, V2 said R7 readmitted at 7:05PM on [DATE]. There were no assessments, vital signs, or nurse notes obtained or entered on R7 for over 4.5 hours after she was admitted to the facility. The only nurse note documented from R7's admission on [DATE] is when R7 fell at approximately 11:35pm on [DATE]. The facility Policy Charting and Documentation reviewed ,[DATE] states Additional documentation requirements will be followed: New Admission - documentation every shift for the first 72 hours.

Based on interview and record review the facility failed to ensure physician prescribed anticoagulant medication was administered to a resident with a history of blood clots for one of five residents (R1) reviewed for medications. This failure contributed to R1 developing a [MEDICAL CONDITION] embolism resulting in R1's death. The findings include: R1's face sheet printed on (MONTH) 5, 2019 showed he was admitted to the facility on (MONTH) 22, 2019 with [DIAGNOSES REDACTED]. R1's physician order [REDACTED]. R1's eMAR (electronic medication administration record) showed R1 did not receive the prescribed anticoagulation medication from his admitted (MONTH) 22, 2019 through his transfer to the acute care hospital on (MONTH) 25, 2019. R1's physician visit nursing home progress note entered by V10 (R1's Physician) with visit date of (MONTH) 24, 2019 showed R1 had recently been admitted to the facility for embolism and was started on an anticoagulant. On (MONTH) 7, 2019 at 2:40 PM, V11 (Medical Director of the Acute Care Hospital Emergency Department) said when R1 arrived in the emergency department on (MONTH) 25, 2019, he was already deceased . R1's State of Illinois death worksheet showed R1's date of death as (MONTH) 25, 2019 and cause of death to be [MEDICAL CONDITION] embolism. On (MONTH) 12, 2019 at 8:25 AM, V2 (Director of Nursing/DON) said, (The anticoagulant) is important due to (R1's) [DIAGNOSES REDACTED]. We noticed the issue on (MONTH) 1. The facility provided a Medication Error Report dated (MONTH) 1, 2019 which showed R1 did not receive his anticoagulant medication from (MONTH) 22 through (MONTH) 25 due to the medication not being sent from the pharmacy. The same form also showed authorization was needed from the facility to send the medication due to the medication having a high cost and authorization was not received. The facility's policy with issue date of (MONTH) 2019 titled Administering Medications showed, .Purpose: To ensure safe and effective administration of medication in accordance with physician orders [REDACTED]. The facility's policy with effective date of (MONTH) 25, 2014 titled Ordering and Receiving Non-Controlled Medications from the dispensing pharmacy showed, .Medications and related products are received from the dispensing pharmacy in a timely basis . B. 1) A licensed nurse: .c. promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.

Based on Observation, Interview and Record Review the facility failed to ensure residents were not mistreated or abused by staff. This failure contributed to R1 being taunted and teased, R3 being pinched, and R8 struggling with staff resulting in a fall. This applies to 3 of 4 residents (R1, R3 and R8) reviewed for abuse in the sample of twelve. The findings include: 1. The Medical [DIAGNOSES REDACTED]. R1's Care Plan dated 11/23/18 showed, Behavioral distress related to being challenged by dementia-related illness. Problems are manifested by physically abusive behavior when agitated. Intervene by speaking calmly and professionally in a soft voice. Staff should avoid raising own voice since this tends to make the resident more upset. This may cause the situation to escalate. R1's MDS (Minimum Data Set) dated 11/21/18 showed a BIMS (brief interview for mental status) score of 3, severe cognitive impairment. On 12/12/18 at 12:23PM V17 (R1's daughter) stated, I put the camera in, because things were turning up missing and all of a sudden, dad was not acting like dad. The camera was where his recliner is now. There is a plug in there and the night stand was there before. The camera was on the side closest to the bathroom. It looks like a phone charger. You can't tell it is a camera. I never set the time and date on it because we did it for us. The camera was put in his room in (MONTH) (YEAR) or (MONTH) (YEAR) and removed in (MONTH) or (MONTH) (YEAR). I blew up at V1 (Administrator) in (MONTH) or (MONTH) (YEAR). I told him that my dad's treatment is sickening. He viewed the video of the hands in dad's face and he was sickened by it and couldn't believe what was going on. He acted like something was going to happen. V1 response was All I can say is I am sorry, something will be done. He knew the staff in the video and mentioned her by name. I felt he was going to investigate. V1 said they were going to do classes. V28,CNA, is the one waving her hands. She has the long nails. V1's assistant said right away it was V28. The assistant quit. V18 is the one swearing. R1 doesn't swear unless he is extremely p***** off. He is quiet, keeps to himself and is clean cut. V17 stated she felt that a staff member waving their hands in her dad's face was abuse. V17 stated, It feels like mental abuse has occurred. V17 was asked how she felt about staff swearing in front of R1? V17 stated, It was sickening and unprofessional. She said just tell them to f*** off! Really? My dad is not that kind of person. He would laugh but laughs when he is uncomfortable. He is not the kind of person to swear. A video from a camera placed in R1's room showed (inaccurate date on video) the following: R1 shut the bathroom door on V20 (housekeeper). R1 then sat in his wheelchair outside of the bathroom door. R1 backed up his wheelchair and picked up a clear bag with food in it from his table. The bathroom door opened and R1 went over and shut the door. R1 backed away from the door. R1 put his foot up to shut the door and keep it shut. V28 ,certified nursing assistance (CNA)walked in the room. V28 proceeded to waive her hands in R1's face/personal space. R1 picked up his bag of food and acted as though he would throw it. V28 walked by R1, turned around and waved her hands at R1 again. V28 walked out the door. V20 was present for the interaction between R1 and the CNA. V28 was identified as the CNA in the room.by V20, the housekeeper. A second video from the camera placed in R1's room showed (inaccurate date on the video) the following: a staff member came into R1's room and told him to come eat. R1 stated he doesn't want to. The staff member stated Come on several times. The staff member stated, Watcha mean you don't want to eat. R1 stated something that was difficult to hear. R1 stated I don't care for it. The staff member stated, Me neither but eat your food and tell them f*** you. The staff member laughed and stated she is just joking. R1 stated, You tell them f*** you. The staff member stated, Get the f*** out of here. You tell them that. I tell them for you R1 responded, but unable to understand his reply. R1 asked the staff member what time it was and she replied 5:44. The CNA told the resident that they were going to roll out and called him homie. In an interview with V17 (R1's daughter) she stated is was V18, CNA, in the room. On 12/12/18 at 8:35AM , R1's room was observed and from where the camera would have been placed in his room, eview of the room is the same as what is observed in the video. On 12/13/18 at 1:40PM, V20 (Housekeeper) stated, I was a housekeeper at the facility. I left 1 -2 months ago. I went to clean R1's bathroom and he shut the door on me. R1 thought it was the funniest thing ever. R1 shut the door again. I thought he was playing. I turned the call light on and V 28, CNA came in, trying to get R1 out of the door. I believe I was leaving when V28 was coming into the room. V20 denies seeing V28 wave her hands at R1 but is clearly viewed on the video as present in the room. On 12/14/18 at 10:40AM, V28 (CNA) stated, I remember hearing about that involving V20 (housekeeper) and V24, (CNA) believed to have been involved by V28. I heard R1 blocked the bathroom door in his bedroom. V28 stated she would not wave her hands at R1 because it would possibly aggravate him. On 12/12/18 at 9:40AM, V3 (Assistant Director of Nursing - ADON) stated it would not be appropriate for staff to wave their hands in R1's face. V3 stated, I don't know why they would do it in the first place. I wouldn't do it with anyone. It sounds like tormenting. V3 stated it could be mental abuse but she doesn't know what they were doing. On 12/12/18 at 10:36AM, V9 (Registered Nurse - RN) was asked if it would be okay to wave your hands in R1's face? V9 stated, I would need to know if they are playing or not. They shouldn't do that if he is in a bad way. They shouldn't be putting hands in his face. I can't see anyone doing it towards his face. R1 is a nice guy. On 12/13/18 at 12:49PM, V2 , DON stated, I wasn't here then. The first time I was aware of this was on 12/11/18. When you came in, they called me and said state was in the building. We provide the abuse policy and procedure to everyone. On 12/14/18 at 4:41AM, V14 (CNA) stated it is not appropriate to swear in front of a resident. V14 stated that if a staff member waved their hands in a residents face or towards the resident that the resident would think they are being attacked or belittled. V14 stated she has heard two CNAs swear, V5 and V18. On 12/14 /18 at 5:15AM, V22 (Licensed Practical Nurse - LPN) stated she has heard of CNAs swearing in front of residents but has not heard it herself . It is not appropriate to swear in the building at all. V22 stated it would not be okay to lunge at a resident or wave hands at a resident because they don't know what is going on and it would be scary to them. On 12/14/18 at 6:06AM, V24 (CNA) stated it is not appropriate to wave hands or lunge at residents with dementia. V24 stated, No one would like that; you don't know what their mind is thinking at that time. V24 stated it would be taunting a resident and stated swearing in front of a resident is not appropriate. On 12/14/18 at 6:29AM, V25 (Licensed Practical Nurse - LPN) was asked if it would be okay to wave hands or lunge into a dementia resident's personal space? V25 replied, I wouldn't think that is okay, dementia or no dementia. A dementia resident is afraid as it is. They don't remember and can't tell; but it puts fear in them they don't need to have. I would consider it mental abuse definitely. They can't defend themselves at all. V25 stated it is not okay to swear in front of a resident because it is unprofessional and could be verbal abuse. 