Every finding on record at Rock River Health Care

Based on observation, interview, and record review the facility failed to ensure a resident's seizures were documented in the resident's medical records for 1 of 3 residents (R1) reviewed for medical records in the sample of 8. The findings include:On 6/2/26 at 10:36 AM, R1 was sitting in his wheelchair on the patio of the facility. R1 was wearing a helmet on his head. R1 said he is epileptic and has seizures all the time. R1 said he does not recall when he has them and can not feel them coming on. On 6/2/26 at 12:20 PM, V9 Certified Nursing Assistant said R1 has seizures almost every other day. V9 said R1 had a seizure yesterday (6/1/26). V9 said when R1 has a seizure they alert the nurse. On 6/2/26 at 1:20 PM, V10 Licensed Practical Nurse said R1 has seizures almost every day. V10 said R1 has a medication they give him when he is having a seizure (Valtoco) and if that doesn't help, they have to call the paramedics. On 6/2/26 at 1:45 PM, V3 Assistant Director of Nursing said nursing should be documenting R1's seizures in the progress notes and that Valtoco is administered in the Medication Administration Record. R1's MAR for May and June 2026 shows an order for Valtoco 15 MG Dose Nasal Liquid Therapy Pack 2 x 7.5 MG/0.1ML (Diazepam Anticonvulsant) 1 spray in each nostril every 12 hours as needed for seizure related to Post Traumatic Stress Seizures. Both of these MAR do not contain documentation that R1 was administered Valtoco for seizures. R1's Controlled Drug Receipt/Record/Disposition Form for Valtoco 15 MG spray shows R1 was given Valtoco on 5/15/26, 5/16/26, 5/17/26, and 5/26/26. R1's Progress Notes do not contain documentation regarding R1 having seizures. The facility's Policy and Procedure Documentation dated 1/25 shows It is the policy of the facility to maintain required and accurate documentation in the residents' chart: The staff is responsible for making their own prompt, factual, concise, complete, and appropriate entriesThe documentation shall include the resident's current status, changes in condition, interventions, and appropriate notifications.

Based on interview and record review the facility failed to ensure a resident with an order for a Urology consult received an evaluation by a urologist for 1 of 3 residents (R1) reviewed for care and services in the sample of 8.The findings include:R1's Physician Order Sheet documents that R1 has diagnoses that include multiple sclerosis (MS) and neuromuscular dysfunction of the bladder needing indwelling urinary catheter due to urinary retention.On 2/9/26 at 8:25 AM, V14 (R1's Power of Attorney/POA) said she had a concern with R1 being hospitalized due to multiple urinary tract infections (UTIs) while R1 was at the facility. R1 had indwelling urinary catheter. R1 also has MS. R1 was supposed to see a specialist due to urinary tract infections. V14 said she did not hear any update from the facility.R1's hospital records dated 12/14/25, documents R1 was admitted to the hospital from [DATE] to 12/19/25 due to sepsis- UTI. R1 was discharged back to the facility on [DATE] with an order for R1 to be referred to a Urologist. R1 was again admitted to the hospital from [DATE]-[DATE] due to UTI-sepsis.On 2/5/26 at 11 AM, V6 (Registered Nurse-RN) said the Urology office in town did not take R1's insurance. V6 said she did not notify R1's physician or family that R1 did not see the Urologist as ordered on 12/19/25. On 2/9/26 at 12PM, V2 (Director of Nursing) said R1 has MS and needs the indwelling urinary catheter due to urinary retention. R1 had recurrent UTI's needing hospitalizations. R1 should have been referred to a Urologist for bladder management and ongoing care due to the recurrent UTI's.

Based on interview and record review the facility failed to ensure resident's safety during care to 1 of 3 residents (R1) reviewed for safety in the sample of 8.The findings include:On 2/6/26 at 11:21 AM V3 (Licensed Practical Nurse/LPN) said on 11/21/25, she was passing morning meds when V4 (Certified Nursing Assistant-CNA) came to her and said please go to R1's room. R1 was upset and angry, V4 (CNA) was about to get R1 up for breakfast. V3 LPN said she went to R1's room. R1 was holding onto the side rails, he was turned over to the left side, then fell over the side rails. V3 said she did not know why V4 was by herself to get R1 up. R1 has MS (multiple sclerosis), R1 is a mechanical lift transfer and needs 2 staff assistance for all transfers due to his MS. R1's fall incident reported dated 11/21/25 documents R1 turned over too quickly and flipped himself over the side rails. The incident report document's R1's predisposing physiological factors include: R1 is resistant to care, weakness, agitated and anxious, (has) involuntary movements and decreased strength.R1's care plan (undated) states, R1 is at risk for falls related to diagnosis of multiple sclerosis with contractures, tremors, impaired cognition, impulsivity, psychiatric diagnosis with behaviors, also has self-care deficits. R1's fall interventions included resident is dependent with ADL care, provide total assistance in all aspects of hygiene and dressing, 2 assist with turning and repositioning, transfers with mechanical lift times 2.On 2/5/26 at 2PM, V2 (Director of Nursing) said R1 is high risk for falls due to having MS, R1 needs 2 assists in all cares for safety.

Based on observation, interview and record review the facility failed to obtain accurate weights on a resident with a feeding tube (R14). The facility failed to weigh a resident (R14) as per the dietician's recommendations. The facility failed to notify the dietician of a resident's (R14) refusals of tube feedings. The facility failed to notify the dietician of missed or omitted tube feedings for R14. The facility failed to notify the dietician or nurse practitioner of R14's significant and continued weight loss in a timely manner. These failures contributed to R14 sustaining a significant weight loss. These failures apply to 1 of 7 residents (R14) reviewed for weight loss in the sample of 19.The findings include:R14's current care plan showed R14 had diagnoses including end stage renal disease requiring dialysis, oral cancer, and Type 2 Diabetes Mellitus. R14 had a gastrostomy tube (G-tube) in place to receive nutritional support. The plan showed R14 was Full Code. R14 was not on hospice.Physician notes for R14 dated 11/4/25 and 12/10/25 showed R14 was cognitively intact. R14's November 2025 Medication Administration Record (MAR) showed R14 received a continuous infusion of Nephro (enteral feeding solution) at 40 mls (milliters) per hour, twenty-four hours a day, from 11/1/25-11/9/25, for nutritional support. R14 was NPO (ate nothing by mouth) during this time. R14's progress note dated 11/9/25 showed R14 was hospitalized for pneumonia and altered mental status. A progress note dated 11/14/25 showed R14 was readmitted to the facility. R14's November 2025 MAR showed R14's tube feedings were changed from continuous feedings to bolus feedings every six hours, upon his readmission to the facility on [DATE]. R14 was allowed to eat foods upon his readmission.R14's Dietary Progress Note dated 11/24/25 showed R14 was seen and assessed by V4 Dietician. The note showed R14 was readmitted (on 11/14/25) on an oral diet with tube feedings to supplement nutritional intakes. Per hospital records, he passed his swallow evaluation and diet was upgraded. PO (oral) intakes have been variable. Tube feeding does provide approximately 88% of residents estimated caloric needs. Plan: continue to monitor. Weekly weights to monitor resident and new tube feeding order.R14's Weights and Vital Summary report, printed 12/9/25, showed R14 weighed 135 pounds (lbs) on 11/1/25. This report showed no documented weight was obtained on R14 upon his readmission to the facility on [DATE]. The report showed no documented weight was obtained on R14 for the week of 11/24/25. The report showed R14 was weighed in the facility on 12/5/25 with a recorded weight of 101.4 lbs. R14's weight decreased to 101 lbs on 12/8/25. This showed R14 sustained a significant weight loss of 25.2% from 11/1/25-12/8/25. On 12/8/25 at 9:40 AM, R14 was in bed. R14 appeared thin and pale. R14 was alert and oriented to person, place and time. R14 stated he is able to eat regular food and also gets bolus tube feedings via his G-tube four times a day. When asked about his bolus tube feedings, R14 stated, I'm not going to lie. Sometimes I don't get a tube feeding because I am too full and don't want it but this weekend, I didn't get my tube feedings like I was supposed to.R14's progress note dated 11/28/25 showed R14 refused one of his bolus tube feedings. The note showed no documentation that V4 Dietician was notified. R14's December 2025 MAR showed R14 did not receive his bolus tube feedings on 12/6/25 at 8 AM and 2 PM. The MAR showed no documentation of R14 refusing these feedings or that V4 Dietician was notified of these omitted/missed feedings. On 12/9/25 at 9:42 AM, V4 Dietician stated she works on a consulting basis for the facility which only requires her to be in the facility once a month. V4 stated she monitors residents for weight loss by monitoring their weight and oral intakes that are documented in the facility's electronic medical records. V4 stated residents should be weighed as per their physician order or by her recommendation. V4 stated residents are to be weighed upon admission and readmission to the facility to ensure we have an accurate weight. V4 stated R14 was readmitted to the facility on [DATE] with an order to eat orally and his tube feedings were decreased to bolus feedings, four times a day. V4 stated, I saw (R14) on 11/24/25. I requested to have him weighed once a week due to the changes in his diet and tube feedings. R14's Weight and Vitals Report (printed 12/9/25) was reviewed with V4. V4 stated, I don't see that he was weighed when he got readmitted (on 11/14/25). I don't see a weight for the week of 11/24/25. No one from the facility called me to tell me about his weight on 12/5/25. I actually noticed his weight from 12/5/25 in the computer yesterday and had the facility reweigh him. I see his weight on 12/8/25 was even lower. If he had been weighed upon readmission (on 11/14/25) or the week of 11/24/25 after I saw him, this weight loss could have possibly been caught. I would have assessed him. I would have possibly increased his tube feedings and added fortified foods. When R4 was asked if the facility had notified her that R14 had refused and missed some of bolus tube feedings, R4 stated, No and they should have told me. That can decrease the amount of calories and nutrition he needs daily. On 12/10/25 at 8:11 AM, V5 Nurse Practitioner stated she had just seen and examined R14 that morning (12/10/25). V5 stated the facility did not call her to notify her of R14's weight loss until 12/9/25. V5 stated all resident weights are to be monitored as ordered. Facility staff are to notify her as soon as any resident excessive weight gains or losses are noted. On 12/10/25 at 9:32 AM, V3 Restorative Nurse presented this surveyor with a revised Weights and Vitals Summary report, dated 12/10/25, for R14. The report showed that V3 had crossed out R14's documented weights on 12/5/25, and 12/8/25. The report showed V3 had added the following weights for R14 of 99 lbs on 11/3/25, 95.1 lbs on 11/18/25, 96.8 lbs on 11/25/25, and 95 lbs on 12/1/25. V3 stated she crossed out R14's weights on 11/1/25, 12/5/25 and 12/8/25 because although our CNA's (certified nursing assistants) weighed him those days, we could not verify if the weights were accurate. When V3 was asked where she got R14's weights from that she recorded on 11/3, 11/18, 11/25, and 12/1/25, V4 stated, Those are not weights we got on (R14). I found those weights last night (12/9/25) when I was looking through his dialysis records. V3 stated the facility was unaware of R14's dialysis weights prior to 12/9/25. V3 stated she had never herself weighed R14. Based on the first (printed 12/9/25) and second (dated 12/10/25) Weights and Vitals Summary records for R14 that were provided to this surveyor by the facility, R14 weighed 106.3 lbs on 10/1/25 and 95 lbs on 12/1/25 which showed R14 sustained a significant weight loss of 10.6% from 10/1/25-12/1/25. The facility's Weight Assessment and Interventions policy dated January 2025 showed, Ensure that residents are monitored for undesirable weight loss or gain so appropriate interventions can be put in place in a timely manner. Weigh the resident upon admission and weekly for a total of four weeks. Do not use the hospital weight. Weights will be entered in the resident's medical record. The dietician will review the weight record to identify and address weight issues. Significant weight changes are defined as: 5% weight gain/loss in 30 days, 7.5% weight gain/loss in 90 days, and 10% weight gain/loss in 180 days.

Based on observation, interview, and record review the facility failed to ensure a certified dietary manager was employed as food service director. This has the potential to effect all residents residing in the facility. The findings include:Centers for Medicare and Medicaid form 671 dated 12/8/25 shows there are 81 residents residing in the facility. On 12/8/25 at 9:31 AM, V13 (Food Service Director) said he is not licensed as a certified dietary manager. V13 said he took the courses at the local community college about 7 to 8 years ago and failed the exam on the first attempt. V13 has not retaken the exam since. V13 said he does initial and quarterly assessments of residents while the contract dietitian performs all assessments on high risk residents. Facility provided course certificates for V13 show that V13 completed courses in food nutrition therapy, food safety sanitation and human resource management, and management of food service operations. Per the Association of Nutrition and Foodservice Professionals, the there are no current certified dietary managers in the nation with the same last name as V13. Facility provided Job Description for Food Service Supervisor shows, . Qualifications: 1. A Bachelor of Science degree in Foods and Nutrition from an accredited college or university. 2. Graduation from a course in food service supervision which meets the established by the [National Association] or graduate of another course in food service supervision with ninety (90) or more hours in classroom instruction with on-the-job counseling by a dietitian.

Based on observation, interview, and record review the facility failed to ensure hand hygiene was performed after touching a garbage can lid and performing other tasks. This has the potential to effect all residents that receive food from the kitchen. The findings include: Centers for Medicare and Medicaid form 671, dated 12/8/25, shows there are 81 residents residing in the facility. Centers for Medicare and Medicaid form 802, dated 12/8/25, shows there are 2 residents that receive nutrition via a tube feed. On 12/8/25 at 11:55, V14 (Dietary Aide) was by the dish machine, grabbed the lid for the garbage can, and placed it onto the garbage can. V14 did not perform hand hygiene before going to another area in the kitchen. V14 then grabbed a clean and sanitized food service pan and walked it over to the storage rack and placed it with the rest of the clean and sanitized food service pans. V14 still had not performed hand hygiene. During this time, V14 would put V14's hands in the front pocket of V14's hooded sweatshirt and remove them to perform other tasks. V14 then was approached by a staff member by the entrance door to the kitchen who requested something from V14. V14 then opened the door to the cooler, grabbed an item, and handed it to the staff member without performing hand hygiene. When finished V14 returned V14's hands to the front pocket of V14's hooded sweatshirt and did not perform hand hygiene. V14 then grabbed three large plastic bags and opened them to get them ready to use to cover the tray carts during service. V14 still did not perform hand hygiene after this task and again placed V14's hands back into the front pocket of V14's hooded sweatshirt. On 12/9/25 at 9:50 AM, V13 (Food Service Director) said kitchen staff should wash their hands after touching the garbage can, lid, or handling garbage. V13 also said staff should wash hands when completing different tasks. Facility Handwashing policy for the kitchen dated 9/21/23 states, . 2. Employees are required to wash hands: . Before starting any task . Touching the hair, face or body . After taking out the garbage .Anytime the hands are soiled .

Based on observation, interview, and record review the facility failed to ensure the pureed pork was a smooth consistency. This applies to 4 of 4 residents (R38, R41, R40, R69) reviewed for pureed diets in the sample of 18. The findings include:Facility provided diet report dated 12/8/25 shows R38, R41, R49, and R69 all receive a pureed diet. On 12/8/25 at 11:45 AM, V15 (Cook) grabbed a pot from the stove that had seven servings of pork slices that were cooked in chicken broth. V15 started the puree process by adding all pork slices to a blender pitcher and added additional chicken broth to help puree. At 11:48 AM, V15 added a thickening powder to the puree pork. At 11:52 AM, V15 finished the pureed pork and transferred it to a food service pan. The consistency of the finished pureed pork appeared chunky and was not smooth. On 12/8/25 at 11:28 AM, V15 said the finished consistency for purees should be similar to pudding consistency and not too thick or too runny. On 12/8/25 at 1:00 PM, a facility provided test tray of the puree meal was tested by this surveyor and V13 (Food Service Director). The consistency of the puree pork was not smooth and required chewing. V13 said the puree pork could be a little thinner, cooked longer, or blended longer to be easier to swallow and was not an appropriate texture. Facility provided Pureed Food Preparation policy dated 9/26/23 states, . 3. Pureed food must be the consistency of pudding or mashed potatoes.

Based on interview and record review the facility failed to ensure a Level 2 Preadmission Screening and Resident Review (PASRR) interview was completed as requested for a resident admitted with known mental illness. This applies to 1 of 7 residents (R4) reviewed for PASRRs in the sample of 19. The findings include: R4's Facesheet shows R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, schizoaffective disorder, dementia, major depressive disorder, post-traumatic stress disorder, and generalized anxiety disorder. R4's PASRR report from 10/2/24 shows that R4 required a PASRR Level 2 evaluation to be completed. The facility was unable to show a PASRR Level 2 evaluation was completed. On 12/10/25 at 12:24 PM, V3 (Restorative Nurse) said the facility requested a Level 2 evaluation for R4 to be completed, but the evaluation was canceled when the evaluator went to R4's previous facility to conduct the evaluation. Facility provided Pre-admission Screening and Resident Review (PASRR) policy states, It is the policy of this facility to: . 2. Request full and complete PASRR materials (Level 1 and 2) from each referral source prior to or soon following admission.