2. On 12/12/18 at 2:28PM R3 stated, It was the stand lift that got me, not the CNA. It was to the left arm. The mark is not there anymore. I use the stand lift and my arm got pinched when they moved me. V18 (CNA) is snotty and she doesn't like me. I am a veteran and I shouldn't be talked to that way. It makes me feel bad the way she talks to me. She has never hurt me. She swears at me and in front of me. I can't say what she says because it is too dirty. I am afraid she will hurt me. Sometimes she is snippy. She is fast with her hands. I want her to leave here and never come back. Every time I see her, I start shaking. I am afraid she will hit me sometime. V18 swears and is rude. I am Catholic and I don't like it. I only cuss if I am really angry. A lot of residents are scared and don't want to say anything. R3 stated he can't read. On 12/14/18 at 5:27AM, V23 (CNA) stated, The only resident that has complained about a CNA is R3. He is afraid of V18 and told me he is terrified of her. I told him to tell someone and I told V31 (Registered Nurse - RN). V31 told me it was under investigation. R3 told me that V18 pinched him and no one believed him. I told him to let someone know and he said that he did. I hear that R3 and V18 go back and forth. V23 stated swearing in front of a resident could be verbal abuse. V23 stated that if you wave your hands in front of a resident and/or lunge at the resident it is not okay because the resident may think you are trying to fight and get scared. V23 stated it is mental abuse. R3's Nurse's Notes showed, 12/1/18 at 8:15AM - Resident reported to me at 8:05AM a bruise to the anterior left upper arm that he states was caused by a CNA pinching him. The bruise is purple in color 2.5cm and non-tender to touch. Text sent to administration regarding this manner; 5:30PM - Full body assessment of resident shows no previously undocumented skin issues other than bruise reported at 8:05AM. Resident reiterated that this occurred in the early AM of 12/1 while CNA With the tattoo on her neck was repositioning resident to facilitate change of brief. CNA placed hand on resident's upper left arm which caused a feeling resident described as a pinch. Resident voices that he smacked her and that the CNA's response was to laugh. Resident voices that he did not report this to the nurse at the time. Resident states that he is scared of previously mentioned aide. The Abuse Investigation for R3 dated 12/1/18 showed statement initialed by the resident and a conversation between the resident, administrator and V33 (Assistant Administrator) that was initialed by R3 who cannot read. The statement dated 12/1/18 by R3 showed, The girl with the tattoo on her neck pinched me and I hit her for it and now I will probably get kicked out of here. R3 went on to say, The other aide was nice to me. He showed the bruise and stated, They were changing me and she grabbed and pinched me and laughed. In the written Interview done by V1 and V33 with R3 dated 12/3/18 showed, Yeah I hit her. She pinched me. At the end of the interview the document showed that R3 then told the administrator that V18 did not pinch him. The document was initialed by R3 who cannot read the document. R3's Care Plan dated 10/24/18 showed, Patient is at risk for abuse and/or neglect due to mental illness, [MEDICAL CONDITION], agitation and suicidal ideation. The MDS dated [DATE] for R3 showed a BIMS score of 15, cognitively intact. 3. On 12/11/18 at 11:00AM, R8 stated, I went to the lobby and V18 told me to go back to bed. I wanted a snack. I didn't want to go back to bed. V18 grabbed my wheelchair and started pulling me in it so I stood up. I bumped and fell into the wall. V18 said, I told you not to stand up because you will fall over. The other one that was with her had her picture up in the lobby but it's gone now. The other one was pushing my chair while V18 was pulling it. I don't think the other one is here. The MDS dated [DATE] for R8 showed a BIMS of 15, cognitively intact and no physical, verbal or other behaviors. The facility's Abuse Prevention Program Facility Policy and Procedure (1/4/18) showed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology.

Based on observation, interview and record review the facility failed to implement a pressure relieving device for a resident with a pressure injury and failed to perform admission skin assessments. This failure resulted in a resident being admitted with a pressure injury and not being identified until it was an infected Stage 3 ulcer. This applies to 3 of 4 residents (R2,R4& R5) reviewed for pressure injuries in the sample of 12. The findings include: 1. The computer face sheet for R5 shows he was admitted to the facility on [DATE]. R5's admission Braden scale for predicting pressure injury risk documents R5 was at a low risk for pressure injuries. The 2/13/18 MDS (Minimum Data Set) section M (skin conditions) documents R5 was not at risk for pressure ulcers and had no documented unhealed pressure injuries. His BIMS (Brief Interview for Mental Status) score was 15, cognitively intact. R5's functional status for ADL (Activities for Daily Living) assistance showed he required physical help with one staff for bathing. The physician orders [REDACTED]. R5's nursing progress notes show on 2/26/18, two open areas are noted to the coccyx. One open area was 8cm x 5cm, and the other measured 6cm x 5cm, and the NP (Nurse Practioner) was aware and protective cream was ordered. R5's progress notes for 3/3/18 document he was seen by the physician and no new orders. The physician note had no documentation of new or current pressure injuries. The progress notes show on 3/5/18, R5 was seen by the dietitian, and she documented R5 had no reported open areas. R5's nursing progress note of 3/8/18 shows the nurse was notified of open areas to coccyx. The notes document two open areas measuring 3cm by 3cm to the right side of the gluteal fold. The weekly wound measurements and assessments were not documented in the progress notes, and were requested from V2, Director of Nursing (DON). None were provided. On 12/14/18 at 10:00 AM, V2, DON, said R5 goes to the wound clinic for his Stage 3 pressure injury. V2 said R5's wound was stubborn to heal, and he had the wound when he was admitted to the facility in January. V2 said the wounds were stage 3 and had always been a stage 3. On 12/12/18 at 2:45 PM, R12 (R5's wife) said (R5) had the sore (pressure injury) before he was admitted to the facility (in January). On 12/14/18 at 2:45 PM, V2 said R5 came to the facility from assisted living, and believed he was going to the wound clinic at that time for the same wound. V2 said on the wound clinic documents a date is put for the date the wound was acquired, and R5's was 1/23/18, one week before his admission. V2 said upon admission, the nurse should have performed a head to toe assessment and documented the wound. V2 said R5 is very independent with all care, but will tell you the wound was there before admission to the facility. The 1/30/18 unit nurse skin review showed upon admission, R5 had no noted skin problems. The 1/30/18 nursing admission screening for skin integrity documents skin is normal color, warm with normal turgor. The assessment documents R5 had no impaired skin integrity upon admission. On 12/14/18 at 2:00 PM, V9 Registered Nurse (RN), said any new admission has a head to toe assessment and any findings are documented on the unit skin review or the skin integrity review. If a new admission is admitted with a pressure ulcer, the wound nurse is notified along with the NP. V9 said not everyone is automatically placed on the weekly skin check list, there needs to be an order. V9 said with every shower a skin check is done and the aides will document any findings in the computer, but will also verbally report any open skin issues directly to the nurse. On 12/18/18 at 11:30 AM, V32 RN,(Wound clinic nurse) said R5 initially came to the clinic on 4/23/18. V32 said the initial wound assessment was documented as a Stage 3 measuring 5.7cm x 4.2cm x 0.7cm. V32 said the nursing notes at the clinic show R5 and his daughter explained the wound was approximately 3 months old. R5 was not sure the date it started, but it was before he entered the nursing home. V32 explained that was why the wound documentation lists the date acquired as 1/23/18. V32 said R5 has no feeling in buttocks, and would not know if wound was present or not, which is why he needs a skin check at least weekly. V32 said a nursing skin assessment should have been done when he was admitted and the wound should have been documented. R32 said R5 had no visits to the wound clinic prior to 4/23/18. On 12/19/18 at 9:15 AM, V34 ,Nurse Practioner (NP) said she performed the initial assessment of R5's pressure injuries at the wound clinic. V34 said the 4/23/18 assessment was the first time R5 had been to the clinic for his wounds. V34 said R5 estimated he had the pressure injury for at least 3 months, but was not sure because he had no feeling in his buttocks. V34 said based on his [MEDICAL CONDITION] and incontinence, it is likely he had this wound longer than he had reported. V34 said he should have had a physical/skin assessment upon admission to the nursing home, it would verify any open areas at the time of admission, it would be the prudent thing to do. V34 said any wound without attention or treatment would decline. Any time a wound is open and exposed it can become infected. R5's wound left unattended in combination with his sitting in the recliner, [MEDICAL CONDITION] and incontinence would have contributed to his infection. R5 would be at a higher risk for skin breakdown because he can not feel anything in his buttocks. V34 said R5 on his initial visit, had an infection in his wound that was positive for Staphylococcus Aureus and he was placed on antibiotics. The weekly measurements beginning 10/29/18 show R5's wound to have an onset date of 3/8/18 and it was facility acquired, and on the 11/19/18 assessment, the place acquired was changed to community acquired. On 12/19/18 at 11:20 AM, V2 said, during the facility's annual survey, she had to locate information for R5's pressure injury for the surveyors. When she received information from the wound clinic it had identified the acquired date of the wounds as 1/23/18, prior to his admission, so she changed the status of the wound to community acquired. The 11/21/18 MDS shows R5 to have a Stage 3 pressure injury, and it was present upon admission, the admission MDS of 2/13/18 documented R5 had no pressure injuries. R5's current care plan for alteration in skin integrity documents the wound as a facility acquired Stage 3 pressure injuries. 2. The weekly pressure injury report of 12/10/18 shows R4 was admitted with a stage 2 pressure ulcer to his right gluteal fold on 11/20/18. On 12/14/18 at 8:45 AM, R4 said he was admitted to the facility after a couple of days in the hospital. R4 said he came into the facility with a sore on his buttocks. R4 denied any pain to the area. R4 said the nurse had put a dressing on it every day. R4 said he can move himself in and out of bed and can do most things for himself, like getting dressed and brushing his teeth. R4's admission Braden score was a 22, low risk for pressure injuries. The admission skin integrity review shows no documentation of a pressure injury to the buttocks. The admission MDS of 12/4/18 showed R4 to have no current or unhealed pressure injuries. R4's 11/21/18 care plans show he is at increased risk for alteration in skin integrity related to stage 2 open area to the right buttocks. The wound measures 1.7cm by 1.0 cm. On 12/14/18 at 2:45 PM, V2 , DON, said R4 came into the facility with a pressure injury, and it should have been identified on his admission skin assessment. V2 stated,on the evening of his admission, she was in R4's room addressing his leg wounds when R4 complained of soreness to his buttocks. V2 said she assessed R4's buttocks at that time and found him to have an open area, a Stage 2 pressure injury. V2 said the nurse should be conducting an assessment of the buttocks, and not asking the resident about sores on their buttocks. The facility's undated policy for admission of a resident showed 8. Conduct a head to toe nursing assessment of body systems, parts, and surfaces identifying functional status abilities, needs or problems. Be sure to measure any areas of redness or skin breakdown on extremities or other skin surfaces. The facility's policy for wound care documents Risk Identification and assessment: 5: Residents should be examined thoroughly at lest weekly by a licensed nurse to identify existing pressure ulcers. a. Findings from the weekly skin assessment should be documented by the licensed nurse. 3. On 12/14/18 at 9:46AM, R2 was sitting in a wheelchair in the hallway. R2 has a sock on her right foot and off loading boot to the left foot. R2's right heel was touching the floor. On 12/14/18 at 2:00PM, R2 was sitting in her wheelchair by the nurse's medication cart with her right foot rubbing on the foot rest. On 12/14 18 at 10:15AM, V2 (Director of Nursing - DON) stated, R2 has a stage I pressure injury to the left heel and has a blister forming to the right heel which is a stage II pressure injury. R2 has the boot to her left heel because it is tender. They had a boot on the left heel and I staged it at a I, not blanchable. The right heel is flat but has a blister forming. We kept her shoe off and it has skin prep on it. R2 has had problems with her heels in the past. V2 stated the pressure injury to R2's right heel was not identified until it was a stage II. On 12/14/18 at 9:36AM, V9, Registered Nurse (RN) stated, R2's left heel has a reddish purple area that was identified on 12/7/18. We put skin prep on it. It is done on nights. It must be getting done two times per day. There is a blister A physician Notification Form dated 12/8/18 for R2 showed, Left heel has a 3 x 3 purple area. Right heel has a 2 x 4 red blister. The Weekly Wound Rounds form dated 12/10/18 for R2 showed her right heel has a stage II pressure injury with a blister that measured 2.0cm x 4.0cm with instructions to keep her shoe off and off load the heel when in bed. R2's Care Plan updated 12/7/18 showed she is at increased risk for alteration in skin integrity related to impaired cognition, impaired mobility status. A non blanchable dark red left heel; boot applied. Right heel outer aspect has an area measuring 2 cm by 4cm and is red with a blister forming. Treatment in place. The Minimum Data Set ((MDS) dated [DATE] for R2 showed a Brief Interview for Mental Status Score of 4, severe cognitive impairment; she requires extensive assistance for bed mobility and transfers.

Based on observation, interview, and record review the facility failed to superivise a resident at risk for falls, failed to apply an alarm device correctly, and failed to evaluate the effectivenes of fall prevention interventions. These failures contributed to R1 having repeated falls and sustaining a fractured neck on [DATE]. R1 expired the same day. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: On [DATE] at 8:35 AM, E3 CNA (Certified Nursing Assistant) demonstrated how on [DATE] she placed the tab alarm on R1. E3 said R1 was seated in a stuffed pleather recliner in front of the nurse's station on the second floor. E3 said the recliner did not have any way to attach the alarm box to the chair so she tucked it into the recliner next to (to the left) R1 in the seat. E3 said she then attached the clip to the back of R1's shirt. The recliner E3 said she used had a handle to the right to recline the chair but the handle was flush to the chair. There was another similar recliner next to this that had a long wooden arm used to recline the chair. E3 identified the recliner with the flush handle as the one R1 was seated in and that was why the alarm was tucked into the chair. E3 said R1 was able to remove the clip on his alarms. On [DATE], all resident ' s (whose names were on the alarm list) alarms were checked for proper placement and function. R1 ' s cognition care plan revised on [DATE] shows R1 was forgetful, confused and had impaired short and long term memory loss. R1 ' s fall care plan dated [DATE], showed a fall history with falls incidents on: [DATE] and 25, 2016 [DATE], and 30, 2016 [DATE], 26 and 30, 2016 [DATE] [DATE] and 23, 2017 R1's Physician order [REDACTED]. According to Mayoclinic. org website this disease includes symptoms of falling, loss of balance, and impulsive behavior. R1 ' s fall care plan revised on [DATE] documents a history of Dementia. the same care plan does not document R1's progressive disease. No interventions specific to the level of supervision R1 requires, or any alarm devices, or other modifications used to prevent falls are documented. R1 ' s Progress notes showed multiple entries of R1 self-transferring and attempting to ambulate unassisted: [DATE] at 4:00 PM documents R1 stands up and tries to walk around and is noncompliant with his alarms. [DATE] at 5:30 AM entry shows staff (witnessed fall) but was unable to reach R1 before he fell . [DATE] at 7:14 PM entry shows R1 was in and out of bed several times attempting to self transfer. [DATE] at 3:29 AM shows R1was transferred to a recliner in front of the nurse ' s station