Based on interview and record review the facility failed to schedule a doctor's appointment for a resident. This failure applies to 1 of 19 residents (R7) reviewed for quality of care in the sample of 19.The findings include:R7's care plan dated 6/27/25 showed R7 was visually impaired related to his diagnosis of Type 2 Diabetes Mellitus with diabetic retinopathy. On 12/8/25 at 10:14 AM, R7 stated, My vision has really gone downhill the past six months. I saw an eye doctor here, but that doctor said I needed to see a specialist for cataracts or glaucoma. No one has made an appointment for me. A facility optometrist report dated 11/24/25 showed R7 was seen and examined in the facility by an in-house optometrist. The report showed R7 was diagnosed with bilateral cataracts with a note that showed facility staff were to make an appointment for R7 to see a glaucoma specialist. R7's physician order report printed 12/9/25 showed no scheduled appointment for R7 to see an optometrist specializing in the treatment of glaucoma. R7's progress notes dated 11/24/25-12/8/25 were reviewed and showed no documentation of staff scheduling this appointment for R7. On 12/9/25 at 10:09 AM, V8 Social Services Director stated she was not aware the facility's in-house optometrist had made a referral for R7 to see an optometrist specializing in glaucoma. On 12/9/25 at 10:01 AM, V7 Charge Nurse stated she is responsible for making outside appointments for residents as soon as she is notified of the request or referral. V7 stated if the facility's in-house optometrist or dentist refers a resident to a physician outside of the facility, they would make a referral through V8 Social Services Director. V8 then would notify V7 that an appointment needs to be made for a resident. V7 stated, I didn't get a referral from (V8 Social Services Director) for (R7) to see a glaucoma specialist. I don't know anything about it. On 12/10/25 at 10:13 AM, V1 Administrator stated the facility did not have a policy on scheduling outside appointments for residents.

Based on observation, interview and record review the facility failed to ensure low air loss mattress settings were programmed to effectively off-load areas of pressure for residents with pressure injuries for 3 of 8 residents (R14, R11, R3) reviewed for pressure injuries in the sample of 19. The findings include:1.R14's Wound Evaluation report dated 12/3/25 showed R14 had a Stage 4 pressure injury to his coccyx. R14's revised care plan dated 8/4/25 showed a pressure reducing (low air loss) mattress was listed as one of R14's pressure relieving interventions for R14's coccyx pressure injury. The plan showed no documentation that R14 requested to have his pressure reducing mattress programmed for a specific setting. R14's weight record dated 12/8/25 showed R14 weighed 101 pounds (lbs). On 12/8/25 at 9:40 AM, R14 was in bed lying on a low air loss mattress. R14's mattress was programmed for a resident weighing 350 lbs. On 12/9/25 at 8:03 AM, R14 is in bed. R14's low air loss mattress remained programmed for a resident weighing 350 lbs.2.R11's Wound Evaluation report dated 12/3/25 showed R11 had a Stage 4 pressure injury to her medial right knee. R11's revised care plan dated 8/8/25 showed a pressure reducing (low air loss) mattress was listed as one of R11's pressure relieving interventions for R11's pressure injury. The plan showed no documentation that R11 requested to have her pressure reducing mattress programmed for a specific setting. R11's weight record dated 12/5/25 showed R11 weighed 81.4 lbs. On 12/8/25 at 9:25 AM, R11 was in bed lying on a low air loss mattress. R11's low air loss mattress was programmed for a resident weighing 400 lbs. On 12/9/25 at 8:00 AM, R11 was in bed. R11's low air loss mattress remained programmed for a resident weighing 400 lbs. 3.R3's Wound Evaluation Report dated 12/3/25 showed R3 had pressure injuries to his left ischium and coccyx area. R3's revised care plan revised on 4/30/24 showed a pressure reducing (low air loss) mattress was listed as one of R3's pressure relieving interventions for R3's pressure injuries. The plan showed no documentation that R3 requested to have his pressure reducing mattress programmed for a specific setting. R3's weight record dated 12/5/25 showed R3 weighed 205.3 lbs.On 12/8/25 at 8:51 AM, the low air loss mattress on R3's bed was programmed for a resident weighing 400lbs.On 12/9/25 at 8:51 AM, R3's low air loss mattress remained programmed for a resident weighing 400 lbs. On 12/9/25 at 9:15 AM, V6 Wound Care Nurse stated low air loss mattress should be programmed at the correct weight of the resident so the mattress can help heal or prevent pressure injuries. V6 stated, If the weight is set too high on the mattress, the mattress will not reduce pressure to the areas with wounds and can impede wound healing. The facility's Pressure Injury Prevention policy dated October 2025 showed, When using low air loss mattress, follow manufacturer's instructions related to use, setting, and care. The facility's low air loss mattress operator's manual (undated) showed, Operating Instructions. Determine the patient's weight and set the control knob to that weight setting on the control unit.

Based on observation, interview, and record review the facility failed to administer medications as ordered by the physician. There were 30 opportunities with 12 medication errors resulting in a 40% medication error rate. These failures apply to 2 of 3 residents (R23, R47) observed in the medication pass. The findings include:On 12/8/25 at 10:13 AM, V9 Registered Nurse prepared R47's morning medications. V9 dispensed a tablet of chewable aspirin 81mg in R47's medication cup. V9 administered the aspirin to R47.R47's Physician Orders dated 11/26/25 shows and order Aspirin Enteric Coated Tablet Delayed Release 81 mg. Give 1 tablet by mouth in the morning for heart health.On 12/09/2025 at 8:13 AM, V10 Licensed Practical Nurse prepared R23's morning medication including 11 oral tablets. R23 was in her room, in chair, with her breakfast on the overbed table. At 8:23 AM, V10 set R23's medication cup with 11 medications on R23's breakfast tray. At 8:30 AM, V10 administered R23's insulin (R23's medications remained on the breakfast tray). V10 left the room, signed off R23's medications in the computer as administered and then pushed the medication cart down the hall to the other side of the building without making sure R23 took her medications. At 8:35 AM, R23's medications were still on her breakfast tray. R23 said she needs to eat before taking her medications. On 12/8/25 at 2:35 PM, V2 Director of Nursing said if the resident's physician order is for enteric coated aspirin, chewable aspirin should not be given.On 12/09/2025 at 1:30 PM, V2 said a complete medication pass includes preparing the medications, bringing them to the resident, and watching the resident take the medications. V2 said medications should not be left at the bedside for residents to take on their own. R23's Physician Orders for December 2025, do not contain an order for R23 to self-administer her medications. The facility's Administering Medications Policy dated 3/24 shows Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, times and positive verifications of the resident's identity.

Based on observation, interview and record review the facility failed to ensure residents medications were securely stored and inaccessible to residents for 2 of 19 residents (R43, R59) reviewed for medication storage in the sample of 19. The findings include: 1.R43's physician order report printed 12/9/25 showed R43 was prescribed Novolog insulin and Ozempic related to his diagnosis of Type 2 Diabetes Mellitus. The report showed no physician order to allow R43 to keep medications in his room or to allow R43 to self-administer his medications. On 12/8/25 at 10:11 AM, R43 was seated in his bed. On R43's bedside table was a Novolog insulin pen and a pen of Ozempic medication. Both pens had been opened and used, with medication missing from each pen. R43 stated he kept the medications by his bedside because sometimes my meds are given late here so I give them to myself. On 12/9/25 at 8:08 AM, R43's Novolog insulin and Ozempic pens remained on R43's bedside table. On 12/0/25 at 8:09 AM, V2 Director of Nursing stated residents cannot have any medications in their room and/or self-administer their medications unless they have a physician order to do so. The resident must also be assessed by facility staff to self-administer their medications. V2 stated, We have these things in place to make sure a resident is safe to self-administer their meds. On 12/9/25 at 12:26 PM, V1 Administrator stated the facility had not completed a medication self-administration assessment on R43. 2. R59's Physician Order Report printed on 12/9/25 showed R59 has an order for Breo Ellipta inhalation aerosol powder orders as 1 puff inhaled orally one time a day related to chronic obstructive pulmonary disease. With the instructions to rinse mouth with water and spit after use. The report had no order for R59 to store medications or self-administer medications. On 12/8/25 at 10:05 AM, R59 was sitting on the side of their bed. R59 has their Breo inhaler on the bedside table. R59 stated he had just finished with it. When R59 was asked if they needed to do something after taking the medication R59 stated they were not sure. R59's medical record showed no assessments related to self-administering medications On 12/9/25 at 12:45 PM 12 Licensed Practical Nurse (LPN) stated if a resident is going to self-administer medications they need to be assessed and have an order for it. R59's Care plan printed 12/9/25 showed no focus areas of R59 wanting or attempting to be able to self-administer medications. The facility's Administering Medications policy dated March 2024 showed, Medications may be self-administered by residents who have been assessed and determined to be safe and upon physician order. The facility's Self-Administration of Medications Procedure policy dated January 2025 showed bedside storage of prescription or nonprescription drugs is not permitted unless a resident has been assessed and demonstrates the practice is safe.

Based on interview and record review the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR) evaluation was resubmitted before expiration of the 60 day approval. This applies to 1 of 8 residents (R71) reviewed for PASRRs in the sample of 19. The findings include:R71's Facesheet shows R71 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder. R71's PASRR Level 1 screening dated 1/24/24 shows R71 was allowed a 60 day stay or less in a nursing facility. This screen also states that a re-screening must be performed by or before the 60 day period. R71's next PASRR provided by the facility was a Level 2 evaluation done on 2/26/25; beyond the 60 days. On 12/10/25 at 9:40 AM, V8 (Social Services Director) said PASRR is done on admission and after a temporary one expires. Most of the time, the hospitals have been doing the 30 or 60 day temp assessments. If someone has a new mental illness diagnosis, PASRR needs to be requested to have the PASRR 2 started with the mental illness.

Based on observation and interview the facility failed to ensure a resident and their personal property was treated with respect. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 3.The findings include:R1's face sheet shows he is a [AGE] year-old male with diagnoses including COPD, asthma, tobacco use, anxiety, hypertension and schizoaffective disorder.On 8/19/25 at 8:53 AM, R1 was in his room wearing oxygen, a laptop and other personal items were on his bedside table. R1's bedside table located next to his bed including his cigarettes, personal hygiene products and personal mail. R1 said on 8/13/25, he went out to the hospital for shortness of breath. When he came back from the hospital, R2 (R1's roommate) told him female staff went through his belongings and took $40.00 and two jars of hemp. R1 showed this surveyor the text to V1 (Administrator) Your people went through my belongings. I'm calling the police. I'm missing $40.00. R1 said he felt violated and disrespected, the staff waited till he left the facility and searched through my things without my permission.On 8/19/25 at 9:07 AM, R2 said after R1 left for the hospital three female staff came into his room. Two were African American. The staff were going through R1's belongings and R2 questioned what they were doing going thru his stuff without him being present. They told him to leave the room. R2 said R1 was not smoking anything in the room and the room did not smell like marijuana. On 8/19/25 at 9:12 AM, V5 (Certified Nursing Assistant-CNA) said if there's a reasonable cause they are allowed to search a resident's room, but we should inform the resident we are conducting a search. V5 said on 8/13/25, she searched R1's belongings because there was a smell of marijuana coming from the hallway. R1 was not in the building he was out in the hospital when she smelt the marijuana. No, she did not ask him for his permission to search his room. V5 and V6 removed several items from his top drawer.On 8/19/26 at 9:35 AM, V6 (CNA) said we should not go through residents' belongings without their permission. She said she did not search R1's property, she searched the facility's property. The drawers are not the residents. We smelt marijuana in his room. R1 was not in the room he had left to go out to the hospital. She said R2 was in the room and later left. V5 (CNA), V7 (CNA) and V3 (Social Services) were in the room during the room search. We removed several contraband items including a scale from his room and several bags of weed.On 8/19/25 at 12:35 PM V8 (LPN) said on 8/13/25, R1 was short of breath, she had been in out of his room to assess him. He agreed to be sent out to the local hospital. There was no smell of marijuana in his room or coming from his room. It's a distinct smell, and I did not smell anything. She heard staff had gone through his things after he left to the hospital and was not sure why.On 8/19/25 at 12:36 PM, V7 (CNA) said she is not sure if they are allowed to search a resident's property without consent or permission. On 8/13/25, she was R1's CNA. R1 was sent out to the hospital for shortness of breath. V5 and V6 (Both CNA's) were working on the first floor. They came up stairs and said they were going to search R1's room. They said R1 was acting suspicious, and they needed to search his room. I'm not sure if they smelt marijuana on him or if someone said anything to them. V5 and V6 were going thru his top drawer, and she was at the end of R1's bed. They removed stuff from his room and placed in a bag. She could not see if there was money in his drawer. R2 was in the room saying something about privacy. If she suspected a concern, she would report it V1 or her nurse. She did not report or notice any concerns prior to V5 and V6 coming upstairs wanting to search his room.On 8/19/25 at 9:22 AM, V4 (LPN) said she is not sure what caused the staff to search his room or what gave them a reason. If she suspected a concern regarding a resident that a room search should be conducted, she would contact V1 and V3 (Social Services) and not have the CNA's conduct a room search without management present.On 8/19/25 at 11:06 AM, V3 said staff are allowed to conduct a room search if they have a suspicion, they will hurt themselves or others. It's their private property and consent is needed to go through their things. If a room search should be conducted, she notifies V1 and she never goes alone during the room search. On 8/13/25, V5 called her and reported a odor on the 2nd floor. She said she could not go in the room because she was with the podiatrist at the time. V3 said she was never in R1's room when his room was searched by the CNA's. Afterwards she went upstairs and saw V5-V6 and told them no one should be going through residents' personal property. R1 has an independent community pass and has never had any violations.On 8/19/25 at 12:09 PM, V1 (Administrator) said if there's a reasonable cause or safety concern they can search a resident's room without their consent. A CNA reported they smelled marijuana and went in and searched R1's room without him there. He was told R2 was not in the room. V5-V7 (All CNA's) searched R1's room and removed items from his room. V1 showed this surveyor the items removed from his room including one small zip lock baggie with two small buds of weed, two jars of cannabis, vaping devices, two marijuana pipes and there was no scale in the bag. V1 said R1 reported he was missing $40.00, and we are still looking into it. R1 has no history of smoking in the building, he has community pass privileges and had never been reprimanded for violating his privileges. V1 said he did not talk to R1's nurse regarding the circumstance that day and not sure who gave the CNA's consent to conduct a room search.The facility schedule dated 8/13/25 shows V5 and V6 were scheduled as staff on the 1st floor.The facility's roster shows R1 resides on the 2nd floor.R1's current care plan shows he is an independent smoker, with no smoking violations, he has an independent community access pass. There has been no documentation of any pass violations.The facility did not provide a policy on residents' rights and conducting a room search policy upon request.

Based on observation, interview, and record review the facility failed to maintain a comfortable temperature by not keep a resident's room below 81 degrees Fahrenheit for 1 of 3 residents (R1) reviewed for comfortable homelike environment in the sample of 3.The Findings include:R1's Face Sheet printed on 7/28/25 indicated R1 had the diagnosis of chronic obstructive pulmonary disease.A facility assessment done on 7/24/25 showed R1's mental status was intact. On 7/28/25 at 8:43 AM, R1 said the temperature in his room was too hot and had been uncomfortable for the last few days. R1 had a built-in wall air conditioner in his room. There was no portable air conditioner in R1's room. On 7/28/25 at 8:43 AM, the surveyor used a thermometer that had been calibrated in an ice bath to check R1's room temperature. R1's room temperature was 81.7 degrees Fahrenheit. The air coming out of the wall air conditioner's vent was 81.6 degrees Fahrenheit.On 7/28/25 at 10:26 AM, R1's room temperature was 81.5 degrees Fahrenheit. The air coming out of the wall air conditioner's vent was 81.3 degrees Fahrenheit. On 7/28/25 at 12:19 PM, V1 (Administrator) used the facility's thermometer and checked R1's room temperature. R1's room was 81.3 degrees Fahrenheit and the air coming out of the wall air conditioner's vent was 81 degrees Fahrenheit.On 7/28/25 at 9:04 AM, V1 said two out of the four compressors for the facility's air conditioner were not working and the air conditioner was running at 50%. V1 said they were waiting for parts to be delivered to repair/replace the compressors. V1 said the facility was using portable air conditioner units along with the facility's air conditioner to keep the room temperatures comfortable. V1 said the portable units were placed strategically throughout the building. The National Oceanic and Atmospheric Administration website forecasted for 7/28/25 a heat index of 104 degrees Fahrenheit. The facility's Hot Weather policy (undated) showed the purpose was to ensure the well-being and comfort of the residents throughout the hot weather months.

Based on observation, interview and record review the facility failed to ensure a resident was free from significant medication error. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 3. The findings include: R1's face sheet shows he is a [AGE] year-old male with diagnoses including post traumatic seizures, COPD, major depressive disorder, anxiety, and personal history of traumatic brain injury.On 7/21/25 at 8:42 AM, R1 was in his room lying in bed, V5 (Licensed Practical Nurse-LPN) was in his room taking his vitals. At 8:43 AM, the emergency services arrived and entered R1's room. At 8:46 AM, R1 left the building with emergency services.On 7/21/25 at 8:46 AM, V6 (Certified Nursing Assistant-CNA) said R1 is alert and oriented x3, he was fine this morning when he got up and ate breakfast. After breakfast he wanted to lay down and usually, he refuses to lay down and stays up in his wheelchair till after dinner. He transferred R1 back in bed and R1's body started jerking in bed, repeatedly.On 7/21/25 at 8:50 AM, V5 (LPN) said R1 got up in his wheelchair this morning and after breakfast he wanted to get back in bed. That was unusual for him, R1 won't lay down for nothing. V6 notified me of R1's seizure activity this morning and she called 911. R1 takes several seizure medications and night shift staff administers his medications. R1 refuses his medications at times when he's aggravated, but we try to re-approach him when he calms down.On 7/21/25 at 10:24 AM, V3 (Registered Nurse-RN) showed this surveyor R1's medication cards. R1's Phenytoin 100 mg (milligrams) shows to give one tablet three times a day for seizures. This card shows 24 out of 30 tablets remained. Divalproex 500 mg three tablets three time a day for seizures. This card shows 13 out of 30 tables remained. Levetiracetam tablet 1000 mg one tablet twice a day for seizures. This card shows 14 out of 30 tablets remained.On 7/21/25 at 12:35 PM, V9 (Ombudsman) said she talked to R1 on 6/26/25 and he expressed concerns about not receiving his seizure medications. R1 said he was only getting one seizure medication, and the nursing staff were not bringing him his medication. She spoke with V1 regarding this concern, and he said R1 is refusing his medication. V9 said she is aware of V1 being on vacation this week.R1's Medication Administration Record (M.A.R.) dated July 2025 shows orders for Aptiom 800 mg give one tablet in the evening daily. The M.A.R. shows this medication was not administered three out of nineteen days. Dilantin 100 mg give three times a day. The M.A.R. shows this medication was not administered three doses out of 30 days.Divalproex Sodium tablet delayed release give three tablets by mouth. The M.A.R. shows six doses out of thirty days the medication was not administered.R1's M.A.R for June 2025 shows Aptiom 800 mg daily. The M.A.R. shows 2 refusals out of 30 days. Three doses of refusals out of thirty days the medication was not administered. Dilantin 100 mg three times a day. The M.A.R. shows five doses of refusals in thirty days. The M.A.R. shows this medication was not administered seven doses in thirty days. Levetiracetam tablet 1000 mg give one tablet twice a day. The M.A.R. shows two doses of refusals in thirty days. The M.A.R. shows this medication was not administered five doses in thirty days.On 7/21/25 at 1:11 PM, V2 said R1 is alert and oriented. He can be non-complaint with everything it depends on his mood. If he refuses medication, we try to re-approach. If the medication is not signed off in the M.A.R. it was not given.On 7/22/25 at 11:00 AM, V2 said the day the medication is dispensed to the facility does not reflect when they start using the medication card. The facility does not document when the nurses start using a new card and sometimes, we have multiple cards of the same medication. V2 said the same medication card is used for the morning and evening doses.The facilities grievance log for June 2025 and July 2025 did not show a grievance for R1's medications.The facilities Administering Medication Policy and Procedure revised 2024 states, To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations.Should a medication be withheld or refused, the physician will be notified when three consecutive doses or a pattern of frequent withholding or refusal is noted. Documentation identifying the explanation of withholding or reason for refusal will be documented in the medical record.

Based on observation, interview, and record review the facility failed to identify a new skin alteration for a resident who is at risk for developing pressure wounds which applies to 1 of 3 residents (R1) reviewed for pressure wounds in a sample of 3. The findings include: R1 facility assessment dated [DATE] showed R1 is a [AGE] year-old cognitive male resident admitted to the facility on [DATE] with diagnoses which include a history of traumatic brain injury, bilateral lower leg amputation, lack of coordination, and unspecified dementia. This assessment showed R1 is dependent or needs maximum assistance with activities of daily living which include transferring, bed mobility, showering/bathing, and getting dressed. On 7/1/25 at 10:30 AM, V2 Director of Nursing performed a skin check on R1. During the skin check, two open areas were identified. One on the right and left lower buttocks. The right open area was measured at 1.2 x 0.5 x 0.1 centimeters (cm). The left buttock open area was measured at 0.75 x 2.0 x 0.1 cm. Both open areas were light red with slight, thin, clear exudate. Both open areas were over previously healed pressure wounds. The facility's undated list of residents with pressure wounds provided on 7/1/25 did not have R1 listed as a resident with current pressure wounds. The facility's scheduling calendar and sign out log show R1 had an appointment with a new primary care provider (PCP) on 6/26/25. These documents showed R1 left the faciity on 6/26/25 at 9:30 AM and returned to the facility at 12:12 PM. R1's shower sheet dated 6/26/25 showed R1 received a complete bed bath with discoloration on buttocks. This document showed no new identified open areas. On 7/1/25 at 10:15 AM, V12 PCP office nurse stated during R1's office visit (6/26/25) two open areas were identified on R1 lower buttocks. R1's medical record showed no new orders, skin assessments, or progress notes related to new open skin areas. R1's current care plan showed R1 is at risk for skin breakdown with interventions which include routine skin checks being done daily with cares and weekly with bath or shower schedules. Any new skin issues or concerns should be relayed to the charge nurse for further assessments and or treatments. On 7/1/25 at 3:00 PM, V2 stated when providing cares for a resident staff should be looking for skin changes/alterations. When a new skin alteration is found they should be notified so they can get the new treatment orders. The facility's wound policy dated 1/2025 showed the purpose of the policy is to promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown.

Based on observation, interview, and record review the facility failed to maintain resident's continuous positive airway pressure (CPAP) machines or supplies which applies to 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for respiratory treatments in a sample of 5. The findings include: On 6/4/25 the facility provided a list of residents using CPAP machines in the facility which included R1-R5. 1. R1's Facesheet printed on 6/4/25 showed R1 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included: acute respiratory failure and obstructive sleep apnea. On 6/4/25 at 9:30 AM, R1 was in his room watching television. R1's CPAP machine was sitting on the nightstand next to the bed. R1 stated he has used the same mask, water tank, and tubing (heated coil tubing) for the machine for over a year. R1 stated prior to coming here he would get supplies delivered every 3-6 months depending on what the item was. R1 stated he had lung issues and did not want to get sick. R1 stated he used a pillow pad mask when using the CPAP machine. R2 stated this was the only mask which had worked for him. The facility has brought other masks, but they are the ones that sit over your nose. R1 stated he had attempted to us that kind of mask before, but they do not seal well on R1's face. R1 stated he cannot sleep if he does not use the CPAP at night. R1 stated he has been washing the same tubing and mask using the sinks tap water which is probably not good for the plastic. R1's machine usage log showed R1 has used the machine consistently for the last 30 days. R1's current careplan printed on 6/4/25 showed R1's CPAP careplan was initiated on 3/9/23. There is no reference to CPAP supplies time frames in the careplan. R1's Physician Order Summary printed on 6/4/25 showed no orders for new CPAP supplies. This Summary showed a start date order for R1 to use a CPAP device on 5/31/23. 2. R2's Facesheet printed on 6/4/25 showed R2 was admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea. R2's Facility assessment dated [DATE] showed R2 to be cognitively intact. On 6/4/25 at 8:35 AM, R2 was in their room eating breakfast. R2's CPAP machine was sitting on the nightstand next to the bed with the tubing and mask laying across R2's pillow. The tubing for R2's machine had a brownish discoloration about halfway along the tubing. R2 stated the tubing or mask has not been changed since she got to the facility. R2 stated she brought the machine with her from home. R2's machine had droplet marks of an unknown liquid on it. R2's machine's usage log showed R2 had used the machine consistently for the last 30 days. R2's order summary showed no orders for a CPAP device or reordering for CPAP supplies. R2's current careplan printed on 6/4/25 showed no care areas related to R2 using a CPAP device. 3. R3's Facesheet printed on 6/4/25 showed R3 was admitted to the facility on [DATE] with diagnoses which included sleep apnea. On 6/4/25 at 10:30 AM, R3 was in their room. R3's CPAP machine was on the bedside table with new tubing in its bag. R3 stated they had just brought in the tubing. R3 stated he had not used the CPAP in a while. R3 stated he needed a new mask, and the masks the facility provided were not sealing appropriately so he stopped using the machine. R3's machine usage log had no entries for the last 30 days. R3's Physician Orders printed on 6/4/25 showed R1 had an order for using an AutoPAP (self adjusting air pressure) with a start date of 6/20/24. These orders showed no order to replace AutoPAP supplies. R3's Careplan printed on 6/4/25 showed no focus for sleep apnea or utilization of the AutoPAP device. 4. On 6/4/25 at 8:45 AM R4 and R5's CPAP devices were on their nightstands. R4 and R5's CPAP machines were covered in a dust film. R4's tubing was hanging down the front of the nightstand with the mask resting on the floor. R5s machine water tank was sitting on top of the machine with a white crusted substance inside the tank. R5's tubing was wrapped up on the nightstand. R4 and R5's devices usage logs showed no machine usage for the last 30 days. On 6/4/25 at 8:40 AM, V4 Licensed Practical Nurse stated the CPAP machines are cleaned by the night shift staff. V4 stated they were not sure what cleaning supplies are used to clean the machines. V4 stated the machines need to be cleaned, but did not know when CPAP supplies (masks, tank, tubing) should be exchanged. On 6/4/25 at 10:00 AM, V6 Infection Control Preventionist stated they should be exchange per the manufacturer's guidelines to reduce the infection risk for those residents. V6 stated replacing old or dirty equipment would reduce the resident's risk for respiratory infections. On 6/4/25 at 11:30 AM, V7 Nurse Practitioner stated the facility does have a pulmonology Nurse Practitioner who comes to the facility. V7 said, they had not written any orders for reapplying CPAP supply items. V7 stated over a year is too long to wait to exchange CPAP supplies. CPAP supplies should be exchanged to prevent infections. On 6/4/25 at 12:10 PM, V8 Pulmonary Nurse Practitioner stated they rounded on residents with lung diagnoses. V8 stated he has not written orders for CPAP usage or supplies. CPAP masks and hoses should be changed to reduce the infection risk of the resident. On 6/4/25 at 12:30 PM, V1 Administrator stated they use an online ordering site for CPAP supplies. V1 stated they order more when the residents or staff let them know they need something. V1 was not sure how often CPAP supplies should be exchanged. The facility uses a third party company to acquire machines if the residents need a machine. The facility's CPAP Policy dated 11/2022 showed no time frame for exchanging masks, tubing, or water tanks. The 3rd party medical equipment company's CPAP replacement schedule for CPAP equipment showed masks should be replaced every 3-6 months and as needed (PRN), mask cushions 1-2 per month, tubing every 3 months, and water chambers every 6 months. The facility's Infection Control Policy dated 1/2024 showed the policy is to establish methods and criteria, necessary within the facility and its operation, to prevent and control infections and communicable diseases.

Based on interview and record review the facility failed to ensure a resident was free from physical abuse for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 6. This failure resulted in R1 being kicked in the genitals and R2 being pushed to the ground and sustaining a fracture of his left femur. The findings include: R1's face sheet showed he was admitted to the facility 4/23/2021 with diagnoses to include acute kidney failure, obstructive uropathy, benign prostatic hyperplasia, and major depressive disorder. R1's medical record showed he had an inguinal hernia repair 3/13/25 and could return to normal activity 3/17/25. R1's 2/17/25 assessment showed he has no cognitive impairment and exhibits no behaviors. On 3/22/25 at 10:12 AM, R1 was sitting in his room watching television. R1 was calm and pleasant. R1 declined to discuss the incident with the surveyor. R1's 3/20/25 Nursing Progress Note showed, Resident [R1] states [R2] kicked him, and he pushed him back and resident [R2] fell down. [R2] denied all treatment and said he was not hurt. R2's face sheet showed he was admitted to the facility 6/19/23 with diagnoses to include alcohol dependence, epilepsy, Wernicke's encephalopathy, and mood disorder. R2's facility assessment dated [DATE] showed he has severe cognitive impairment and exhibits hallucinations and delusions. R2's care plan initiated 3/14/24 showed, The resident requires psychotropic medication to help manage and alleviate: Agitation and aggressive behavior . R2's 3/22/25 Nursing Progress Note showed, Late entry on 3/20/25, I heard an altercation went to observe resident laying on the floor when resident tried to sit notice his left leg was awkwardly placed. 911 called and the DON (Director of Nursing), ED (Emergency Department) and brother, other resident stated that resident kicked him, and he pushed him back. R2's acute care hospital notes dated 3/20/25 showed, . CT (Diagnostic Scan) of the left hip showed: Displaced fracture of the proximal femoral shaft . On 3/22/25 at 10:15 AM, V3 CNA (Certified Nursing Assistant) said, . [R2] gets confused and doesn't understand why he is here. [R2] is ambulatory and roams the halls . He gets aggressive with other residents but usually just verbally . If you don't intervene fast enough a fight could start because he won't back down from anybody . On 3/22/25 at 12:45 PM, V7 CNA (Certified Nursing Assistant) said, . My coworker was screaming my name to help, [R2] was on the floor in pain . I've never seen him yell at or be physical with other residents. He says a lot of things but never seen him be physical . On 3/22/25 at 12:24 PM, V6 CNA (Certified Nursing Assistant) said, [R2] was on the floor. I asked [R1] what happened, and he said [R2] kicked him in the balls, so he hit him . [R1] said he punched him . On 3/22/25 at 10:22 AM, V4 LPN (Licensed Practical Nurse) said, On that day [R2] was agitated . I tried to redirect him but towards the end of the day he starts sundowning (period of increased behaviors in the evening hours) . I heard yelling, usually when you got yelling, there is something going on, by the time I got out there I saw [R1] standing up and [R2] was on the floor. I asked what happened and [R1] said [R2] kicked him . [R2] said 'I did something I shouldn't of' . when he started trying to get up, he started yelling about his leg . I have never seen [R2] hit but he is verbally aggressive . I think since [R1] just had that hernia repair it was a reaction to get getting kicked. [R1] told me it was a reaction . When [R2] gets verbally aggressive you have to intervene as quickly as possible . The facility's policy with issue date of 01/24 showed, Abuse Prevention Program . Policy: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment .

Based on interview and record review the facility failed to ensure the accuracy of medication administration records (MAR) for 3 of 3 residents (R1, R2, and R3) reviewed for pharmacy services in the sample of 3. The findings include: 1. R1's MAR printed on 3/5/25 had blank spots for 2/8/25 and 2/9/25 for the following medications: aspirin, budesonide-formoterol fumarate inhaler, cholestyramine, colchicine, flecainide acetate, folic acid, glipizide, furosemide, pregabalin, metoprolol, pantoprazole sodium, apixaban, and hyoscyamine sulfate. On 3/5/25 at 1:10 PM, R1 said to the best of her recollection she did receive her medications on 2/8/25 and 2/9/25. A facility assessment done on 3/4/25 showed R1's mental status was intact. 2. R2's MAR printed on 3/5/25 had blank spots for 2/8/25 and 2/9/25 for the following medications: aripiprazole, atorvastatin, cholecalciferol, clonazepam, donepezil hydrochloride, fenofibrate, fluoxetine, furosemide, Humalog insulin, Lantus insulin, miconazole, polyethylene glycol, montelukast sodium, multivitamin, mirabegron, nystatin powder, olanzapine, oxybutynin chloride, clopidogrel bisulfate, cholestyramine, Humalog insulin, apixaban, hydroxyzine pamoate, metoprolol tartrate, potassium chloride, vitamin c, carbidopa-levodopa, and gabapentin. R2's Controlled Drug Receipt document showed R2 received clonazepam on 2/8/25 and 2/9/25. On 3/5/25 at 1:20 PM, R2 said she received her medications on 2/8/25 and 2/9/25. A facility assessment done on 1/5/25 showed R2's mental status was moderately impaired. 3. R3's MAR printed on 3/5/25 had blank spots for 2/9/25 for the following medications: cholecalciferol, escitalopram oxalate, lispro insulin, lantus insulin, multivitamin, clopidogrel bisulfate, pantoprazole sodium, sevelamer HCL, vitamin C, and loratadine. On 3/5/25 at 1:15 PM, R3 said he did receive his medications on 2/9/25. A facility assessment done on 1/30/25 showed R3's mental status was intact. On 3/5/25 at 1:53 PM, V10 (Licensed Practical Nurse) said she took care of R1, R2, and R3 on 2/8/25 and 2/9/25 during the time frame that corresponded with the blank spots on the MARs. V10 said she gave R1, R2, and R3 all their scheduled medications but forgot to document on the MAR that the medications were given. On 3/5/25 at 1:41 PM, V4 (Registered Nurse) said once a nurse gives a medication it should be documented as given on the MAR. V4 added that the MAR is documented proof medications were given to the residents. V4 said, if there were blank spots on the MAR it could lead to confusion if a medication was given. On 3/5/25 at 12:13 PM, V1 (Administrator) said there should be no blank spots on the MAR. V1 said blank spots on a MAR indicates the medication was not given.