because he was constantly attempting to get up unassisted. [DATE] at 11:38 PM the progress note shows R1 was on the floor after being in the wheelchair. R1 ' s chair alarm was not sounding. [DATE] at 3:56 AM documents R1 attempts to transfer self at times and tries to ambulate independently. [DATE] at 1:44 PM shows R1 was near the nurse ' s station for high visual contact to ensure resident safety from falls. [DATE] at 10:30 AM documents R1was on both knees with arms resting on the wheelchair. The pad alarm was not sounding. [DATE] at 4:46 AM shows R1 was redirected often to not transfer self or ambulate by self due to unsteady gait. [DATE] at 7:14 AM the progress note shows R1 was in the TV room near the nurses station and was found laying on the floor. [DATE] at 12:27 AM , shows R1 was up walking around in room. The patient alarm was not sounding. [DATE] at 7:00 AM documents R1 had a fall from the recliner at 3:00 AM. [DATE] at 6:10 PM shows R1 attempting to stand up. [DATE] at 1:13 AM shows R1 attempts to self transfer and stand. He (R1) is unable to make most of his needs known due to significant cognitive impairment, both short and long term memory impairments. [DATE] at 10:07 AM the progress note shows R1 continues to attempt to self transfer and stand. [DATE] at 10:56 its documented R1 needs frequent reminders to stay in the chair. [DATE] at 4:15 PM the electronic Medication Administration Record (MAR) shows R1 was restless and repeatedly attempting to independently transfer self. An Incident note dated [DATE] at 9:50 AM, shows R1 attempted to self transfer from the recliner and fell before staff could reach him. R1 ' s alarm was not sounding and it (the alarm) was observed shoved in the bend of the recliner. R1 suffered three lacerations to his forehead. The Social Service Progress note dated [DATE] at 6:56 AM shows R1 ' s Cognitive Summary score was 4. (4 = severe cognitive impairment). The Psychiatric Progress note dated [DATE] at 7:35 PM; shows R1 had impaired judgment, insight, immediate memory and attention. The Fall Risk assessment dated [DATE] assessed R1 at high risk for falls. R1 ' s MDS (Minimum Data Set) dated [DATE] shows he required extensive assistance to transfer, toilet and move about the facility. The same MDS shows R1 is not steady and is only able to stabilize with staff assistance. The Progress note dated [DATE] at 1:13 AM documents R1 has significant cognitive impairment. The facility ' s Fall Investigation form and interviews dated [DATE] at 3:10 AM show R1 fell from a recliner in the sitting area in front of the nurse ' s station. Three staff members (E,[DATE]) were at the nurses station at the time, and the fall was not witnessed. On [DATE] at 12:00 PM, E14, CNA (Certified Nursing Assistant) said she was seated at the nurse ' s station with two other staff on [DATE] (E15 and E16) when R1 fell . E14 said none of the three staff present witnessed R1 ' s fall. E14 said R1 was placed by the nurse ' s station so staff could keep an eye on him as he kept attempting to get up without assistance. E14 said R1 tried to get up from the recliner five times before falling. We just kept readjusting him in the chair and the alarm. E14 said by the time we all looked up R1 was on the floor. On [DATE] at 1:20 PM, E16 CNA said R1 kept trying to get up so he was placed in the sitting area (by the nurse ' s station) so more eyes would be on him. E16 said she was sitting at the nurse ' s station but did not see R1 fall. E16 said By the time I saw him (R1) he was already on the floor. E16 said R1 was positioned with his back to the nurse's station facing the TV. Staff had to go around the desk and around R1 ' s chair to get to him on the floor. According to the facility ' s interviews, E14 CNA (Certified Nursing Assistant) said she was charting when R1 fell . E15 RN (Registered Nurse) said she was charting, looking up information and texting E2 DON (Director of Nursing) when R1 fell . E16 CNA said R1 was trying to get out of bed all night so he was placed in a recliner in front of the nurse ' s desk. E16 said she was sitting at the nurse's station when she looked up R1 was on the floor and she did not witness the fall. The facility's fall investigation and interviews regarding R1's [DATE] fall shows R1 was sliding out his chair at 9:47 AM and 9:53 AM. The timeline provided by the facility shows R1 attempted to independently transfer out of the recliner and fell on [DATE] at 9:54 AM. The same document shows the alarm did not sound and it was found shoved into the bend of the recliner. On [DATE], R1 left the facility by ambulance at 10:13 AM to a local hospital, later that day he transferred to a larger hospital due to a neck fracture . Later the same day R1 expired at 10:53 PM. On [DATE] at 11:15 AM, E7 LPN (Licensed Practical Nurse) said R1 slid down in the recliner twice on [DATE] before he fell . E7 said the alarm did not sound when R1 fell . The alarm was shoved in the bend of the recliner. E7 said R1 would remove the clip alarm once in a while. E7 said she was at nurse's station and saw R1 attempt to stand up from the recliner and he fell straight onto his forehead. E7 said they could not get to R1 fast enough to prevent his fall. On [DATE] at 8:35 AM, E3 CNA said on [DATE] R1 was in his wheelchair in front of the nurse's station. R1 stood up and said he wanted to get in the recliner so I assisted him to transfer. R1 slid down in the recliner twice before he fell . E3 said she attached the clip from the alarm onto the back of R1's shirt and tucked the alarm into the recliner next to R1. E3 said the alarm box was not attached to any fixed part of the recliner. E3 said R1 knew how to remove the alarm from his clothing. E3 said she was standing at the nurse's station and could not get to R1 before he fell . On [DATE] at 11:30 AM, E8 CNA said R1 would take his clip alarms off. On [DATE] at 9:40 AM, E2 DON (Director of Nursing) said if alarms are not used properly a fall may occur and staff response would be delayed. E2 said E10 MDS coordinator (Minimum Data Set) evaluates fall interventions randomly. On [DATE] at 10:55 AM, E6 CNA said on [DATE] R1 kept trying to get up out of his chair. R1 had a clip alarm on and kept taking it off his shirt, he always did that. The alarm did not go off when he fell . E6 said she was seated behind the desk when R1 fell . E6 said if we had been 1:1 with R1, distracting him or pushing him around in his chair maybe he would not have fallen. On [DATE] at 2:10 PM, E5 CNA said an alarm can prevent a fall and would consider an alarm an intervention to prevent a fall. On [DATE] at 2:35 PM, E2 said when R1 fell on [DATE] it was verified by viewing the video recording that there was no alarm on R1. E2 said the cause of R1's fall was that R1 was restless and wanted to stand up. E2 said it was not uncommon for R1 to try to stand up from a chair unassisted. On [DATE] at 1:40 PM, E10 measured the distance from behind the middle of the nurse ' s station desk to the area of R1 ' s fall on [DATE]th as approximately 28 feet. The manufacturer ' s recommendations for the alarm device used for R1 on [DATE] shows failure to comply with all directions may result in injury and death. It shows that alarms are not intended to be used as a substitute for visual monitoring. The recommendation shows they are to be used on wheelchairs, standard upright chairs and beds. The directions for use show to attach the alligator clip to the resident's clothing and attach the device to a wheelchair, chair or bed using the strap, bedrail clip or wheelchair clip. On [DATE] at 10:05 AM, E13 (Maintenance) said straps were added to the sides of the recliners by the nurse's station on [DATE] so there would be a place to securely hold the magnet alarms like we ' re supposed to. On [DATE] at 9:45 AM, E1 Administrator said if R1's alarms were working or not the staff members (E3, E5 and E6) would not be able to get to him in time to prevent the fall. E1 said this was based on the video surveillance of the incident. R1 was positioned approximately 20 feet away with his back to the nurse's station with other resident's in chairs on both sides of him. On [DATE] at 8:50 AM, E10 said R1 took his clip alarms off frequently and the alarm intervention was not in R1's care plan. E10 said after each fall the IDT (Interdisciplinary Team) meets to ensure interventions were in place and implement new interventions if appropriate. A meeting of this type is how it was determined that alarms were deemed appropriate for R1. E10 said it is not appropriate to set an alarm next to a resident because the box could move and not trigger the alarm. If alarms are not working properly staff may not be alerted to a resident ' s movement, which is the purpose of an alarm. The facility ' s policy on Fall Prevention Alarm Devices dated [DATE] shows the purpose of alarms is to alert staff members of a resident ' s attempt to stand and to prevent resident falls. The policy shows all alarms will be applied as per manufacturer recommendations. R1 ' s medical records from the hospital showed R1 was pronounced dead at 10:53 PM on [DATE]. On [DATE] at 1:50 PM, Z1 Trauma Surgeon said R1's fall of [DATE] and subsequent injuries directly contributed to his death. The swelling around his spinal cord eventually impaired his ability to breathe.