Based on observation, interview and record review the facility failed to perform a pain assessment on R42 who was admitted for a left tibia and fibula fracture. They also failed to provide R42 with her prescribed hospital discharge pain medications, this failure resulted in R42 having to return to the hospital to be treated for uncontrolled pain for 1 of 2 residents (R42) reviewed for pain in the sample of 20. The findings include: On 10/07/24 at 9:00 AM, R42 was lying in bed with her left lower leg wrapped with an elastic dressing. On 10/07/24 at 9:01 AM, R42 said, I fell and broke my tibia and fibula close to the foot. I am currently non-weight bearing. The doctor told me he was going to wrap it for now and will eventually place me in a cast .a walking cast, I hope. I was admitted [DATE]. I did not get my medications. The facility's pharmacy is in a city two hours away. On 09/14/24, I still did not have my pain meds or regular meds by the evening. I was in so much pain I had to return to the hospital. I was provided with pain meds at the hospital and sent back. My medications are late today. I brought my medications from home to ensure compliance, but the facility took them away. My medication routine is off compared to how I take them at home. Some of my medication I take on an empty stomach, others I must take with food. I will not get my 7:00AM, medication until 10:00AM-10:30AM. On 10/09/24 at 11:29 AM, V2 DON (Director of Nursing) said, some of R42's medication had not arrived. At 2:00 PM (09/14/24) R42 was sent to hospital. On 09/15/24 at 1:37 PM, R42 received her oxycodone. We only had hydrocodone/acetaminophen in our backup pharmacy, the hospital did not send a prescription with the discharge instruction. R42's hand signed prescription from the hospital uploaded into R42's electronic medical record on 09/13/24 shows, September 13, 2024, at 9:29AM, oxycodone hydrochloride 5 milligrams dispense 30 tablets, take 1 tablet by mouth every 8 hours as needed for pain. On 10/09/24 at 11:54 AM, R42 said, hydrocodone/acetaminophen does not work as well as oxycodone. I did not get the hydrocodone/acetaminophen until Sunday. When I went to the hospital they gave me the oxycodone. When I returned from the hospital, the facility still did not have my medication. They explained they had access to other medication and then provided me with hydrocodone/acetaminophen. The pain started about 4:00PM, on Friday (09/13/24). I reported pain 10/10, I think they gave me acetaminophen. I could not get my medications because they had to order it from a pharmacy two hours away. I did not get my regular medications until Monday. The pain is from my broken foot, ankle, leg area from my fall. On 10/09/24 at 12:46 PM, V12 NP (Nurse Practitioner) said, the facility called me when R42 was first admitted . I put in my note, waiting for oxycodone to be delivered. On September 14, 2024, I wrote the prescription for the hydrocodone/acetaminophen and oxycodone. Everybody is different so I cannot say one works better than the other, it depends on the individual what will work to relieve pain. I provided hydrocodone/acetaminophen because I knew the facility had it on hand. I sent the prescription to the facility on [DATE], if notified on the 9/13/24 that R42 was in pain I would have sent the prescription in right away. When I saw R42's requested to go to the emergency room , I was in the facility at 7:00AM, by 2:00PM, R42 wanted to go to the emergency room for Pain. R42 did not have any complaints after. R42's progress note dated 9/13/2024 shows, R42 admitted /Time: 9/13/2024 3:00 PM admitted From: Hospital Primary Admitting Dx: fracture left fibula Vitals: Weight 367.6 lb - 9/16/2024 10:27 Scale: Mechanical Lift Blood Pressure 118/64 - 9/13/2024 15:48 Position: Sitting Right arm Temperature 98 - 9/13/2024 17:49 Route: Forehead (non-contact) Pulse 72 - 9/13/2024 17:49 Pulse Type: Regular R 20 - 9/13/2024 17:50 Height 67.5 inches - 9/13/2024 16:22 Method: Lying down , skin issues: No, Diet: No Added Salt, Psychotropics Anticoagulants Hypoglycemic Opioid. (NO PAIN ASSESSMENT PERFORMED) R42's admission assessment dated [DATE] at 4:13PM, shows, In Progress. R42's Pain Assessment was blank. R42's first pain assessment in facility, found in the Vital Sign Record dated 09/14/2024 at 9:01 AM, shows, PAIN 10/10. R42's progress note dated 9/14/2024 shows, This writer alerted to resident room. Resident lying flat in bed, face flush and sobbing. Resident requests ER-emergency room transport for uncontrolled pain.

Based on observation, interview, and record review the facility failed to follow the dietitian's recommendation for free water flushes for a resident with a gastrostomy tube (g-tube) for 1 of 1 resident (R1) reviewed for g-tubes in the sample of 3. This failure resulted in R1 becoming dehydrated, requiring hosptilization. The findings include: R1's admission record showed R1 was a [AGE] year old female that was diagnosed with esophageal obstruction. The same document showed R1 was admitted to the facility on [DATE]. On 2/28/24 at 8:45 AM, R1 was in bed with her g-tube connected to a tube feeding. On 2/28/24 at 10:25 AM, V3 (Dietitian) said R1 is completely dependent on her g-tube for nutrition/hydration and R1 has been dehydrated. V3 said she assessed R1's hydration needs on 11/15/23 (two days after being admitted to the facility) and made the recommendation for free water flushes of 200 milliliters (ml) every 6 hours. V3 said she did not know why R1 was getting dehydrated because the free water flushes of 200 ml every 6 hours that she recommended would meet R1's hydration needs. V3 said the recommendations that she makes are given to V2 (Director of Nursing) who then contacts the doctor and if the doctor agrees with the recommendation the order is placed. V3 said the process normally takes 24 hours. R1's Nutrition Recommendations document dated 11/15/23 showed V3 recommended free water flushes of 200 ml every 6 hours to meet R1's fluid need for hydration. The bottom portion of the form was dated 11/28/23 indicating the doctor agreed with the recommendation and an order was entered. On 2/28/24 at 1:10 PM, V2 said R1 was hospitalized from 11/18/23-11/20/23 and that is why there was a delay in contacting the doctor regarding the recommendation for the free water flushes. On 2/28/24 at 12:15 PM, V8 (Registered Nurse) said R1's free water flushes were documented on the Medication Administration Record (MAR). R1's November MAR indicated R1 started receiving free water flushes on 11/21/23 of 100 ml every 6 hours. There was no documented free water flushes from 11/13/23 (admission) thru 11/18/23 (sent to the hospital). There was no indication on the November MAR that R1 received the 200 ml free water flushes that V3 recommended. The December MAR showed R1 started to receive 200 ml free water flushes every 6 hours on 12/1/23. On 2/28/23 at 1:40 PM, V2 said R1 returned from the hospital on 11/20/23 without a tube feeding or water flush order. V2 said the nurse practitioner was contacted for a tube feeding and free water flush order that was started 11/21/23. The water flush order was for 100 ml four times a day. On 2/28/23 at 11:18 AM, V6 (Nephrology Nurse Practitioner) said R1 is prone to dehydration because of her comorbidities. According to V6, getting free water flushes would help prevent dehydration. V6 added that getting even an extra 200 ml of free water would help R1's hydration status. V6 said hypernatremia (elevated/high sodium level) would indicate dehydration. R1's progress note dated 11/18/23 (three days after V3 made the recommendation for free water flushes) showed R1 was lethargic and sent to the emergency room . R1's hospital paperwork indicated R1 was admitted to the hospital from 11/18/23-11/20/23. R1's hospital Admitting Note indicated R1's sodium level was high at 155 and was being admitted for , hypernatremia - lack of free water intake, and volume depletion. R1's Hospitalist Note dated 11/19/23 showed R1 had, Acute metabolic encephalopathy: due to dehydration, hypernatremia.

Based on observation, interview, and record review the facility failed to ensure a resident's discharge hospital orders were followed for medication administration, and discharge procedures and appointments. The facility failed to assess and monitor a resident with a known vision impairment, and a known facial infection on antibiotic therapy. The facility failed to monitor and assess a central venous catheter site. This failure resulted in a resident with a vitreous hemorrhage having no surgical intervention and follow up care, and the resident continuing to complain of decreased vision, facial pain, and swelling. This applies to 1 of 17 residents (R59) reviewed for quality of care in the sample of 17. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/12/23 when R59 was readmitted to the facility with a vitreous hemorrhage. V1 Administrator was notified of the Immediate Jeopardy on 9/12/23 at 3:55 PM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 9/12/23; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On 09/10/23 01:45 PM, R59 was walking down the hall with his walker, looking upward. R59 said he had right cheek pain pointing from his right cheek by his nose to his ear. R59 pointed to his right upper chest and said he had an infection, and they were supposed to change his line. R59's right cheek was swollen with some slight redness as compared to R59's left cheek. R59 had a central venous catheter (CVC) on his right upper chest covered with a transparent dressing. The dressing was not dated, and the ends of the catheter were exposed. R59 said he had an infection in his ear and teeth and finished his medications 2 months ago. R59 said the doctor said he was supposed to have this (pointing to his chest) out a month ago, but the nurse doesn't know anything. R59's Progress Notes dated 6/5/23 at 10:03 AM, shows writer called to dialysis den by staff. Upon entering room, R59 is visibly shaking and crying. R59 reports a headache that has increased pressure and pain. R59 stated the pain was radiating into his jaw, down his neck, and into his chest. Given cardiac history 911 was called. R59's After Hospital Care Plan dated 6/12/23 shows Active Issues Needing Follow UP: Follow up appointment for Intraocular Pressure check. Please schedule a follow up appointment with your Primary Care Provider. This appointment should take place within 2 weeks of your hospital discharge. Appointments Scheduled: 7/7/23, Procedure with V21 (Ophthalmology) at hospital inpatient operating room. 7/8/23 at 9:30 AM, Office Visit with V21. This same Care Plan shows R59 is to start 6 new eye drop medications (acetazolamide daily for acute angle-closure glaucoma, brimonidine tartrate three times a day for increased intraocular pressure, dorzolamide hcl three times a day for increased ocular pressure, latanoprost at bedtime for open-angle glaucoma, rhopressa at bedtime for ocular hypertension, and timolol maleate twice a day for increased ocular pressure). R59's Hospital Progress Note dated 6/8/23 shows intraocular pressure greatly elevated on admission with hyphema and unreactive pupil. Discussed at length with cardiology and anesthesia the possibility of doing bedside versus operating room glaucoma procedure to lower the pressure. Both teams agree that this would be very high risk given R59's pulseless electrical activity arrest after cataract surgery but before developing a vitreous hemorrhage. Therefore, it is possible that he still has overall good vision potential even if we do not operate on his left eye urgently. Vitreous hemorrhage: both eyes, right eye greater than left eye, will plan for vitrectomy with V21. R59's Progress Notes dated 6/12/23 at 6:30 PM, written by V2 Director of Nursing (DON) shows R59 was admitted from the hospital with a diagnoses: increased intraocular pressure, bilateral vitreous hemorrhage. This same note does not contain documentation of follow up appointments or procedures needed or an assessment of R59's vision or pain. R59's Progress Notes dated 6/19/23 written by V13 Registered Nurse (RN) shows patient requesting to go to emergency room with complaints of headache, ear pain, and jaw pain. Tylenol administered patient persistent on going to emergency room . Ambulance called patient sent to hospital for further eval. R59's Hospital Discharge Packet dated 6/29/23 shows R59's admission diagnoses: mastoiditis of right side, facial cellulitis, infection of external ear, right, and chronic renal failure. The same packet shows a Central Venous Tunneled Catheter was inserted 6/29/23. The discharge medication list in this packet shows Meropenem 1 gram intravenous every 24 hours for 21 days and Vancomycin 500 mg intravenously every Monday, Wednesday, Friday for 20 days. R59's After Hospital Care Plan in this same packet shows Appointments Scheduled: 7/7/23 Procedure with V21, 7/8/23 at 9:30 AM post op with V21 and 7/18/23 at 1:30 PM office visit with V16 Infectious Disease Doctor. R59's Progress Noted dated 6/29/23 at 5:30 PM, written by V13 shows admitted from hospital, diagnosis Mastoiditis of right side. This same note does not contain an assessment of R59's pain, or R59's right cheek and does not show follow up appointments. R59's Infectious Disease Progress Notes dated 6/28/23 and faxed to the facility on [DATE] shows Catheter Care line maintenance per protocol: Normal saline flush 5 ml pre/post use. R59's Infectious Disease Progress Note dated 7/18/23 shows Completed antibiotic treatment for mastoiditis, Follow up with V21 Ophthalmology, Follow up with Ear Nose and Throat Doctor, will schedule removal of central line on Friday 7/21/23. R59's Instructions for Procedure 8/16/23 (CVC removal) was faxed to facility on 8/10/23 and shows tunneled central line catheter has been scheduled for Wednesday, 8/16/23. Pre-admissions nurse will call by 3 PM the business day before the procedure. On 9/11/23 at 11:40 AM, R59 was in his room in bed. R59 stated I need to go to the eye doctor. My right eye has a little bit of shadows, and my left eye sees shadows only. I have pain to my right cheek and ear (motioning with his hand on the right cheek from his nose to his ear) No doctor has seen me here. My eyes are getting worse. I'm supposed to get this line out (touching his right upper chest), but no one knows nothing. I'm not sure if its set up, they don't tell me. The nurses don't touch the catheter except for today. The doctor said when I finished the medicine it's supposed to come out (touching the catheter on his right chest). I gave the papers from the doctor to them. It was supposed to come out the 16th. When the 16th came, I asked, and they don't know. I can't see well. I can't see TV. I walk with a walker, but I have to look for the light and I remember the path. R59's CVC had a new transparent dressing dated 9/11/12 with gauze dressing over the catheter ports. R59's Minimum Data Set, dated dated dated [DATE] shows R59 is cognitively intact, has moderately impaired vision, and requires supervision for activities of daily living. On 9/11/23 at 8:15 AM, V10 RN said she was not sure who makes appointments or schedules transportation for residents. V10 said she didn't know anything about R59's catheter and had not assessed it. On 9/11/23 at 8:18 AM, V11 Certified Nursing Assistant (CNA) Supervisor said the nurses are supposed to make resident appointments and transportation. On 9/11/23 at 8:21 AM, V12 Social Services said the nurses schedule appointments and transportation. V12 said nurses review the resident's discharge paperwork and orders for medications and appointments. V12 said sometimes V2 Director of Nursing (DON) helps with the orders. V12 said resident appointments are on the home screen of the computer so nurses and CNAs can see. On 9/11/23 at 8:30 AM, V10 RN, with this surveyor, viewed the computer home screen and R59 had an appointment listed for 9/20/23 at 12 PM for his CVC removal (2 months after finishing the antibiotics) and a hearing screening on 10/12/23 at 11 AM. There were no other appointments listed for R59. On 9/11/23 at 9:06 AM, V13 RN said she vaguely recalled R59's hospitalization and didn't remember making any appointments for R59 or could not recall doing anything with R59's CVC. V13 said V9 Facility Physician is R59's doctor and either V9 or V17 Nurse Practitioner (NP) sees R59. V13 said when a doctor or NP see a resident, they document in the progress notes. V13 said R59 is alert and oriented and not a big complainer, so if he complains something is wrong. V13 said R59 has no chronic pain, but has vision problems, he can only see out of one eye. V13 said nurses set up appointments and communicate via shift to shift report if they need to arrange appointments or transport. On 9/11/23 at 9:15 am, V14 Ophthalmology Surgery Clinic Scheduler said R59 had surgery scheduled for his eyes, but it was canceled due to resident not getting a surgical clearance. V14 said R59 didn't go for his preop surgical clearance that had been scheduled locally. V14 said she had reached out to the physician's office where the surgical clearance was scheduled and R59's appointment had never been rescheduled. V14 said R59 was seen urgently in the hospital and was scheduled for a vitrectomy of his right eye due to a vitreous hemorrhage. V14 said R59 was supposed to have this surgery within 2-8 weeks from hospital discharge (6/12/23). V14 said R59 does not have an appointment scheduled currently. V14 said she would have V21 Ophthalmology Doctor call this surveyor. R59's July Medication Administration Record (MAR) shows R59 missed antibiotic (Meropenem) doses on 7/10/23, 7/12/23, and 7/19/23. The same MAR shows acetazolamide eye drop was missed on 7/12/23, 7/17/23, 7/17/23, and 7/19/23; latanoprost eye drop missed on 7/2/23, 7/6/23, 7/15/23, 7/16/23, 7/19/23, 7/24/23, and 7/28-7/30/23; rhopressa eye drop missed on 7/2/23, 7/6/23, 7/15/23, 7/16/23, 7/19/23, 7/24/23, and 7/28-7/30/23; timolol eye drop missed on 7/2/23, 7/6/23, 7/15/23, 7/16/23, 7/19/23, 7/24/23, and 7/28-7/30/23; brimonidine tartrate eye drops missed on 7/2/23, 7/6/23, 7/12/23, 7/10/23, 7/12/23, 7/15-7/17/23, 7/19/23, 7/24/23, and 7/28-7/30/23 and Dorzolamide eye drop missed on 7/2/23, 7/6/23, 7/10/23, 7/12/23, 7/15-7/17/23, 7/19/23, 7/24/23, and 7/28-7/30/23. R59's Progress Notes from 6/19/23 to 9/11/23 do not contain any progress notes from V9 (R59's facility Physician) or V17 Nurse Practitioner. These same notes do not contain any documentation on R59's appointment or procedures with V21, or R59's CVC removal or any assessments on R59's CVC or assessments of R59's vision or face or missed medication doses. On 9/11/23 at 12:51 PM, V17 NP said she had not seen R59, V9 (MD) sees him. V17 said the facility has a policy on CVC care and they should be monitoring/assessing for signs of infection of the site. V17 said orders for medications including intravenous antibiotics and eye drops should be followed as prescribed and if medications are not given as ordered or doses are missed it should be reported to the physician. V17 said if antibiotics are not given as ordered there is a risk of the infection not being treated correctly, the resident can develop antibiotic resistance. On 9/11/23 at 1:27 PM, V13 RN said she had never set up eye appointments for R59 and she was not sure why R59's CVC removal appointment on 8/18/23 was missed. V13 said the hospital called to reschedule the CVC removal for 9/20/23 and she put the appointment in the home screen of the computer, not in the progress notes. V13 said there is usually a doctor's order regarding catheter care, when to flush, monitoring for signs and symptoms of infection and dressing change. V13 said there wasn't any orders for R59's CVC and she didn't know why. V13 said if a medication is missed or not given the doctor should be called and there should be a progress note. On 9/11/23 at 1:37 PM, V1 Administrator and V4 Nurse Consultant reviewed R59's progress notes and said R59 was seen by physiatrist and psychology, but they didn't see any physician notes. V1 said physicians should see the resident within one week of re-admission to the facility. V1 said nurses should review the discharge orders and appointments and put them in the computer. V1 said there is facility policy for CVC care and the nurses should follow the policy. V1 was not sure why there were no orders for CVC care for R59 until today. V1 said he was not sure why R59 missed his appointments including the 8/16/23 CVC removal, it wouldn't have been a transportation issue because the facility bus would transport R59. V1 said nurses should follow physician orders as prescribed. V1 said floor nurses review the hospital discharge papers when the resident is admitted , and the DON should review the orders as well. V4 said the Interdisciplinary team should look at this, this is a process problem. On 09/11/23 at 01:04 PM, V9 MD said he couldn't recall R59 without looking him up and he would be in the facility tomorrow. V9 said he is at the facility almost weekly to see residents. V9 said residents should be seen within a few days when readmitted from the hospital and should be seen at least every two months. On 09/12/23 at 08:03 AM, V21 Ophthalmology was called, and a second message left to speak with V21. There was no return call from V21. On 9/12/23 at 9:20 AM, V1 Administrator said R59 had his CVC catheter out last night (26 days after it was scheduled to be removed). V9 MD walked into V1's office and said he located his notes and shook papers in the air. V9 said he was behind due to medical problems and was catching up. V9 said he would put his notes into the computer that day and said he did see R59 after his hospitalization . V9 said he was not aware of R59 missing any appointments or medications doses. On 09/12/23 at 10:50 AM, V6 Licensed Practical Nurse said R59 gets eye drops for glaucoma. V6 said R59 had cataract surgery and his vision was better for a while, but now it is worse again. V6 said you have to guide R59 with the walker, R59 doesn't see well at all. On 9/12/23 at 11:50 am, V2(DON) said R59 was supposed to go to a preop appointment and didn't because he was in the hospital, so R59's surgery was canceled. V2 said she was unaware of R59's surgery even though she admitted R59 on 6/29/23 and the appointments were in the hospital discharge paperwork. V2 said the nurses should review admission orders, enter the orders, and look at follow up appointments. V2 said R59's eye surgery had not been rescheduled and there was no follow up appointment to the eye doctor scheduled for R59. V2 said she was not sure why R59's catheter was not removed on 8/16/23, but the hospital had called, and it was rescheduled for 9/20/23. V2 said V9 MD saw R59 today and asked to get R59 sent out to hospital as a precaution for his right cheek. V2 said we are looking into doing a 24 hour audit and they currently don't know why R59's appointments were missed. V2 stated they generally double check; we're going to work on that. There is no admission/re-admission procedure in place until now for the nurses. Today and moving forward we will have a plan. V2 said V9 had not documented his June visits for R59 yet, and she had discussed R59's missed eye appointments and CVC with him. V2 said there was no order for CVC care, and she was not sure if there ever was, she hadn't dug that far yet. V2 said a CVC should have an order for flushes, dressings changes weekly, and to monitor for signs and symptoms of infections every shift. V2 was not aware of any missed IV medications or eye drops for R59, but she spoke to V9 about it, and she was investigating it. V2 said physician orders are to be followed and if medications are missed the doctor should be called and documented. On 09/12/23 at 10:34 AM, V18 RN for V16 Infectious Disease Physician, said R59 was treated for mastoiditis and there was destruction of the bone involved. V16 said the importance of intravenous antibiotics is to stop the spread of infection and the length of treatment is important to get rid of infection so there is no more destruction of the bone. V16 said she would expect the nurses to call the doctor if doses of treatment are missed. V16 stated as long as a CVC is in, they should be doing catheter care and assess for signs and symptoms of infection and doing dressing care. R59's CVC is a tunneled catheter and should be surgically removed. R59 was scheduled for 8/16/23 but I'm not sure why it was not done. The area around the catheter should be maintained and assessed, and they should call the doctor and inform us of any right side swelling or pain to R59's face. They should monitor R59's face for increased redness, tenderness, pain or warmth to touch and report it to us. The complication of not receiving catheter care is infection and the line is a straight shot to the heart, so there is an increased risk for sepsis. R59's Physician Orders from June to Current 2023 shows CVC to right upper chest: weekly dressing changes and as needed if becomes soiled or dislodged every day shift every Monday for Catheter Care, IV Type: Right CVC, IV: flush all ports with 10 ml normal saline every 24 hours when not in use, with a start date of 9/11/23. (Order was placed 74 days after R59 was admitted with a CVC). R59's Progress Note dated 9/11/23, written by V3 Wound RN shows this writer has completed weekly and as needed dressing changes to the CVC right chest site since the antibiotic was discontinued. There have not been any signs or symptoms of infection, no redness, no pain, or complications. On 09/13/23 09:23 AM, V2 DON said V3 did not document catheter care in the medical record and there were no documents to provide showing catheter care was done. V2 said catheter care should be documented in the medical record when it is completed, and resident appointments should be documented in the resident's progress notes. R59's Physician Progress Note dated 9/13/23 at 12:26 PM, shows asked to see resident 9/12/23 due to new complaint of right face tingling and swelling. Resident in dialysis, comfortable and in no distress. Resident with recent history of right face cellulitis and mastoiditis treated with intravenous antibiotics. Right side of face with mild swelling compared to left side, no erythema. Due to acute change and the history of right face cellulitis and mastoiditis, resident transferred to emergency room for workup and further care. R59's Progress Note dated 9/13/12 at 11:58 AM, shows R59 has been admitted for facial swelling. R59's Physical Examination dated 9/11/23 from V9 shows examined 7/11/23, hx of right face cellulitis, treated with 2 IV antibiotics, plan- continue the IV antibiotics per Infectious Disease, continue supportive care, meds reviewed please note: pharmacy able to remove the line for the antibiotics 9/11/23 without complication, blood loss or difficulty, monitor. R59's Physician Note dated 9/11/2 shows late entry. examined 8/1/23 for long term care, plan-continue current supportive care, increase activity, meds reviewed. R59's Care Plan does not address R59's assessment and care needs after R59's hospitalization for vitreous hemorrhage or right cheek mastoiditis and treatment with antibiotics. The facility's Physician Orders Policy dated 11/22 shows to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. The facility's Central Venous Catheter Policy dated 11/8/22 shows to provide guidance in the care of central venous access devices: monitor site for signs of infection (e.g., inflammation, purulent drainage at catheter insertion site, tenderness, erythema, and duration; flush catheters at regular intervals to maintain patency and dressing changes. The facility's Admission and Assessments Policy dated 4/2022 shows a primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The facility's Frequency of physician visits policy dated 12/20 shows a physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. The facility's Medication Administration Policy dated 3/2022 shows medications must be administered in accordance with a physician's order, e.g., the right resident, right medication, right dosage, right route, and right time. R59's Vascular Access Solutions Consult Note shows R59's CVC was removed on 9/11/23 at 6:16 PM without difficulty. The facility's unlabeled document dated 9/13/23 show R59 is scheduled for a prep screening on 10/20/23 for surgery with V21 on 11/14/23 and post op appointments scheduled 11/15/23 and 11/22/23. The Immediate Jeopardy that began on 6/12/23 was removed on 9/12/23 when the facility took the following actions to remove immediacy. R59 was sent to the hospital on 9/12/2023 as a precaution, due to a medically complex history regarding swelling to the right cheek. Tunneled IJ catheter was removed by Pxxxxxx on 9/11/2023 at approximately 18:16 and was successfully removed; R59 tolerated the procedure well without complications. An appointment for ophthalmology surgery was made for November 14, 2023, with V21. Time to be determined. Careplan has been updated and will be revised upon anticipated return to the facility. All licensed nursing staff, certified nursing staff, administrative nursing staff and Administrator were re-educated on the following topics: 1. Ensuring a residents discharge hospital orders were followed for medications and discharge procedures and appointments. 2. Ensuring a resident is assessed and monitored with a known vision impairment, a known facial infection on antibiotic therapy and monitor and assess a central venous catheter site. 3. Ensure the residents receive treatment for vitreous hemorrhage and increased intraocular pressure and red swollen cheek. 4. Ensure Residents central venous catheter is assessed and removed as ordered. 5. Ensure all residents follow up appointment are scheduled and arranged and prescribed medications are administered. 6. Ensure policies and procedures are in place for new admissions and readmission orders are carried out. Education initiated on 9/12/2023 and completed on 9/12/23 by the Administrator, DON and MDS RN. All licensed nursing staff and C.N.As were educated via phone 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. 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. This will include staff on vacation or out due to illness. Spot education will continue to ensure compliance. Licensed nursing staff new hires will be educated during orientation. A baseline house audit was completed on 9/12/2023 to ensure compliance with monitoring a resident, discharge hospital orders were followed for medications and discharge procedures and appointments. Ensuring a resident is assessed and monitored with a known vision impairment, a known facial infection on antibiotic therapy and monitor and assess a central venous catheter site. Ensure the residents receive treatment for vitreous hemorrhage and increased intraocular pressure and red swollen cheek. Ensure Residents central venous catheter is assessed and removed as ordered. Ensure all residents follow up appointments are scheduled and arranged and prescribed medications are administered. Ensure policies and procedures are in place for new admissions and readmission orders are carried out. A QA tool was developed to ensure all admission and readmissions will be completed by the Director of Nursing or designee to ensure compliance to ensure orders are carried out to include: Ensuring a residents discharge hospital orders were followed for medications and discharge procedures and appointments. Ensuring a resident is assessed and monitored with a known vision impairment, a known facial infection on antibiotic therapy and monitor and assess a central venous catheter site. Ensure the residents receive treatment for vitreous hemorrhage and increased intraocular pressure and red swollen cheek. Ensure Residents central venous catheter is assessed and removed as ordered. Ensure all residents follow up appointment are scheduled and arranged and prescribed medications are administered. Ensure policies and procedures are in place for new admissions and readmission orders are carried out. QAPI audits will be completed for 3 months. 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 3 months. The QAPI committee will determine if the audits will continue at that time. Medical Director is aware and in agreement with the abatement plan.

I. Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Centers of Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering Person Under Investigation (PUI) resident rooms to prevent exposure to COVID-19 and failed to identify residents on transmission based precautions (TBP) for two of two residents (R320 & R318) reviewed for transmission based precautions. This failure has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on May 10, 2021 when V8 Registered Nurse (RN) entered R320's room without donning full PPE (droplet precautions). On May 11, 2021, V9 Certified Nursing Assistant (CNA) did not have her PPE on correctly. The Immediate Jeopardy was identified on May 10, 2021. V1 Administrator was informed of the Immediate Jeopardy on May 14, 2021. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on May 14, 2021; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R320's Resident Information sheet printed on May 12, 2021 showed R320 was admitted to the facility on [DATE]; there were no diagnoses listed that showed she has had Covid-19. The Covid-19 Vaccination Record Card for R320 showed she received the [NAME] and [NAME] Vaccine on May 7, 2021 (5 days prior). . R318's Resident Information sheet printed on May 12, 2021 showed R318 was admitted to the facility on [DATE]; there were no diagnoses listed that showed he has had Covid-19. There were no vaccination records available for R318. The Centers for Disease Control Preparing for Covid-19 in Nursing Homes-Create a Plan for Managing New Admissions and Readmissions updated 11/20/2020 shows, HCP (Healthcare personnel) should wear an N95 or higher-level respiratory, eye protection, gloves, and gown when caring for new admissions and readmissions. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. On May 10, 2021 at 8:18 PM, V8 Registered Nurse (RN) entered R320's room wearing only a surgical mask. V8 did not don a PPE gown, gloves, or surgical mask over an N95. V8 administered medication to R320, exited R320's room and walked down the hall. The sign on the door of R320's door stated, Please see nurse before entering. There were no signs posted for droplet precautions, contact precautions, donning or doffing of PPE. The isolation cart outside of the room did not have any signs for the type of isolation/precautions, donning or doffing. On May 10, 2021 at 8:26 PM, V8 stated R320 was on isolation because she was a new admission to the facility and is a PUI for fourteen days. V8 stated, For a resident that is a PUI you are supposed to put on an isolation gown, gloves, and mask. I know you got me. I thought about it when I came out. On May 11, 2021 at 9:38 AM, V24 Certified Nursing Assistant Supervisor (CNA) stated when staff go into PUI rooms they are to put on a gown, N95 mask, gloves, and sometimes shoe covers but right now the shoe covers are not available. V24 stated staff know what to put on because they are given an in-service once a week. There are signs (isolation precautions) posted somewhere. On May 11, 2021 at 9:49 AM, V9 Certified Nursing Assistant (CNA) had a surgical mask on barely covering the tip of her nose. V9 donned an N95 mask over the surgical mask. The N95 mask did not cover her nose and was under her nose. V9 donned a disposable gown and did not tie the gown. V9 had her glasses on but did not have goggles and/or a face shield on. The sign on the door of R318's door stated, Please see nurse before entering. There were no signs posted for droplet precautions, contact precautions, donning or doffing of PPE. The isolation cart outside of the room did not have any signs for the type of isolation/precautions, donning or doffing. On May 11, 2021 at 10:39 AM, V3 Registered Nurse/Infection Control Preventionist stated, For PUI rooms staff are to wear full PPE which is an isolation gown, gloves and N95 mask. The N95 goes on first and then a surgical mask goes on over the N95. The N95 mask is used only for that resident and is not able to be used in other resident rooms. The N95 mask is stored in a paper bag in the drawer of the isolation bin outside the door. Goggles and face shield are not required because the resident is not a true Covid -19 case. That's how it was communicated to me. The purpose of PUI is meant to help control and prevent the spread of Covid. In case they were symptomatic or have another other illness then the resident is isolated, and it is controlled to that room. On May 12, 2021 at 10:08 AM, V3 Registered Nurse/Infection Control Preventionist stated, R318 was placed as a PUI upon admit to the facility. I think he has had the first shot for the Covid 19 vaccination and has an appointment for the second one. I don't know if he has had his second shot or not. As far as I know residents are to be PUI in the facility for 14 days if they are a new admission to the facility and have not been vaccinated. They are also to be a PUI if they are a new admit and/or readmission to the facility for two weeks after they have been fully vaccinated. So they need to be fully vaccinated and will be on isolation for 14 days afterwards as a PUI. On May 12, 2021 at 3:30 PM, V2 Director of Nursing (DON) stated there is more than enough PPE in the facility. On May 14, 2021 at 11:13 AM, V1 (Administrator) stated 318 has not been vaccinated for Covid-19. The facility is using the State of Illinois Updated Interim Guidance for Nursing Homes and Other Long-Term Care Facilities Incorporating Covid-19 Vaccination guidance dated 3/19/21 as part of their policy and showed a fully vaccinated (new): The vaccination status of a person who is greater than or equal to two weeks following receipt of the second dose in a valid two dose series, or greater than/equal to two weeks following receipt of one dose of single-dose vaccine. PPE supply: As specified in the guidance for PPE, a NIOSH- approved N95 equivalent or higher-level respirator is recommended when caring for suspected or confirmed patients with Covid -19. If the facility has sufficient PPE, it is not operating at crisis capacity, as defined by CDC. All staff must wear appropriate PPE when indicated. Newly admitted or readmitted Residents (New) residents who are not fully vaccinated must quarantine for 14 days upon admission or readmission to the facility in transmission- based precautions. Core principles of Covid-19 Infection Prevention: Instructional signage throughout the facility and visitor education on Covid-19 signs and symptoms, infection control precautions, other applicable facility practices. Appropriate staff use of PPE. The facility's PPE during Covid-19 policy (5/8/21) showed, The facility will utilize NIOSH approved N95 equivalent or higher-level respirator when caring for suspected or confirmed patients with Covid 19 All persons entering isolation rooms are required to wear appropriate PPE for the type of isolation. The Immediate Jeopardy that began on May 10, 2021 was removed on May 14, 2021 when the facility took the following actions to remove the immediacy. 1. Education: On following infection control policies and recommendations from the Centers of Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering Person Under Investigation (PUI) resident rooms to prevent exposure to COVID-19. Staff is re-educated on the highly contagious nature of COVID-19 and its higher mortality rate in Long-Term care setting; staff educated on appropriate PPE for PUI-face shield/goggles, N95, gown and gloves was initiated on May 14, 2021 and the initial education will be completed by midnight on May 14, 2021. The Administrator and Nursing management will complete the education. All staff educated via phone will be re-educated prior to the beginning of the next shift worked and will sign education sheets. New hires will be educated during orientation. 2. System: A weekly audit is being conducted to ensure appropriate PPE is worn in PUI resident rooms (face shield/goggles, gloves, gown, N95) and signage is appropriately placed outside the resident room. Audits will continue through the duration of the pandemic Audits will be completed by Nursing Management and presented through QAPI. 3. Signage: Signage posted informing all residents, staff, and visitors/associates at the entrance of the PUI rooms required PPE to be worn while in the room completed May 14, 2021. A weekly audit for appropriate signage is being completed to ensure compliance. A root cause analysis is being conducted to identify barriers and further education needed. To be completed May 14, 2021. 4. QA: 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 the duration of the pandemic. QAPI will determine if the audits will continue at that time. II. Based on observation, interview, and record review the facility failed to wear appropriate Personal Protective Equipment and the facility failed to have a COVID testing plan and policy for staff and residents that refuse testing. This failure has the potential to affect all residents in the facility. The findings include: A. The CMS-672 of 5/12/21 showed 71 residents resided in the facility. On 5/10/21 at 6:00 PM, the State survey team entered the conference room. V2 Director of Nursing (DON), V3 Infection Preventionist Nurse, and 4 staff persons including V4 Registered Nurse (RN), V5 RN, and V6 Licensed Practical Nurse (LPN) were seated in the conference room for a staff meeting. V4-6 were seated less than 3 feet apart from each other at a table and were not wearing face masks. V6 covered her mouth with a piece of paper and left the room to obtain a face mask. On 05/10/21 at 06:43 PM, V3 said employees should be at least six feet apart from each other and wearing face coverings over the nose and mouth. If this doesn't happen, then there could be transmission concerns. Staff should wear face coverings to prevent transmission of infectious diseases. On 5/12/21 at 12:19 PM, V2 said it is her expectation staff have face coverings on (if not eating or drinking). The staff (on 5/10/21) should have been seated further apart (at least 6 feet) to stop the spread of COVID and other infectious diseases. B. On 5/11/21 at 11:10 AM, V2 said COVID testing is done weekly for unvaccinated staff only. Residents are not being tested . If someone refuses testing, they would be taken off of the schedule. I don't believe it's in a policy. Maybe it was in something the county health department. A COVID Testing Plan containing how the facility addresses testing refusals of residents and staff was requested three times. The first time this surveyor was referred to the State 3/19/21 Interim Guidance for Nursing Homes. The Testing Plan and Response Strategy showed the facility testing plan includes: a policy for addressing residents and staff that refuse testing in each of the following situations a) symptomatic, or (b) asymptomatic. The second time this surveyor was given a copy of an email dated 3/5/21 from the local health department advising of the county's positivity rates and what testing is recommended. The third time, this surveyor was given a copy of an email dated 5/11/21 from the local health department providing testing updates. A facility Testing Plan was never received