Based on observation, interview and record review the facility failed to ensure that a resident with Dementia was not force fed and was allowed to use the bathroom. This failure resulted in R1 being visually upset. This is for 1 (R1) of 4 residents reviewed for abuse. The finding includes: R1's Face Sheet shows her [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) of 1/11/2011 shows the resident has cognitive deficits and requires assistance with transfers, ambulation, dressing, and bathing. The MDS shows that she is independent with eating, only needing set-up assistance. On 2/25/2011 at 1:00 PM, R1 was observed lying in bed, asleep. At 4:30 PM, the resident was observed reclined in a geriatric chair, sleeping. Z1 (Family) was visiting with the resident. She said the resident is on Hospice services and is declining. Z1 said she had just received [MEDICATION NAME] and had slept most of the visit. She said the resident has Dementia and did not know her today. On 2/25/2011 at 1:00 PM, E1 (Administrator) and E2 (Director of Nursing) were interviewed. The surveyor asked to review all abuse investigations for the past 3 months. They said they had only had 1 investigation and it was not substantiated. E1 said she received a call at home on 2/15/2011, during the second shift, stating that E4 (Shift Coordinator and Certified Nursing Assistant - CNA) allegedly abused R1 by force feeding her. E1 said E4 was pulled off of the floor, interviewed, and sent home on suspension. E1 said the investigation was completed and the allegation was not substantiated, allowing E4 to return to work. E1 said E4 received a written Disciplinary Action on 2/17/2011 and was demoted from the CNA shift coordinator to a floor CNA. E1 said E4 has a tone of voice that is rough and could be perceived as being verbal abuse. E4 returned back to work on 2/17/2011. E4 has worked 17 hours since the facility said they did not think the abuse occurred. E1 presented the surveyor with her statements from the people she interviewed. On 2/15/2011 at 10:10 PM, E5's (CNA) type-written statement says, "...I saw (E4) standing over (R1) telling her that she had to eat...(R2) turned to me and said if anyone ever spoke to me and treated me that way I wouldn't be able to deal with it. (R1) was sobbing and E4 was forcing the spoon into her mouth and holding her by her shoulders. I told E8 (Registered Nurse)...she talked to (R1) and did not get much response from her...". E6's (CNA) statement (2/15/2011 at 10:25 PM) reads, "I was sitting feeding (another resident)...E4 was forcing the spoon in her (R1) mouth and she (E4) was grabbing her (R1) shoulder and telling her she had to eat and couldn't leave the dining room until she ate. (R1) was yelling no, pushing her (E4) hands away and crying. She was saying she didn't want to eat and she wasn't hungry...(R2) said that it was horrible behaviors and she didn't like the yelling and she hopes she would never be treated like that...". E9's (CNA) type-written statement of 2/15/2011 at 10:34 PM, states, "(E4) was trying to get (R1) to eat...(E4) said you have to eat, it was a little on the harsh side. She was telling her she couldn't leave the dining room until she ate something...(R1) was saying she didn't want to eat, she was holding up her hand...I was walking somebody so I couldn't stop. (R2) said something like (E4) was a little hard on her trying to get her to eat." E10's (CNA) undated statement says, "(E4) was feeding (R1)...She was stern with her; she said she couldn't leave until she ate. The resident seemed in distress...". E1 provided notes she took when interviewing R2 regarding the incident. R2 said the CNA has an awful attitude. She said she never wanted her relatives, friends, or herself treated in such a way. R2 said the CNA was very loud, demanding, and persistent when trying to get (R1) to eat. R2 said,"(R1) sat there saying 'no, no, no' because she doesn't have the mind to snap back at her." On 1/25/2011 at 3:20 PM, confidential interviews were conducted. They said R1 has never been a big eater, is receiving Hospice Services, and recently has been rapidly declining. They said R1 is confused and has severe Dementia. One of the interviewees said the resident will eat yogurt, applesauce, and sometimes will drink ensure. The interviewees said during the evening meal at approximately 6:30 PM, they witnessed E4 speaking roughly to R1. E4 had her hands on the resident's shoulder, pushing her toward the food, and forcing a spoon into her mouth. The interviewees said the resident was trying to push E4 away from her. She was crying and heard saying 'no, no, no, you are hurting my teeth'. They said the resident wanted to leave the dining room and she needed to use the bathroom. According to the interviews, E4 told R1 she could not leave the dining room or use the bathroom until she ate at least half of the food on her plate. All of the interviewees said the episode lasted approximately 10 minutes. They all said what they witnessed was both verbal and physical abuse. On 2/25/2011 at 4:40 PM, E1 said the resident's are not officially screened for being at risk for abuse and there are no careplans in place showing how they will protect the resident from abuse. E1 again confirmed their abuse investigation regarding E4 was completed. She said E4 was off work with a physician excuse, due to illness, but would be returning to CNA duties as soon as she is released from the doctor. She said she could not substantiate the abuse allegation. The facility's Abuse Prohibition Policy and Procedure (11/99) states, "The facility actively prohibits resident abuse including neglect, involuntary seclusion, misappropriation of property, and injuries of unknown source." The Purpose of the policy is "to protect residents from any kind of abuse such as verbal, sexual, physical, including corporal punishment, neglect, misappropriation of property and involuntary seclusion." The policy has the following definitions: 1. Abuse means any physical or mental injury or sexual assault inflicted on a resident other than by accidental means. 2. Physical abuse means the infliction of injury on a resident that occurs than by accidental means and that required medical attention. Physical abuse may include, but is not limited to such acts as: hitting, slapping, kicking, hair pulling, and pinching, etc. 3. Verbal abuse means the use by an employee or agent of oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability. 4. Mental abuse includes, but is not limited to humiliation, harassment, threats of punishment or deprivation, or offensive physical contact by an employee or agent.

Based on interview and record review the facility neglected to have a hydration policy and a system in place to identify residents at risk for dehydration and develop hydration plans showing how they will meet the fluid requirements for their residents; the facility failed to follow their Hydration Assistance Policy; the facility neglected to follow their Resident Change in Condition Policy and Procedure; and the facility neglected to follow their Intake and Output Policy and Procedure. This neglect began on 9/3/2010 when R1 had a recommendation to be NPO. The resident was not made NPO until 9/8/2010. The facility continued to feed the resident for 5 days. This failure contributed to R1 being admitted to a local hospital for Aspiration Pneumonia, Difficulty in Swallowing, Significant Dehydration, Electrolyte Abnormalcies, and Hemoconcentration. R2 was admitted to a local hospital with [DIAGNOSES REDACTED]. An Immediate Jeopardy was identified on 9/24/2010 and began on 9/3/2010. Although the immediacy was removed on 9/24/2010, the facility remains out of compliance at a level 2 due to the need to evaluate the implementation of the in-servicing provided to staff. This is for 2 (R1 & R2) of 3 resident's sampled. The examples include: The facility's Change in a Resident's Condition (12/02) policy says that the facility will notify a resident's physician when there is a change in a resident's condition. Listed as some of those possible changes are when there is a significant change in the resident's physical, mental, or psychosocial status; a need to alter the resident's treatment significantly; and when it is necessary or appropriate in the best interest of the resident. On 9/21/2010 at 10:30 AM, E1 (Administrator), and E2 (9/24/2010 at 10:00 AM) verified that the facility does not have a Hydration policy, risk assessment, nor guidelines to show the facility will ensure and meet a resident's required fluid intake. The facility's Intake and Output (dated 2/04) policy and procedure states that the objective is to maintain an accurate record of the resident's fluids balance. The procedure lists that staff are to "check with resident to make sure that all fluid intake has been measured, including all fluids served between meals and total intake at the end of each shift". The facility's Hydration Assistance Policy and Procedure dated 7/08 states the purpose is "to provide adequate daily fluids to all residents to avoid dehydration". R1's Minimum Data set (MDS) of 8/10/2010 shows that the resident has severe cognitive impairment and requires total assistance from the staff with eating. The MDS shows that the resident's methods of communication are by signs, gestures, and sounds. The MDS documents that the resident is rarely or never understood. R1's [DIAGNOSES REDACTED]. On 9/20/2010 at 10:15 AM, Z1 said that R1 came into the GI (Gastrointestinal) Lab on 9/9/2010 for PEG (Percutaneous Endoscopic Gastrostomy) tube placement, as an outpatient. Z1 said that when the resident presented to the lab, the resident was observed to be very "dry". She said that R1's tongue was stuck to her teeth. She said that the resident was given mouth care. The inside of her mouth had ulcers. Z1 said that her tongue looked like "cobblestones". It had very deep grooves. Z1 said that she called the facility and spoke with E5 (Licensed Practical Nurse) who said she did not know how long the resident had not had any water. She said that the resident had not had anything to eat since September 3, 2010 (9/3-9/8/2010). On 9/22/2010 at 3:30 PM, Z4 said, "When we first saw (R1) her mucous membranes were very dry and she was having difficulty breathing. She was too unstable to do the PEG (Percutaneous Endoscopic Gastrostomy) tube procedure. I ordered lab tests and she was admitted to the hospital. We found that her Na (sodium) level was high, she was severely dehydrated, and her blood was hemoconcentrated. She had gone some time without fluids. We needed to correct her Na and rehydrate her. She would have been better off if she would have gotten in for the