Based on observation, interview, and record review, the facility failed to safely transfer residents according to their plans of care. This failure contributed to R10 sustaining two fractures in her left arm. This applies to 2 of 16 residents (R2, R10) reviewed for safe transfers in the sample of 16. The findings include: 1. R10's Physician order [REDACTED]. On October 4, 2016 at 9:15 AM, R10 was sitting outside of her room in her wheel chair. R10 was sitting on a full body sling for the mechanical lift. R10 was waiting for E16 CNA (Certified Nursing Assistant) to come clean her up after she vomited. R10's left arm was in a soft cast and soft sling. This surveyor asked R10 if she was ok. R10 stated she was in pain. This surveyor also asked R10 what happened to her arm. R10 said, The CNA broke my arm. He did not use the mechanical lift to put me back in bed. E16 returned to clean R10 up. R10 requested for this surveyor to return later in the day. At 1:00 PM, R10 stated, The male CNA, E7 (Resident named CNA by first name and described what E7 looked like) transferred me from my wheel chair to my bed in like a bear hug. He put his arms around me and then put my arms around his neck and stood me up. My arm slipped down and got caught in between us and I felt a crack. It hurt like hell. He said he was sorry. I told them I was in pain and I went to the hospital early the next morning. He did not use a transfer belt and he did not use a mechanical lift. At 1:50 PM, E16 needed to change R10's shirt again. After E16 removed R10's shirt, R10 had a soft cast from her armpit area down to her fingers on her left arm. R10 had swelling to her left hand and shoulder. There was dark purple bruising that extended from R10's left shoulder all the way to the middle of her right breast. R10's MDS (Minimum Data Set) dated July 22, 2016, shows R10 was an extensive two person assist for bed mobility and that R10 was totally dependent on two persons in her transfer ability. R10's Resident Plan of Care with an admitted [DATE], shows R10 transfers via mechanical lift with two person assist. R10's Care Plan initiated on July 18, 2016, shows R10 has been assessed to need a mechanical lift for transfers. R10 is unable to bear weight on her legs and has very poor sitting balance due to a stroke and contractures of her extremities. The interventions include that R10 will be transferred with a two person transfer when using a mechanical lift. The Incident Report dated September 30, 2016 at 11:12 PM, by E15 LPN (Licensed Practical Nurse), shows E15 assessed R10 and noted purple bruising to her inner left elbow with slight swelling. R10 stated to E15 that her left arm and shoulder had severe pain since the transfer into bed. R10 heard a pop in her arm during the transfer. The incident report also shows that R10 is oriented to person, time, place, and situation. On October 5, 2016 at 10:17 AM, E15 stated, Around 11:00 PM, the CNA told me R10's left arm was hurting. I assessed her and notice bruising by her inner elbow with some swelling. The resident said when E7 transferred her into bed she felt her arm pop. After R10 was in bed, E7 came to me and said he did not know R10's arm flopped. I asked R10 if E7 used the mechanical lift to put her into bed and she said no. There is supposed to be two staff when using a mechanical lift. I got an order for [REDACTED]. She went to the hospital after that. The Radiology Report from the travel x-ray done at the facility on October 1, 2016, shows there are oblique fractures involving the proximal neck (up by the shoulder joint) and middle portion of the humerus (upper arm bone) with moderate displacement. The local emergency department Imaging Results dated October 1, 2016, shows there is a segmental fracture of the humeral diaphysis with evidence of displacement by about 1.3 centimeters of the distal fracture line. The local emergency room notes dictated by Z6 (Medical Doctor) on October 1, 2016, shows R10 reported that nursing home personnel moved her arm above her head and she felt a pop. This occurred after she was being moved from the wheel chair to a bed. The notes also show the radiology spray demonstrated a spiral fracture just underneath the ball of the humerus and another spiral fracture in the distal two thirds of the humeral shaft. On October 4, 2016 at 3:45 PM, E7 stated, I transferred R10 with a mechanical lift into the bed. I did the mechanical lift all by myself. I did not know her left arm was flaccid (drooping). R10 had a bowel movement, so I turned her away from me, on her right side, to clean her. I pushed her on her right side with one of my hands on her left shoulder and my other hand on her left hip. She yelled out and said her arm hurt. On October 5, 2016 at 4:42 PM, E23 CNA stated, I was supposed to help E7 transfer R10 into bed but she was already in bed when I got there. R10 complained of pain in her left arm. I don't recall a mechanical lift pad underneath her. R10 did not tell me what happened. On October 4, 2016 at 3:25 PM, E2 DON (Director of Nursing) reported that she interviewed E7 and R10 after the incident occurred. During E2's interview with E7, E7 stated, R10's injury happened during cares. Her arm came over and flopped onto the bed and she complained of pain. I used a mechanical lift to transfer her by myself. During E2's interview with R10, R10 stated, E7 transferred me by picking me up and my left arm slid between us. My arms were around his neck and I heard a pop. E2 stated, I don't know if he had a safety belt on her. When a mechanical lift is used, two staff are required. The undated interview done by E2 with R10 shows R10 stated E7 picked her up out of her chair by placing her arms on each of his shoulders. R10 stated when E7 lifted her, her left arm slipped down in between them and she heard a pop and her arm began hurting. The facility's investigation timeline provided by E1 shows that E7 entered R10's room at 8:35 PM with the mechanical lift, then left R10's room at 8:36 PM, returned to R10's room at 8:37 PM, left again at 8:39 PM, returned to R10's room at 8:41 PM, then left R10's room with the mechanical lift at 8:45 PM. This shows that E7 was in R10's room for no more than four consecutive minutes. R10 Brief Interview for Mental Status dated July 22, 2016, shows R10's cognitive ability was moderately impaired. On October 5, 2016 at 9:20 AM, E1 Administrator stated, We did not suspend E7 during this investigation of injury of unknown origin, because R10 stated E7 did not hurt her intentionally and we believed her. R10 stated E7 picked her up out of her chair and placed her arms around his shoulders to transfer her into bed. We were unable to conclude where the injury came from. On October 5, 2016 at 4:42 PM, E23 CNA stated, R10 did not tell me what happened. On October 6, 2016 at 9:05 AM, E20 CNA stated, I can believe what R10 says. She is able to make her needs known. R10 reported to E1, E2, E15, and this surveyor on (two different occasions) that E7 did not use a mechanical lift during transferring. The facility's list of new hires shows that E7 start date with this facility was September 27, 2016. This was nine days prior to the improper transfer violation. E7 was re-educated after this incident on October 1, 2016 about where to look when the transfer status is unknown. E7 also received a counseling form dated October 1, 2016 that shows failure to follow the plan of care for a resident by not using two people to transfer resident with a mechanical lift. The initial violation of not using a mechanical lift for transferring was crossed through and amended from not using a mechanical lift and to not using two persons. E2 said that R10 reported E7 did not use a mechanical lift but E7 told me he did. 2. R2's electronic profile sheet shows she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On October 4, 2016 at 12:40 PM, E7 (Certified Nursing Assistant-CNA) transferred R2 from the wheel chair to her bed using a gait belt. R2 was unsteady during the transfer. When R2's buttocks touched the mattress, R2 was not able to stop herself from lying back before E7 was able to lift her legs and turn her, to position her on the bed. On October 4, 2016 at 8:00 AM, E32 (Restorative Nurse) said R2 requires assistance of 2 staff members for transfers. E32 said the Therapy Department is currently working with R2 and they have not recommended that R2 be a 1 assist yet. E32 stated, Therapy gives me a referral form when they feel the resident is safe and then I change the information on the door care plan (The instruction sheet located inside the resident's closet that describes the resident's care needs) and (R2's) care plan. E32 stated, Staff should be transferring her (R2) with 2 assist with a gait belt. They should not be transferring her as a 1 assist with a gait belt. On October 5, 2016 at 8:20 AM, Z2 (Director of Rehab Department) said R2 needs 2 assist transfer with a gait belt. Z2 said both staff assisting R2 with the transfer should have their hands on the gait belt. On October 5, 2016 at 10:50 AM, E2 (Director of Nursing-DON) said R2 is a 2 assist with a gait belt. E2 said both staff with their hands on the gait belt. I would not expect staff to transfer her (R2) as a 1 assist with a gait belt for the resident's and the staff's safety. E2 stated the door care plan on R2's closet door was incorrect yesterday. E2 said she was the one that updated the door care plans that go in the resident's closets. On October 5, 2016 at 12:35 PM, E7 (CNA that transferred R2 by himself) said he transferred R2 by himself with a gait belt because that is what the door care plan said. E7 said I guess she is actually a 2 assist. On October 5, 2016 at 2:35 PM, E8 and E13 (Certified Nursing Assistant-CNAs) said R2 is a 2 assist with a gait belt for transfers. R2's Minimum Data Set of September 20, 2016 shows she is dependent on 2 staff for transfers. R2's Activities of Daily Living Care Plan dated September 19, 2016 shows (R2) has been assessed and has been determined to need 2 assist, with weight bearing as tolerated, very poor sitting balance. Recent fracture right hip, with joint replacement surgery. R2's September 6, 2016 Fall Risk Review shows R2 is a high risk for falls. The review shows R2 has had a decrease in muscle coordination. The facility's July 2014 Limited Lifting Resident Handling Policy shows 5. The transferring needs of residents will be assessed on an ongoing basis. The policy showed 7. Assessment of residents transferring needs shall include a. mobility status b. Weight bearing ability c. Cognitive status. The policy continued to show 8. The policy will be followed at all times.

Based on observation, interview and record review the facility neglected to follow its Policy and Procedure for Handling Self Harm Behavior as it relates to R12's suicide attempts in April and June of 2014. These failures resulted in an Immediate Jeopardy when R12 made another suicide attempt on 9/22/14. The Immediate Jeopardy began on 4/29/14 when R12 returned from a psychiatric hospitalization . Facility staff was not aware of her crisis plan nor was her care plan revised to include it. E1 (administrator) was informed of the Immediate Jeopardy on 9/22/14 at 2:30PM. The Immediate Jeopardy was removed on 9/22/14 at 6:15PM. The facility remains out of compliance at a level two as the facility needs to complete training of all staff on a revised Handling Self Harm Behavior Policy and the monitoring of staff compliance with the policy. These failures apply to one of two residents (R12) at risk for suicide attempts in the sample of 19. The findings include: The facility's undated policy titled Policy and Procedure for Handling Self Harm Behavior that was in place at the time the Immediate Jeopardy occurred, shows that this policy emphasizes proactive intervention, promoting enhanced physical and psychosocial well-being. This facility protocol recognizes impending self harm behavior and instructs staff in management techniques to ensure the safety of each resident. A hospital History and Physical report shows that R12 was admitted to a psychiatric Hospital from 4/9/14-4/29/14 after putting a cord around her neck to kill herself and later changed her mind. The My Safety Crisis Plan sent with R12 on discharge from the psychiatric hospital on [DATE] shows R12's Triggers and Stressors include: "any kind of sexual abuse reference, slamming doors, raised voices, conflict, feeling ignored, feeling invisible, people coming up behind me, unpredicted changes." R12's warning signs include: sleeping too much, getting angry over little things, eating too much, and withdrawing. Other plans on the My Crisis Plan Sheet included guidance on coping skills and People to call and Reminders. This sheet was marked as copy for patient. This form was discovered in the thinned portion of R12's record, stored in the basement, not readily available to the resident or staff. On 9/22/14 at 4:00PM, E2 (Director of Nursing) said this should be incorporated into her care plan. R12's Care Plan dated through June 2014 was not revised to include areas included on the My Crisis Plan Sheet and did not include removing plastic bags and shoelaces, supervision checks, and attending groups as identified on R12's PASAAR II form. Areas to work on included (Professional Observation (MD/RN) for medication monitoring, adjustment and/or stabilization, Instrumental Activities of Daily Living training/reinforcement, Mental Health Rehabilitation activities, Illness self management, and Community re-integration activities). The Care Plan dated through June 2014 shows R12 has a history of suicide attempts as well as suicidal ideation. In the past two years she has had more than 50 attempts. The care plan shows R12 has [DIAGNOSES REDACTED]. R12's Care plan states, "In the event that R12 exhibits behavior of thoughts or attempts to harm herself, R12 is to be placed on one to one, psychiatrist and Medical Doctor to be notified, resident will be monitored till discharged to (a) hospital". The Policy and Procedure for Handling Self Harm Behavior under section II describes what the facility is to do when a resident threatens or attempts to self harm. Under Verbal Threat and plan, in the event a resident makes a negative statement (indicating) self harm and voices a plan: a) the resident will be immediately placed on one to one supervision, b) The nurse in charge will immediately contact the Administrator, Director of Nursing and the Social Service director, c) the nurse in charge will contact the physician for (an ) order for a psych evaluation, d) If an order cannot be obtained from the physician, the resident will be sent out on petition with 911, and e) (the) responsible Party will be notified of the event and facility policy. The 6/12/14 Social Services Notes by E3 (Social Service Director) state, " ....R12 shows signs and symptoms of depression. R12 tends to appear and feel depressed daily has had thoughts of suicide, has sleep disturbances, and lacks energy at times ....R12 has had three psych hospitalization s for suicidal ideation since admission, currently stable." No further actions were shown to be taken by the facility on this date. R12's Psychiatric Consultation progress note dated 6/16/14 said, R12 with recent suicide ideation and plan in place. R12's plan is to place a plastic bag around her neck. The trigger is relieved by removing the pillow case bag on pillow. There are significant symptoms of depression and mood changes. R12 needs more psychotherapy. No further actions were shown to be taken by the facility on this date. On 6/20/14 Z6 (Psychiatrist) notes state, " R12 reports chronic suicidal thought. R12 reports 2 days ago she had thoughts to wrap her panty hose around her neck. R12 then hid her panty hose. R12 reported last night she hid her Trazadone (Anti-psychotic medication) in her closet with the plan to save her meds and take them on Monday night. 15 minute checks at night ...and increase [MEDICATION NAME] dose." The Nurse's Notes dated 6/20/14 show, R12 has been storing Trazadone in her closet. R12 said, she had a plan to take all her medications at once one night. Fifteen minute checks ordered and watch R12 take medications. On 6/20/14 the Social Service Notes by E3 state, " Z6(Psychiatrist) called facility and spoke with nurse stating that during visit R12 stated that she was not taking Trazadone. R12 was saving pills to hurt herself. A Room check was done and two pills were found. Z6 placed R12 on 15 minute checks." No further actions were shown to be taken by the facility on this date. Fifteen minute checks were documented for R12 on 6/20 and 6/21/14. For 6/22/14 (Saturday) there was no documentation of 15 minute checks for R12. On 6/22/14 at 5:55 PM, An Incident and Accident Report states, " R12 wrapped shoe strings and call light around her neck and R12's face was turning blue. All ties and cords cut and removed." The Nurses Note dated 6/22/14 states, " Certified Nursing Assistant to answer R12's call light and then yelled out loudly multiple times "Help!!!" I ran to R12's room and observed shoelaces and call light cord all tied around her neck and R12's facial color was beginning to turn blue. I immediately used my medical scissors and cut all ties around her neck and also removed call light cord. R12's color returned to pink immediately and she let out a deep gasp. ..I asked R12 why did you decide to do this? R12 stated, "I ' m done." ...What are you done with? R12 stated, "Life ..." How long have you been feeling this way? R12 states, "3 days" I asked her did you tell anyone about how you were feeling? R12 states, "Yes, the doctor and he only said, he would increase my medication ...." Section III of the Policy and Procedure for Handling Self Harm Behavior titled Readmission/Return from Psych evaluation states: a) once it is determined that resident is safe to return to facility, resident will be reassessed and care plan will be done to address the risk for self harm, b) For the first five days resident will be on 30 minute checks. Staff will monitor (the resident whereabouts and what they are doing every 30 minutes and c) Social Service will document on resident ' s mood mental function and behavior status as needed. On 9/17/14 at 11:45 AM, there were four pairs of shoes with shoelaces underneath R12's bed. On 9/17/14 at 2:00 PM, there were two garbage cans with trash bags in R12's room. On 9/22/14 at 3:05 PM, a garbage bag was in R12's bathroom and a garbage bag was near her roommate's bed. As of 9/22/14, R12's care plan did not contain the precautions about the shoe laces, the plastic bags or the points from the 4/29/14 My Crisis Plan. On 9/22/14, the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: 1. Corrective Action taken for Residents displaying self Harm behaviors: The resident at risk will be assessed for warning signs and triggers. The staff will use the best of their knowledge to remove or prevent any triggers that would cause the resident to decide to harm themselves. This will be done using the new Suicide Risk Assessment. The facility has five residents who could be considered high risk. These five residents had the Suicide Risk assessment done on 9/22/14. 2. Identification of other residents that have potential to be affected by the same deficient conduct: All other residents that have the potential to be affected by the conduct will have quarterly assessments done. These will also be done on an as needed basis. Nursing staff will be in-serviced on how to identify different warning signs and possible triggers. The Director of Nursing, Social Service and administrator will implement this tool effective 9/22/14. All residents that were admitted previous to this date will be assessed using this tool within 30 days from this date. 3. Measures taken to prevent deficient conduct from reoccurring: The Suicide Risk assessment will be done upon admission by the social service department. The nursing staff will then use this assessment to determine possible triggers for each resident. These assessments will be assessed weekly by the Director of Nursing and social service representative. The Director of Nursing will also assess any 15 minute check forms every Monday through Friday. At the time of any occurrence the Director of Nursing, administrator and Social Services rep will be notified immediately so that the proper action can be taken beginning 9/22/14. 4. Quality Assurance The Social Service representative, Director of Nursing, and administrator will give in-services monthly for the next three months on the suicide risk assessment tool and how to take proper suicide precautions for a resident at risk. At this time an initial in-service will be given at the beginning of every shift before the employees take care of the residents until we hit 100% of staff in-serviced. This training will include review of the policy and procedure for handling self harm behavior, Asta care healthcare center ' s contract for safety and the initiation of the blue triangle to alert staff that the resident is at high risk for suicide.

A. Based on observation, interview, and record review the facility failed to supervise a resident (R12) with a history of recent suicide attempts by not conducting 15 minute checks as ordered and failed to place R12 on 1:1 supervision when she expressed thoughts of suicide. The facility failed to remove items she planned to use in a suicide attempt (trash bags, and shoe laces) from her room which R12 had talked about using or had used in previous attempts. These failures resulted in R12 attempting suicide with her shoe laces and call cord around her neck on [DATE]. As a result of this failure an Immediate Jeopardy was identified. The Immediate Jeopardy began on [DATE] when R12 expressed suicidal thoughts. On [DATE] at 2:30PM, E1 (Administrator) was informed of the Immediate Jeopardy. The immediacy was removed on [DATE] at 6:15PM, when all residents at risk for suicide were reassessed and the policy regarding residents at risk for suicide was revised and was presented to staff. The facility remains out of compliance at a level 2 as staff on all shifts had not been in-serviced on the new policy and procedure. This applies to one of five residents (R12) reviewed for safety related to suicide risk in the sample of 19. The findings include: R12's Pre-Admission Screening (PAS) Assessment Summary Information on [DATE] shows R12 has a [DIAGNOSES REDACTED]. R12 would likely benefit from continued groups to gain coping skills and symptoms management. The Pre-Admission Screening Mental Health Level II Notice of Determination dated [DATE] shows R12 requires special services: "Professional Observation (MD/RN) for medication monitoring, adjustment and/or stabilization, Instrumental Activities of Daily Living training/reinforcement, Mental Health Rehabilitation activities, Illness self management, and Community re-integration activities." R12 was admitted to a psychiatric Hospital from [DATE]-[DATE] for inpatient treatment due to the severity of her suicidal and self-destructive thoughts. The Medical history and physical examination [REDACTED]. R12 put a cord around her neck to kill herself and later changed her mind. R12 has a history of physical and sexual abuse at the age of 10. R12 has auditory and visual hallucinations ... R12 hears devil 's voice...R12 suffers from...Post Traumatic Stress Disorder." The My Safety Crisis Plan sent with R1 on discharge from the psychiatric hospital on [DATE] shows R12 ' s Triggers and Stressors include: "any kind of sexual abuse reference, slamming doors, raised voices, conflict, being feeling ignored, feeling invisible, people coming up behind me, unpredicted changes. "R12's warning signs include: sleeping too much, getting angry over little things, eating too much, and withdrawing. Things I like to do:"Walking nature trails, reading, playing games on kindle, bingo and devotionals." The Screening Assessment for Evaluating Self-Harm/Suicide Risk dated [DATE] shows R12 has a score of 14(a score of ,[DATE] represents a moderate risk). The [DATE] Risk Screening Assessment for Indicators of Aggressive, Harmful and/or Inappropriate Behaviors shows R12 has a score 8. (a score of ,[DATE] shows a minimal/low risk). The Screening Assessment to Determine the Presentation of Abuse and/or Neglect Factors [DATE] shows R12 has a score of 5 (a score of 4 or more represents high risk). On [DATE] the Social Services Notes by E3 (Social Service Director) states,"...R12 shows signs and symptoms of depression. R12 tends to appear and feel depressed daily has had thoughts of suicide, has sleep disturbances, and lacks energy at times ...R12 has had three psych hospitalization s for suicidal ideation since admission, currently stable." On [DATE] the Screening Assessment for Evaluating Self-Harm/Suicide Risk shows R12 has a score 10. A score of ,[DATE] is at moderate risk. The Risk Screening Assessment for Indicators of Aggressive, Harmful and/or Inappropriate Behaviors [DATE] shows R12 has a score of 6 (a score of ,[DATE] is at minimal/low risk). The Screening Assessment to Determine the Presentation of Abuse and/or Neglect Factors [DATE] shows R12 has a score of 4 (a score of 4 or more represents a high risk). The Psychiatric Consultation progress note dated [DATE] said, R12 with recent suicide ideation and plan in place. R12's plan is to place a plastic bag around her neck. The trigger is relieved by removing the pillow case bag from the pillow. There are significant symptoms of depression and mood changes. R12 needs more psychotherapy. On [DATE] Z6 (Psychiatrist) stated,"R12 reports chronic suicidal thought. R12 reports 2 days ago she had thoughts to wrap her panty hose around her neck. R12 then hid her panty hose. R12 reported last night she hid her Trazadone (Anti-psychotic medication) in her closet with the plan to save her meds and take them on Monday night. 15 minute checks at night ...and increase Lithium dose." The Nurse's Notes dated [DATE] said, R12 has been storing Trazadone in her closet. R12 said, she had a plan to take all her medications at once one night. Fifteen minute checks ordered and watch R12 take medications. On [DATE] the Social Service Notes by E3 states, "Z6 (Psychiatrist) called the facility and spoke with nurse stating that during visit R12 stated that she was not taking Trazadone. R12 was saving pills to hurt herself. A Room check was done and two pills were found. Z6(Psychiartist) placed R12 on 15minute checks." On [DATE] the Screening Assessment for Evaluating Self-Harm/Suicide Risk shows a score of 13. A score of ,[DATE] is at moderate risk. E3(SSD) wrote on the Screening Assessment, R12 was reassessed on this date related to making a suicide statement. E3 felt that resident was not a threat to herself. For [DATE] (Saturday) there was no documentation of 15 minute checks for R12. On [DATE] at 5:55 PM, An Incident and Accident Report states, "R12 wrapped shoe strings and call light around her neck and R12 ' s face was turning blue. All ties and cords cut and removed. R12 kept pulse during whole process ....911 called, Director of Nursing on site, Medical Doctor notified, family called, sent to emergency room per protocol." The Nurses Note dated [DATE] states,"Certified Nursing Assistant to answer R12's call light and then yelled out loudly multiple times " Help!!!" I ran to R12's room and observed shoelaces and call light cord all tied around her neck and R12 ' s facial color was beginning to turn blue. I immediately used my medical scissors and cut all ties around her neck and also removed call light cord. R12's color returned to pink immediately and she let out a deep gasp..I asked R12 why did you decide to do this? R12 stated," I ' m done." ...What are you done with? R12 stated, "Life"... How long have you been feeling this way? R12 states, "3 days" I asked her did you tell anyone about how you were feeling? R12 states," Yes, the doctor and he only said, he would increase my medication ...." The Social Services Note dated [DATE] by E3(SSD) states," R12 was readmitted on this date from Rockford Memorial Hospital Behavioral Health Unit ...To ensure R12's safety the following actions have been put in place. R12 will be on 15 minute checks for first 24 hours on ,[DATE] and ,[DATE] R12 will be on 30 minute checks. On ,[DATE] ...R12 will be on 1 hour checks for 90 days. R12's call light has been removed ...R12 also has had all laces removed from shoes...no plastic bags ...all precautions have been care planned ...R12 will be encouraged to attend group in facility ...." The 1 Hour Care Sheet for R12 from [DATE] - [DATE] shows no documentation for 9 days. 7 Care Sheets are completed hourly, and remaining sheets are not documented hourly. On [DATE] at 11:00AM, E22 (Medical Records) said, these are the only hourly care sheet records he was able to find. The Care Plan dated through [DATE] shows R12 has a history of suicide attempt as well as suicidal ideation. In the past two years she has had more than 50 attempts with most recent choking herself with shoe laces and call light cord around her neck on [DATE]. R12 has a [DIAGNOSES REDACTED]. R12's Care plan states," In the event that R12 exhibits behavior of thoughts or attempts to harmself, R12 is to placed on one to one, psychiatrist and Medical Doctor to be notified resident will be monitored till discharged to hospital." R12's Care Plan was not revised to include removing plastic bags and shoelaces, supervision checks, and attend group. On [DATE] at 11:45 AM, there were four pairs of shoes with shoelaces underneath R12's bed. On [DATE] at 2:00 PM, there were two garbage cans with trash bags in R12's room. On [DATE] at 3:05 PM, a garbage bag was in R12's bathroom and a garbage bag was near her roommate's bed. On [DATE] at 4:10 PM, E19 (Housekeeping Supervisor) stated,"I took the bags out of her room. I didn't know they weren't supposed to be in there. I will pass that on to my housekeepers." On [DATE] at 2:00 PM, E3 (SSD) stated, "R12 comes to me when she has feelings or issues ....There has been no gap in time where she doesn't come and see me ...I do one to one meetings with R12 as needed ....All staff are aware what should not be in her room garbage bags, shoe laces, and call light ...I don ' t have groups running right now. They stopped in July." On [DATE] at 9:00 AM, R12 said, Groups have not been offered for about 2 months. I think the groups helped me when we had them. On [DATE] at 9:25 AM, E23(Licensed Practical Nurse) said, R12's behaviors are managed well when she is kept busy. Isolation increases her triggers. The Physician order [REDACTED]. Based on observation, interview and record review the surveyor confirmed the facility took the following actions to remove the immediacy: 1. Corrective Action taken for Residents displaying self Harm behaviors: The resident at risk will be assessed for warning signs and triggers. The staff will use the best of their knowledge to remove or prevent any triggers that would cause the resident to decide to harm themselves. This will be done suing the new Suicide Risk Assessment. The facility has five residents who could be considered high risk. These five residents had the Suicide Risk assessment done on [DATE]. 2. Identification of other residents that have potential to be affected by the same deficient conduct: All other residents that have the potential to be affected by the conduct will have quarterly assessments done. These will also be done on an as needed basis. Nursing staff will be in-serviced on how to identify different warning signs and possible triggers. The Director of Nursing, Social Service and administrator will implement this tool effective [DATE]. All residents that were admitted previous to this date will be assessed using this tool within 30 days from this date. 3. Measures taken to prevent deficient conduct from reoccurring: The Suicide Risk assessment will be done upon admission by the social service department. The nursing staff will then use this assessment to determine possible triggers for each resident. These assessments will be assessed weekly by the Director of Nursing and social service representative. The Director of Nursing will also assess any 15 minute check forms every Monday through Friday. At the time of any occurrence the Director of Nursing, administrator and Social Services rep will be notified immediately so that the proper action can be taken beginning [DATE]. 4. Quality Assurance The Social Service representative, Director of Nursing, and administrator will give in-services monthly for the next three months on the suicide risk assessment tool and how to take proper suicide precautions for a resident at risk. At this time an initial in-service will be given at the beginning of every shift before the employees take care of the residents until we hit 100% of staff in-serviced. This training will include review of the policy and procedure for handling self harm behavior, Asta care healthcare center ' s contract for safety and the initiation of the blue triangle to alert staff that the resident is at high risk for suicide. B. Based on observation, interview and record review the facility failed to ensure residents safety by not revising approaches for a resident who had 12 falls in the past 9 months (1 fall resulting in a hip fracture), failed to conduct neurochecks after a resident fell twice and hit his head, failed to lock the treatment cart and failed to keep chemicals in locked storage. This applies to 2 of 3 residents (R5, R17) reviewed for safety in the sample of 19. The Findings Include: 1. R5's [DATE] Physician order [REDACTED]. R5's History and Physical from a previous hospitalization on [DATE] states, R5 has a history of recurrent hip dislocations ...R5 reported that she was trying to get out of bed alone and fell . The Minimum Data Set assessment of [DATE] shows R5 transfers with a two person assist. On [DATE] at 1:20 PM, R5 stood up by herself attempting to transfer from her wheelchair to her bed. R5 held on to her side table and bed for assistance. E10(Licensed Practical Nurse) was at the bedside and did not assist R5 with her transfer. The chair alarm did not alarm. On [DATE] at 9:41 AM, R5 stood up from her wheelchair by herself. The chair alarm did not alarm. On [DATE] at 1:05 PM, E10 (Licensed Practical Nurse) said, R5 transfers with 1 staff assist and has a chair/bed alarm. R5's Care Plan dated through [DATE] shows R5 had a fall that resulted in a hip replacement. It shows staff to assist with all transfers. R5 is not to transfer to/from wheelchair or toilet without staff. R5's Care Plan was last revised on [DATE]. R5 has had 8 falls since then. The bed/chair alarm was not in the Care Plan. The Fall Risk Assessments dated July with no year documented shows R5 has a score 12. A score of 10 or more represents a high risk for falls. 2. On [DATE] at 11:30 AM, one of the two treatment carts on the second floor was unlocked and unsupervised. The treatment cart was located at the end of long hall around the corner from the nurse ' s station. The treatment carts were not in direct view from the nurse ' s station. The treatment cart contained prescription ointments, ointments for skin/perineal care, fingernail clippers, razors, iodine, dressings, gauze, and wound cleansers. On [DATE] at 8:35 AM, E23 (Licensed Practical Nurse-LPN) stated, " (The treatment cart) should be locked at all times except when in use " . An allegation of abuse on [DATE] showed R41 opened the medication cart while E6 was a few feet away helping another resident. The facility ' s policy on Medication Administration (No Date) shows, the medication cart should always be locked unless it is in direct view of the unit nurse. 3. The February 2014 physician's orders [REDACTED]. The Minimum Data Set (MDS) of [DATE] assessed R17 as severely impaired for decision making and needing limited assistance of 1 staff for transferring. R17 was assessed as being unsteady for balance during transfers. R17 required ,[DATE] staff for all ADL's (Activities of Daily Living) except eating. The fall risk assessment completed [DATE] showed R17 was at high risk for falls. R17's nurse's notes document the following: "On [DATE] at 10:15pm, "Resident alert to self. Transferred self to/from wheelchair without supervision is reminded by staff that he should request assist due to safety." "On ,[DATE] at 10:30pm, "Resident alert to self. Self propels wheelchair able to transfer self but needs reminders to request assist for safety." "On ,[DATE] (10:20pm), Resident needs reminders not to get out of bed or up from chair without assist." The care plan initiated [DATE] showed R17 has cognitive/function or Dementia related to impaired thought processes. The falls care plan is dated [DATE] and showed R17 is at risk due to deconditioning. Approaches include: Anticipate the resident's needs. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. The care plan was revised on [DATE] to include: the pad alarm in bed/recliner and while in wheelchair, check functioning with every transfer and ensure it is on and active prior to leaving the room. The nurse's note show R17 had no alarm in place on [DATE] (POA wants the resident to have an alarm like he had in the hospital). The nurse's notes on [DATE] (6:10am) describe , R17 was witnessed by staff transferring from wheel chair to recliner and fell . Resident stated he fell and hit the back of his head on the wall. The nurse's notes at 5:00pm document MD and POA were not notified of the fall that occurred at 6:10am. The "Head Chart" form is used to monitor patients vital signs, pupils, and level of conciousness after head injuries/unwitnessed falls for 72 hours. R17's Head Chart documented the time of the incident was 6:10am on [DATE]. The head chart was incomplete and only done 6 of 21 times in a 72 hour period: at 6:25am, 6:40am, 6:55am, 10:10pm and on ,[DATE] at 6:10am and 2:10pm. E2's name was in the area as completeing the assessment but there was no documentation of vitals shown on ,[DATE] from 6:55am to 2:10pm. There was no documentation of vitals/nerochecks on [DATE] at 2:10pm to [DATE] at 6:10am (72 hour monitoring) Comments on the fall checklist described R17 fell backwards, with just socks on, transferring self to wheelchair. On [DATE] at 10:00am, E2 was asked why R17's head chart form for [DATE] was incomplete. E2 stated, "I honestly don't know why there were gaps in the neurochecks." R17's nurse's note on [DATE] (8:00am), Sat in wheel chair all night, refused to sit in recliner and elevate edematous legs. No alarm present, 30 min checks by staff all night. (9:20pm) Resident in room in wheel chair next to the bed, attempted to stand without locking wheelchair, resident in stocking feet. When resident stood, started to slide, which alerted nurse and CNA, but staff could not get to resident. He slipped and landed on butt next to bed. Assisted off floor per 2 and into recliner. Post-Fall investigation report dated [DATE] showed alarm was not attached to the resident. The nurse's note for R17 on [DATE] (3rd shift) showed, Vital signs taken. Alert with confusion. Up in recliner at times during the night, complained of headache. PRN Tylenol given. R17 blew nose and large amount of blood was in tissue. Alarm in place. Will monitor. (1st shift)- Resident alert but to self only, refused dialysis said, "I'm not feeling well." Gave Tylenol for headache and Ativan but resident still refused dialysis. Dialysis informed nurse that stat labs to be drawn for Hemoglobin. Results back and Hemoglobin 5.6. Received orders to send resident to ER for eval and treatment with transfusion. Resident returned from hospital on [DATE]. The Physical Therapy note dated [DATE] showed R17 is a fall risk occasional impulsive as to transfers, decreased safety awareness, required cues for redirection and safety. Ambulation: Unable to perform at this time due to decreased endurance, strength and activity tolerance. R17's nurse's note [DATE] (12:20am) Client heard falling on to the floor, alarm did not sound. Client on back and wheel chair had fallen on the side. Bed/chair alarm was on resident's chair. CNA last seen resident in his chair at midnight with alarm attached. To ER as resident stated he hit the back of his head. 1:05am left for ER. Late entry on [DATE] at 5:00am documented R17's vital signs were taken but no other assessment was done. Reason for fall, R17 was getting up to get his cell phone. CNA and nurse assisted resident to his bed to await ambulance. The incident report of the same date documented R17 had a bump on the back of his head the size of a fifty cent piece. The chair alarm did not sound on ,[DATE] to alert staff before R17 fell and sustained a subdural hematoma. There was no initial neurocheck sheet completed after R17 complained of hitting his head. On [DATE] at 10am E2 said (on [DATE]) R17 fell and was sent out and suffered a hematoma. The previous Director of Nursing was the nurse in charge covering a call off when it happened. (The procedure when someone falls) an incident report is done, resident is reassessed and vitals are taken for 72 hours, neurochecks are done and the fall investigation tool is filled out by the CNA and nurse for proper interventions. R17's History & Physical of [DATE] showed, "CT scan of the head was done which showed some old and possible subdural hemorrhage." R17 was admitted to the Intensive Care Unit (ICU). The Coroner's Report dated [DATE] described the details of the incident, On [DATE] at 12:36am the ambulance company received a call from the nursing home stating that R17 had fallen. At 12:52am the ambulance arrive at the nursing home and found R17 sitting in a chair in his room with a bump to the back of his head. He seemed confused and the nurse stated that this was normal and also he falls alot. R17 was able to stand and get on their cot. At the ER, R17 was given a CT scan of the head which showed a subdural hematoma. He was admitted to ICU. More CT's of the head were done and showed his subdural hematoma had worsened. His mental status did not change after a few days and he was seen by the palliative care team. On [DATE] the family opted to send R17 to another facility. He remained on comfort care and his condition did not improve. R17 expired on [DATE] at 12:50am. The cause of death was Subdural Hemorrhage, secondary to a Fall. 4. On ,[DATE], ,[DATE], and [DATE] the soiled utility room on the 2nd floor was unlocked. The door's lock mechanism was covered over by masking tape. The room contained bulk cleaning supply containers such as disinfectant, toilet bowl cleaner and floor cleaner. The containers posted warning labels, "Harmful if Swallowed", "May Cause Eye Irritation" and "Keep Out Of Reach Of Children." On [DATE] (Housekeeping Supervisor) said the lock was broken