procedure sooner. R1's diet Care plan of 8/13/2010 shows that the resident has a problem with chewing and swallowing related to dysphagia. The problem list shows that on 4/13/2010 the resident choked on pureed food. Interventions included are to offer fluids to meet hydration needs and monitor and record intake at all meals. There are no specific interventions on how the facility plans to meet the RD's recommendation of fluid needs (1650 cc per 24 hours - 4/21/2010 RD assessment) for R1. R1's Meal Intake Record for 8/2010 and 9/1 through 9/8/2010 shows that out of 117 meals there is no documentation of fluid intake for 34 meals. For 42 of 83 meals documented the resident consumed less than 75% of her fluids. The fluids were not measured. Staff based the fluid intakes on percentages. A swallow study was conducted by Z5 (Speech Therapist) on 9/3/2010 at which time a recommendation was made to make the resident NPO (nothing by mouth). On 9/21/2010 at 2:50 PM, the facility could not provide evidence that R1's physician (Z8) had been notified of the resident's poor oral intake or the results of the swallow study and the NPO recommendation by Z5. On 9/21/2010 at 2:50 PM, Z3 (Nurse Practitioner) said that she saw R1 on 9/8/2010. Z3 said that the resident's mouth appeared dry. Z3 said, "I did not know that a swallow study had been done on 9/3/2010 and that there was a recommendation for the resident to be NPO. I was not made aware of that until 9/7/2010 (at which time Z3 signed the Speech Therapy order) She went from 9/3 to 9/8/2010, before the NPO order was carried out." Z3 was shown R1's intake records. She said, "I had not been made aware of (R1's) poor intake for August through September 7, 2010. I would have acted sooner if I'd have known." On 9/21/2010 at 10:30 AM, E1 (Administrator), E3 (Licensed Practical Nurse - Restorative Nurse), and E6 (MDS Coordinator) said that the facility does not do hydration assessments. E3 said that resident's are considered at risk for dehydration if they have skin issues or if a resident is on diuretics. 2. R2 is an [AGE] year old female resident admitted to the facility on [DATE] according to the facility face sheet. R2 has [DIAGNOSES REDACTED]. The POS showed R2 takes [MEDICATION NAME] 80 mg daily (diuretic). During an interview on 9/24/10 at 9:10 AM, E2 (Director of Nursing) stated when there is a deviation in a resident's baseline status, the physician should be notified of that change immediately. E2 reviewed R2's weight records and intake sheets and verified that R2 had lost 37 pounds between 6/4/10 and 7/14/10. E2 acknowledged that R2's physician was not notified until 8/12/10, (one month after the 37 pound decline). E2 verified the delay in notification was unacceptable. E2 stated R2's physician, family and the dietician should have been notified as soon as R2 began to loose weight or have a decline in oral intake. E2 said she would have expected interventions to have been implemented and evaluated to prevent further loss between 6/4/10 and 7/14/10. R2's Meal Intake Records dated June, July and August 2010 showed, of the 240 documented meals, R2's fluid intake was less than 50% of her required amounts for 103 meals. The Dietary Care Plan dated 5/19/10 identified R2's needs as 1750-1960 calories, 84-91 grams of protein and 1750-2450 ml. of fluid daily. This care plan stated R2's needs would be met if she (R2) consumed 80-85% of all her meals. The Dietary Care Plan dated 8/15/10, (3 months later), identified R2 as having an Oral Intake of 25-50%. On 9/24/10 at 9:10 AM, E2 (DON) verified the facility does not track specific amounts of fluid intakes, (ml's/cc's). R2 had been treated for [REDACTED]. On 9/19/10, R2 was admitted to the hospital with [REDACTED]. As a part of the plan of treatment, the physician admission note stated, "I am going to hold the [MEDICATION NAME] and start her on IV fluids...The patient will be given extra potassium in the IV". E1 (Administrator) was informed of the Immediate Jeopardy on 9/24/2010 at 11:45 AM. The surveyor confirmed that the facility took the following steps to remove the immediacy of the situation: On 9/24/10 all residents in the facility were assessed for hydration status using the Nutritional Assessment. The assessment includes a review of mouth pain, difficulty swallowing, the resident's feeding capabilities, activity levels, mental status, and a review of recent laboratory results and medication side effects. The assessment is completed upon admission, quarterly, and with significant changes. The facility reviewed the resident's care plans to ensure that appropriate measure were in place in an attempt to prevent dehydration. Beginning 9/24/2010, Intake records will be monitored and reviewed by the shift coordinators before the end of each shift. Intake records will also be reviewed by the Director of Nursing, Restorative Nurse, and the Minimum Data Set Coordinator each morning. Identified problems will be immediately followed up on. The Intake Records have been revises to ensure that they accurately reflect the amount of liquid consumed by the patient in cubic centimeter (cc) measurement. on 9/24/2010, The facility reviewed and revised its Monthly Nutritional Monitoring Sheet to ensure that hydration issues are communicated to the Registered Dietician. As of 9/24/2010,All direct care staff and dietary staff will be in-serviced regarding meeting residents' hydration needs. Staff not currently working will not be allowed to return to patient care until they have been in-serviced.

Based on observation, interview and record review the facility failed to notify a resident's physician when a resident was drinking 75% or less of all her fluids for over 1 month. The facility failed to ensure R1's fluid needs were met according to assessed needs. The facility failed to have a system in place to identify residents at risk for dehydration and develop hydration plans showing how they will meet the fluid requirements for their residents. This failure contributed to R1 being admitted to a local hospital for Aspiration Pneumonia, Difficulty in Swallowing, Significant Dehydration, Electrolyte Abnormalcies, and Hemoconcentration. R2 was admitted to a local hospital with [DIAGNOSES REDACTED]. An Immediate Jeopardy that was identified on [DATE] and began on [DATE]. Although the immediacy was removed on [DATE], the facility remains out of compliance at a level 2 due to the need to evaluate the effectiveness of the in-servicing provided to staff. The examples include: R1's Minimum Data set (MDS) of [DATE] shows that the resident has severe cognitive impairment and requires total assistance from the staff for mobility, dressing, eating, and hygiene. The MDS shows that the resident's methods of communication are by signs, gestures, and sounds. The MDS documents that the resident is rarely or never understood. R1's [DIAGNOSES REDACTED]. On [DATE] at 9:00 AM, R1 was observed seated in a geriatric chair, in her room. The surveyor attempted to communicate with the resident, but received no verbal response or eye contact. A feeding pump with formula was observed next to the resident's chair. On [DATE] at 10:15 AM, Z1 said that R1 came into the GI (Gastrointestinal) Lab on [DATE] for PEG tube placement, as an outpatient. Z1 said that when the resident presented to the lab, the resident was observed to be very "dry". She said that R1's tongue was stuck to her teeth. She said that the resident was given mouth care. The inside of her mouth had ulcers. Z1 said that her tongue looked like "cobblestones". It had very deep grooves. Z1 said that she called the facility and spoke with E5 (Licensed Practical Nurse) who said she did not know how long the resident had not had any water. She said that the resident had not had anything to eat since [DATE] (,[DATE]-[DATE]). Z1 said she took the resident to see Z4 (physician) at which time the resident appeared to be in respiratory distress with Oxygen saturations in the 80's (Normal is ,[DATE]% - MayoClinic.com). Z1 said that the resident's legs were mottled and she was not responsive. Z1 said that the resident is mute. On [DATE] at 3:30 PM, Z4 said, "When we first saw (R1) her mucous membranes were very dry and she was having difficulty breathing. She was too unstable to do the PEG (Percutaneous Endoscopic Gastrostomy) tube procedure. I ordered lab tests and she was admitted to the hospital. We found that her Na (sodium) level was high, she was severely dehydrated, and her blood was hemoconcentrated. She had gone some time without fluids. We needed to correct her Na and rehydrate her. She would have been better off if she would have gotten in for the procedure sooner". Z4's consultation report of [DATE] states, "...When I went to see her, she was extremely dehydrated and was having difficulty breathing...Her Oxygen saturation is about 75% on room air and on a nonrebreather mask it is around 90%...Mucous membranes are extremely dry...". Z4's recommendations are, " 1. the patient needs a correction of her electrolytes and volume status. 2. She needs correction of her respiratory status as well. 3. After she has been stabilized, we will proceed with an upper endoscopy with placement of a PEG tube". Z4's Discharge Summary of [DATE] states, "...While in the GI suite, she was found to be quite dehydrated and she became hypoxic...When she came in, she was very dehydrated and she was also given oral care while here." The Discharge Summary shows the resident's principal [DIAGNOSES REDACTED]. R1's initial laboratory results of [DATE] shows the following: WBC (white blood cell) 12.10 - High (Norm 4.5 - 11.0) Hemoglobin 17.9 - High (Norm 12.7 - 14.7) Hematocrit 53.8 - High (Norm 36 - 44.9) Glucose 159 - High (Norm ,[DATE]) BUN 32 - High (Norm ,[DATE]) Potassium 3.6 - Low (Norm 3XXX,[DATE].1) The Merck Manual of Geriatrics, 3rd edition states under dehydration and volume depletion ( page 562 - 568) an increased Hematocrit and BUN (Blood Urea Nitrogen), [MEDICAL CONDITION], and [MEDICAL CONDITION] are indicative of dehydration and decreased water intake. A Web MD (www.webmd.com) article, Potassium in Blood states, "Potassium levels often change with sodium (Na) levels. When Na levels go up, potassium levels go down...other conditions that can cause low blood potassium levels include...dehydration...". The [DATE] RD (Registered Dietician) documents that R1's fluid requirements are 1650 cc's in a 24 hours period. R1's diet Care plan of [DATE] shows that the resident has a problem with chewing and swallowing related to dysphagia. The problem list shows that on [DATE] the resident choked on pureed food. Interventions included are to offer fluids to meet hydration needs and monitor and record intake at all meals. There are no specific interventions on how the facility plans to meet the RD's recommendation of fluid needs for R1. R1's Meal Intake Record for ,[DATE] and ,[DATE] through [DATE] shows that out of 117 meals there is no documentation of fluid intake for 34 meals. For 42 of 83 meals documented the resident consumed less than 75% of her fluids. The fluids were not measured. Staff based the fluid intakes on percentages. On [DATE] at 9:30 AM, E4 (Licensed Practical Nurse - LPN) said that the nurse aides fill out the intake records in the dining room. She said that if there is a problem they let the nurse know. The nurses don't review the intake records unless a problem is brought to their attention. A swallow study was conducted by Z5 (Speech Therapist) on [DATE] documented a recommendation was made to make the resident NPO (nothing by mouth). On [DATE] at 2:50 PM, Z3 (Nurse Practitioner) said that she saw R1 on [DATE]. Z3 said that the resident's mouth appeared dry. Z3 said, "I did not know that a swallow study had been done on [DATE] and that there was a recommendation for the resident to be NPO. I was not made aware of that until [DATE] (at which time Z3 signed the Speech Therapy order) She went from ,[DATE] to [DATE], before the NPO order was carried out." Z3 was shown R1's intake records. She said, "I had not been made aware of (R1's) poor intake for August through [DATE]. I would have acted sooner if I'd have known." The Long Term Care Legal Desk Reference HCPro. MA. 2006, states, "...Resident who are at high risk for dehydration must be identified...Contributing factors to inadequate hydration: fever, infection, dysphagia, nausea, vomiting, diarrhea, malabsorption, [MEDICAL CONDITION], inability to consume fluids or refuses fluids...Signs and symptoms of dehydration: sunken cheeks, sunken eyeballs, dry tongue and membranes, dry, inelastic skin, weight loss, [MEDICAL CONDITION], increased pulse, weakness, mental confusion, constipation and impaction, abnormal laboratory values (elevated hemoglobin/hematocrit...BUN...Sadly by the time signs and symptoms appear and are evident to staff most resident are already quite dehydrated, making the need for aggressive interventions essential...Chapter 12, Nutrition, pages ,[DATE] states, "...Interventions have been evaluated repeatedly and periodically and modified according to the resident's responses to the intervention...Evaluate I&O over at least one week, compare with dietitians's calculations of the resident's minimum daily fluid requirements..." The American Medical Directors Association (AMDS), Dehydration and Fluid Maintenance-Clinical Practice Guideline (www.amda.com.2001) states,"...The facility's health care practitioners and staff must know how to recognize, assess, treat, monitor, and reduce the risk of dehydration or fluid/electrolyte imbalance...Because dehydration is both common among frail older persons and yet under recognized and under treated, all long-term care providers must be vigilant at identifying patients who have or are at risk for dehydration or other fluid/electrolyte imbalances..." Nursing Notes show that there is no mention of the resident's poor intake in the month of August, 2010. On [DATE] at 7:51 PM, Nursing Notes states, "Resident refused to eat supper." On [DATE] at 7:14 PM, Nursing Notes document, "...took only two bites of supper, would let food sit in mouth and not swallow...". The nursing documentation for ,[DATE] and ,[DATE] show that there were no hydration assessments done. The Second Edition of the Nursing Care of Older Adults Theory and Practice (page 204) states, "...In older adults, total body water may be further diminished by poor fluid intake secondary to age-related factors, such as diminished thirst sensation. Older adults must consume 1,500 to 2,000 mL (milliliters) of fluid daily to maintain adequate hydration... (page 527) Examination of the mucous membranes and skin turgor over the abdomen provide more accurate clues to dehydration...older people may have a diminished thirst response...A visual examination of urine concentration will provide some clues to hydration. When any indicators of...dehydration are identified, the next step is to determine whether the hydration...status can be improved adequately without removing the person from the setting. The role of the nurse can be especially important in assessing hydration...". The facility's Intake and Output (dated ,[DATE]) policy and procedure states that the objective is to maintain an accurate record of the resident's fluids balance. The procedure lists that staff are to "check with resident to make sure that all fluid intake has been measured, including all fluids served between meals and total intake at the end of each shift". The facility's Hydration Assistance Policy and Procedure dated ,[DATE] states the purpose is "to provide adequate daily fluids to all residents to avoid dehydration". On [DATE] at 10:30 AM, E1 (Administrator), and E2 ([DATE] at 10:00 AM) verified that the facility does not have a hydration policy, risk assessment, nor guidelines to show the facility will ensure and meet a resident's required fluid intake. The facility's Intake and Output (dated ,[DATE]) policy and procedure states that the objective is to maintain an accurate record of the resident's fluids balance. The procedure lists that staff are to "check with resident to make sure that all fluid intake has been measured, including all fluids served between meals and total intake at the end of each shift". The facility's Hydration Assistance Policy and Procedure dated ,[DATE] states the purpose is "to provide adequate daily fluids to all residents to avoid dehydration". 2. R2 is an [AGE] year old female resident admitted to the facility on [DATE] according to the facility face sheet. R2 has [DIAGNOSES REDACTED]. The POS showed R2 takes [MEDICATION NAME] 80 mg daily (diuretic). R2's Meal Intake Records dated June, July and [DATE] showed, of the 240 documented meals, R2's fluid intake was less than 50% of her required amounts for 103 meals. The Dietary Care Plan dated [DATE] identified R2's needs as ,[DATE] calories, ,[DATE] grams of protein and ,[DATE] ml. of fluid daily. This care plan stated R2's needs would be met if she (R2) consumed ,[DATE]% of all her meals. The Dietary Care Plan dated [DATE], (3 months later), identified R2 as having an Oral Intake of ,[DATE]%. On [DATE] at 9:10 AM, E2 (DON) verified the facility does not track specific amounts of fluid intakes, (ml's/cc's). R2 had been treated for [REDACTED]. On [DATE], R2 was admitted to the hospital with [REDACTED]. As a part of the plan of treatment, the physician admission note stated, "I am going to hold the [MEDICATION NAME] and start her on IV fluids...The patient will be given extra potassium in the IV". R2's lab values dated [DATE] show: ? BUN 47 High (Normal ,[DATE] mg/dl) ? Creatinine 1.79 High (Normal 0XXX,[DATE].04 mg/dl) ? Potassium 3.7 Low (Normal 3XXX,[DATE].1 mEq/L) E1 (Administrator) was informed of the Immediate Jeopardy on [DATE] at 11:45 AM. The surveyor confirmed that the facility took the following steps to remove the immediacy of the situation: On [DATE] all residents in the facility were assessed for hydration status using the Nutritional Assessment. The assessment includes a review of mouth pain, difficulty swallowing, the resident's feeding capabilities, activity levels, mental status, and a review of recent laboratory results and medication side effects. The assessment is completed upon admission, quarterly, and with significant changes. The facility reviewed the resident's care plans to ensure that appropriate measure were in place in an attempt to prevent dehydration. Beginning [DATE], Intake records will be monitored and reviewed by the shift coordinators before the end of each shift. Intake records will also be reviewed by the Director of Nursing, Restorative Nurse, and the Minimum Data Set Coordinator each morning. Identified problems will be immediately followed up on. The Intake Records have been revised to ensure that they accurately reflect the amount of liquid consumed by the patient in cubic centimeter (cc) measurement. As of [DATE], the facility reviewed and revised its Monthly Nutritional Monitoring Sheet to ensure that hydration issues are communicated to the Registered Dietician. As of [DATE], all direct care staff and dietary staff will be in-serviced regarding meeting residents' hydration needs. Staff not currently working will not be allowed to return to patient care until they have been in-serviced. II. Based on interview and record review the facility failed to have a plan to monitor residents at risk for dehydration which includes: 1. An initial screening for residents at risk for dehydration risk 2. A proactive hydration program to assure that resident fluid needs are met. This applies to 58 of the 84 residents residing in the facility (R1, 3&4, 7 & 8, 10. 12, ,[DATE], ,[DATE], ,[DATE], 36, 38, ,[DATE], 44, 45, 48 & 49, 50, ,[DATE], ,[DATE], ,[DATE], 74, 75, 77, 79 & R80). The example includes: On [DATE] at 10:30 AM, E1 (Administrator), E3 (Licensed Practical Nurse - Restorative Nurse), and E6 (MDS Coordinator) said that the facility does not do hydration assessments. E3 said that resident's are considered at risk for dehydration if they have skin issues or if a resident is on diuretics. On [DATE] at 3:30 PM, E1 presented a list of resident's at risk for dehydration. The list included 58 of the 84 residents residing in the facility (R1, 3&4, 7 & 8, 10. 12, ,[DATE], ,[DATE], ,[DATE], 36, 38, ,[DATE], 44, 45, 48 & 49, 50, ,[DATE], ,[DATE], ,[DATE], 74, 75, 77, 79 & R80). The facility could not show how it determined that each of the residents were at risk for dehydration. The careplans for each of the residents were not specific and did not include the RD's fluid recommendations or how the facility was going to try to meet those requirements. On [DATE] at 10:30 AM, E1 (Administrator), and E2 ([DATE] at 10:00 AM) verified that the facility does not have a hydration policy, risk assessment, nor guidelines to show the facility will ensure and meet a resident's required fluid intake. The facility's Intake and Output (dated ,[DATE]) policy and procedure states that the objective is to maintain an accurate record of the resident's fluids balance. The procedure lists that staff are to "check with resident to make sure that all fluid intake has been measured, including all fluids served between meals and total intake at the end of each shift". The facility's Hydration Assistance Policy and Procedure dated ,[DATE] states the purpose is "to provide adequate daily fluids to all residents to avoid dehydration".

Based on interview and record review the facility failed to notify a resident's (R1) physician regarding her poor low intake for the months of August and September 2010. The physician was not informed of her inability to swallow, and the results of a speech therapist's evaluation and recommendation that R1 receive nothing orally by mouth (NPO) for 5 days. This failure contributed to R1 being admitted to a local hospital for Aspiration Pneumonia, Difficulty in Swallowing, Significant Dehydration, Electrolyte Abnormalcies, and Hemoconcentration. This is for 1 (R1) of 3 residents reviewed for dehydration. The example includes: R1's Minimum Data set (MDS) of 8/10/2010 shows that the resident has severe cognitive impairment and requires total assistance from the staff for mobility, dressing, eating, and hygiene. The MDS shows that the resident's methods of communication are by signs, gestures, and sounds. The MDS documents that the resident is rarely or never understood. R1's [DIAGNOSES REDACTED]. On 9/20/2010 at 10:15 AM, Z1 said that R1 came into the GI (Gastrointestinal) Lab on 9/9/2010 for PEG (Percutaneous Endoscopic Gastrostomy) tube placement, as an outpatient. Z1 said that when the resident presented to the lab, the resident was observed to be very "dry". She said that R1's tongue was stuck to her teeth. She said that the resident was given mouth care. The inside of R1's mouth had ulcers. Z1 said that R1's tongue looked like "cobblestones" and it had very deep grooves. Z1 said that she called the facility and spoke with E5 (Licensed Practical Nurse) who said she did not know how long the resident had not had any water. E5 said that the resident had not had anything to eat since September 3, 2010 (9/3-9/8/2010). Z1 said she took the resident to see Z4 (physician) at which time the resident appeared to be in respiratory distress with Oxygen saturations in the 80's (Normal 95-100% - MayoClinic.com). Z1 said that the resident's legs were mottled and she was not responsive. Z1 said that the resident is mute. On 9/22/2010 at 3:30 PM, Z4 said, "When we first saw (R1) her mucous membranes were very dry and she was having difficulty breathing. She was too unstable to do the PEG tube procedure. I ordered lab tests and she was admitted to the hospital. We found that her Na (sodium) level was high, she was severely dehydrated, and her blood was hemoconcentrated. She had gone some time without fluids. The sores in her mouth were due to her mouth being so dry. We needed to correct her Na and rehydrate her. She would have been better off if she would have gotten in for the procedure sooner. R1's Meal Intake Record for 8/2010 and 9/1 through 9/8/2010 shows that out of 117 meals there is no documentation of fluid intake for 34 meals. For 42 of 83 meals documented the resident consumed less than 75% of her fluids. A swallow study was conducted by Z5 (Speech Therapist) on 9/3/2010 at which time a recommendation was made to make the resident NPO (nothing by mouth). On 9/21/2010 at 2:50 PM, Z3 (Nurse Practitioner) said that she saw R1 on 9/8/2010. Z3 said that the resident's mouth appeared dry. Z3 said, "I did not know that a swallow study had been done on 9/3/2010 and that there was a recommendation for the resident to be NPO. I was not made aware of that until 9/7/2010 (at which time Z3 signed the Speech Therapy order). She (R1) went from 9/3 to 9/8/2010, before the NPO order was carried out." Z3 was shown R1's intake records. She said, "I had not been made aware of (R1's) poor intake for August through September 7, 2010. I would have acted sooner if I'd have known." On 9/21/2010 at 2:50 PM, the facility could not provide evidence that R1's physician (Z8) had been notified of the resident's poor oral intake or the results of the swallow study and the NPO recommendation by Z5. The nursing documentation for 8/2010 and 9/2010 show that there were no assessments done to show the resident's (R1's) hydration status. The facility's Change in a Resident's Condition, (12/02) states," Our facility shall promptly notify the resident, and or resident's representative, and his or her attending physician of changes in the resident's condition and/or status. The policy says: 1. The nurse will notify the resident's attending physician when: a. The resident is involved in any accident or incident that results in an injury or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychosocial status; c. There is a need to alter the resident's treatment significantly; d. The resident is discharged without proper medical authority; and/or e. Deemed necessary or appropriate in the best interest of the resident. 2. R2 is an [AGE] year old female resident admitted to the facility on [DATE] according to the facility face sheet. R2 has [DIAGNOSES REDACTED]. The POS showed R2 takes [MEDICATION NAME] 80 mg daily (diuretic). During an interview on 9/24/10 at 9:10 AM, E2 (Director of Nursing) stated when there is a deviation in a resident's baseline status, the physician should be notified of that change immediately. E2 reviewed R2's weight records and intake sheets and verified that R2 had lost 37 pounds between 6/4/10 and 7/14/10. E2 acknowledged that R2's physician was not notified until 8/12/10, (one month after the 37 pound decline). E2 verified the delay in notification was unacceptable. E2 stated R2's physician, family and the dietician should have been notified as soon as R2 began to loose weight or have a decline in oral intake. E2 said she would have expected interventions to have been implemented between 6/4/10 and 7/14/10 with the effectiveness of the interventions being monitored and evaluated.

Based on interview and record review the facility failed to ensure that a speech therapy recommendation for a resident (R1) to receive nothing by mouth was followed for 5 days. This failure resulted in the resident being admitted to the hospital with [REDACTED]. This is for 1 (R1) of 3 residents sampled. The example includes: R1's Minimum Data set (MDS) of 8/10/2010 shows that the resident has severe cognitive impairment and requires total assistance from the staff for mobility, dressing, eating, and hygiene. The MDS shows that the resident's methods of communication are by signs, gestures, and sounds. The MDS documents that the resident is rarely or never understood. R1's [DIAGNOSES REDACTED]. A swallow study was conducted by Z5 (Speech Therapist) on 9/3/2010 at which time a recommendation was made to make the resident NPO (nothing by mouth). The Meal Intake Record for the days of 9/3/2010 through 9/7/2010 shows that the facility continued to attempt to feed R1 after the NPO recommendation. Nursing notes state the following: 9/4/2010 at 9:49 PM "Resident has problems with swallowing, took some food but could not swallow it." 9/5/2010 at 1:58 PM "Needs to be reminded repeatedly to swallow when giving meds or feeding", and on 9/5/2010 at 9:56 PM "took small amt of diet, has difficulty with swallowing." The 9/8/2010 Nurses Notes written at 2:33 PM document that speech therapy orders were received and noted. At 5:42 PM the notes show that an order was received by Z3 (Nurse Practitioner) for the resident to be NPO. On 9/22/2010 at 12:30 PM, E1 (Administrator) verified that the facility staff continued to attempt to feed the resident until 9/8/2010. Nursing Notes of 9/3/2010 through 9/7/2010 do not state that a swallow study was done and there is no documentation that the resident's diet was changed to NPO. There is also no evidence that the resident's physician was notified of the speech therapist's recommendation. On 9/21/2010 at 2:50 PM, Z3 (Nurse Practitioner) said that she saw R1 on 9/8/2010. Z3 said that the resident's mouth appeared dry. Z3 said, "I did not know that a swallow study had been done on 9/3/2010 and that there was a recommendation for the resident to be NPO. I was not made aware of that until 9/7/2010 (at which time Z3 signed the Speech Therapy order). She (R1) went from 9/3 to 9/8/2010, before the NPO order was carried out." Z3 was shown R1's intake records. She said, "I had not been made aware of (R1's) poor intake for August through September 7, 2010. I would have acted sooner if I'd have known." On 9/22/2010 at 12:30 PM, E1 said that the facility does not have a policy and procedure on following up with recommendations such as speech therapy. A hospital Discharge Summary of 9/13/2010 shows the resident's principal [DIAGNOSES REDACTED].