Based on observation, interview, and record review, the facility failed to maintain residents nutritional status by not identifying causes for a 20 pound weight loss in one month for a resident who receives all their nutrition through a feeding tube. This failure resulted in R7 experiencing a 20 pound weight loss in one month and developing an open wound while being solely tube fed. This applies to 1 of 2 residents (R7) reviewed for tube feeding in the sample of 19. The findings include: On 9/15/14 at 11:20 AM, R7 had Fibersource HN 1.2 tube feeding being administered at 50ml (milliliters) per hour with a pump. R7's MDS dated [DATE] showed that she is totally dependent on staff for activities of daily living and that she is at risk for pressure ulcers. On 5/22/14, R7's Braden scale-for predicting pressure sore risk was 7 (severe risk). R7's care plan for tube feeding initiated on 6/4/14 shows an intervention of: RD (registered dietitian) to evaluate quarterly and as needed (PRN). Monitor caloric intake, and estimate needs. Make recommendations for changes to tube feeding as needed. The facility's undated tube-feeding policy states, " The dietician will complete a comprehensive nutritional assessment determining the appropriateness of the tube feeding order. The dietitian may make a recommendation to the physician to consider changing the tube-feeding if indicated. The dietitian will reassess the tube-fed resident's needs on a monthly basis. The facility's undated nutritional assessment policy states, " A comprehensive nutritional assessment is completed by the appropriate health professional within 14 days of admission. This includes information on the resident's nutrition status and requirements. Nutrition needs are reassessed quarterly and annually unless there is a change of condition which pertains to the resident's nutritional status. R7's admission physician's orders [REDACTED]. R7's complete metabolic panel done on 6/4/14 shows a glucose of 152mg/dL (normal 70-102) and an [MEDICATION NAME] (blood protein) of 2.8 g/dL (normal 3.4-5.0). R7's July weight that was documented on the facility's weights list report was 165 lbs. R7's August weight that was documented on the facility's monthly weights and vitals 2014 form was 145 lbs. R7 had a 20 pound weight loss in 1 month. R7's resident admission nursing assessment dated [DATE] showed R7 had no pressure ulcers. The facility's wound spreadsheet dated 7/29/14 showed a facility acquired wound to the right buttock measuring 2.6 cm x 2.6 cm x .1 cm open wound with 50% granulation tissue and light serous drainage. R7's medical records were reviewed and no dietitian notes were found. On 9/16/14 at 8:50 AM, E2 (director of nursing-DON) stated, " There has not been a registered dietitian here since February."

Based on Interview and Record Review the facility failed to provide necessary services for R89's current condition by not assessing and monitoring the skin to his left buttock. This failure resulted in R89 having a painful abscess to his left buttock with purulent drainage that was identified by the physician on 12/10/13. This is for 1 of 1 residents (R89) reviewed for an abscess in the sample of nineteen. The findings include: On 12/10/13 at 11:19am, Z3 (Physician) walked out of R89's room and stated to E8 (Licensed Practical Nurse - LPN), "R89 has a wound and I need you to culture it." E8 stated, "When? I don't know about any wound." Z3 stated, "Now, R89 still has his pants down." On 12/10/13 at 11:21am, R89 was sitting on his bed with an incontinence brief and sweatpants pulled down in the back. R89 had a long scar from the left side of his lower back down into his buttock. The scar had deep grooves to the buttock area with some yellow-white drainage between the grooves of the scar on his buttock. R89 stated his buttock was painful. R89 stated, "I have had this for 1 week and it is painful. It is an abscess and I have had it before because of my surgery. The nurses haven't looked at it." E8 cultured the drainage from R89's left buttock. E8 stated, "This is something new. No one reported it to me. R89 hasn't been to the hospital in a long time." The Physician order [REDACTED]." On 12/11/13 at 8:37am, E1 (Director of Nursing - DON) stated, "E8 (Licensed Practical Nurse - LPN) did not tell me about R89's wound. I did not know Z3 (Physician) saw the wound. I did a skin in-service awhile ago. There is a new form they are to use for any reddened or open area regardless of where it is, it needs to be initiated. It doesn't matter if it is pressure or some other type of wound. The form goes to E5 (Registered Nurse/Wound Nurse). E5 then does a skin risk assessment and assesses the wound. Nurses will check interventions in place, make changes if necessary and put it in the care plan." E1 reviewed the Skin Risk assessment dated for R89 and it showed a score of 17 (low risk skin assessment). E1 stated the number for sensory perception should be 2, mobility should be a 2, friction and shearing should be a 1; the other numbers documented by the facility she agreed with the original score of 2 for moisture, 2 for activity and 3 for nutrition. When the numbers are added up the total score is 12 and a score of 12 or less is a high risk score. The Wound Documentation for R89 showed, "Date identified: 12/9/13 - Abscess; Location - Buttock; 12/10/13 - Three pinpoint areas on buttock; Drainage - moderate, purulent; Wound related pain - No." The Wound Documentation for R89 dated 12/9/13 did not show if the wound was on his right or left buttock and the body diagram did not show where the open areas were located. The Wound Care Specialist's Initial Evaluation for R89 showed, "12/10/13 - discussed with Z3 (Primary Care Physician). R89's buttock region has multiple areas of scar tissue. R89 appears to have had multiple surgeries/procedures to this region. R89 is unsure why and it is not clear on his chart. Today there are 3 pinpoint areas that are draining purulent drainage. Z3 ordered an x-ray of the sacrum, a culture, complete blood count and started him on [MEDICATION NAME]. I agree with the current plan. Await tests and monitor closely. If there is no improvement with antibiotics, R89 may need surgical intervention." On 12/11/13 at 10:05am, E1 (Director of Nursing - DON) stated, "The wound documentation for R89 that E5 (Registered Nurse/Wound Nurse) gave me said they knew about the wound on 12/9/13 but that she did not see it until 12/10/13. It is an abscess. I asked E5 about the inconsistent documentation on for the date identified because there isn't any documentation to show that it was identified on 12/9/13. E5 said she looked at R89's wound with the wound doctor and there are 3 small open areas inside the crack in the scar on his buttock." The Minimum Data Set (MDS) with an Assessment Reference Date of 10/3/13 for R89 showed extensive assistance needed for bed mobility, transfers, dressing, toilet use, and bathing; Brief Interview of Mental Status (BIMS) score of 15 - cognitively intact. The Physician order [REDACTED].

Based on observation, interview, and record review the facility failed to provide pressure redistribution for residents with pressure sores and failed to prevent infection to a pressure sore. These failures contributed to a delay in healing. This is for 2 of 3 residents (R14 & R37) reviewed for pressure sores in the sample of 19. The findings include: 1. The facility's 12/3/13 Pressure Wound Log shows that R37 has a stage 4 sacrum/coccyx pressure sore that was acquired in the facility on 8/27/13. R37's Wound Care Specialist Evaluation Notes show on 10/8/13 the wound size was 3.0 X 2.8 X 1.5 centimeters (cm) with 2.3 cm of undermining at the 6 o'clock position. The wound had 30 % thick devitalized necrotic tissue and 40 % slough. R37's wound was improving and had increased granulation tissue. On 11/12/13 R37's wound was 3.5 X 3.5 X 2.5 cm with 5.0 cm of undermining at the 6 o'clock position. A 2.0 X 0.5 cm area of detached bone was removed from the middle of the wound and was sent for culture and biopsy to rule out osteo[DIAGNOSES REDACTED] (infection of the bone). R37's wound progress was not improved. On 12/10/13 R37's wound was 4.0 X 4.0 X 3.0 cm with 4.0 cm of undermining at the 1 o'clock position. R37's wound progress was stable- showing neither improvement nor decline. R37's 11/15/13 laboratory final report shows acute osteo[DIAGNOSES REDACTED] of the bone. R37's December 2013 Physician order [REDACTED]. Apply anti fungal ointment to skin around the wound and cover with a dressing. R37 is receiving IV antibiotics every 8 hours ([MEDICATION NAME] 2.25 grams IV). On 12/9/13 at 3:00 PM, R37 was reclining flat on her back in the [MEDICAL TREATMENT] chair. On 12/10/13 at 9:00 AM, R37 was in the bed flat on her back. R37's reclining wheelchair had an inflatable plastic waffle cushion approximately 1 inch thick. On 12/10/13 at 11:30 AM, E4 (Certified Nursing Assistant) said the plastic waffle cushion was all R37 had for her wheelchair. "She (R37) asked me to put a pillow on top of it because it was so hard to sit on." On 12/10/13 at 11:35 AM, Z1 (Wound Care Specialist Physician) said R37 needs a better seat cushion. The current cushion provides no pressure reduction. Pressure reduction is needed for a wound to heal. R37's 12/3/13 Pressure Ulcer care plan states, "Follow facility policies/protocols for the prevention/treatment of [REDACTED]." The facility's 7/2006 Pressure Ulcer Treatment Protocols policy states, "Foam or gel cushions on chair when up out of bed. If unable to reposition self in bed or chair, staff to reposition every 2 hours, minimally." 2. The facility's 12/3/13 Pressure Wound Log shows that R14 has a stage 4 pressure sore to the right heel that was acquired in the facility on 8/23/13. R14's December 2013 Physician order [REDACTED]. Apply [MEDICATION NAME] and Santyl ointment with wet to moist gauze to the right heel and wrap with gauze daily. On 12/9/13 at 12:25 PM, R14 was in the dining room, seated in a wheelchair with both feet on the wheelchair foot rests. R14 had a gauze dressing on her right heel and no waffle boots. R14 stated, "It (the waffle boot) was tight around the toe so they (CNA's) took it off earlier today. They (CNA's) didn't put it back on. I only have one boot in my room because I only have one sore." On 12/10/13 at 10:30 AM, Z1 (Wound Care Specialist Physician) said R14's right heel wound is a pressure sore that is complicated by her Diabetes. Off loading pressure to the wound is needed for healing. R14's Wound Care Specialist Evaluation Notes show on 12/10/13 the right heel measured 3.7 X 5.3 X not measurable cm. There was no redness around the wound however the wound edges were macerated (white and moist). R14's care plan (initiated on 8/23/13 and revised on 12/10/13) states, "the resident has a diabetic ulcer of the right heel related to Diabetes." Interventions include- "Determine and treat the cause: pressure area, infection. Ensure appropriate protective devices are applied to affected areas."

Based on observation, interview and record review, the facility failed to provide staffing to meet the transfer, toileting and personal cares including shaving, nail cleaning, and showers, to residents in a timely manner. This failure resulted in R8 obtaining a laceration to his left leg. The wound resulted in profuse bleeding and 10 sutures being placed at the local Emergency Department. This applies to 7of 13 residents (R4, R5, R8, R9, R11, R12 & R13) reviewed for care provision. The findings include: R8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R8's Minimum Data Set (MDS) of 8/11/13 shows he has a Brief Interview for Mental Status (BIMS) score of 13 which shows no cognitive impairment. The MDS also shows R8 is totally dependent on 2 person physical assist for transfers and 2 person extensive assistance for repositioning. The MDS section for balance shows R8 is "only able to stabilize with staff assistance" for moving on and off the toilet. The MDS section for Range of Motion (ROM) codes R8 as a 2 for lower extremity mobility which documents an "impairment on both sides". The skin treatment section of the MDS showed R8 requires a turning and repositioning program. R8's care plan dated 7/1/13 under discharge care plan, documents "he requires assistance with all ADL's (activities of daily living) and is unable to propel himself in his wheelchair." The ADL care plan identified R8 requires the assist of 2 CNAs for toileting and use of a mechanical lift transfers. On 10/17/13 at 11:00 AM, R8 was brought to the conference room by a Certified Nursing Assistance in a bariatric manual wheel chair with bilateral foot/leg rests in the upper (extended) position. R8's legs were not positioned on the rests but were hanging loosely between the foot/leg rests. A mechanical lift transfer sling was under R8 in the chair. R8 stated this was not his wheelchair. R8 said he personally owns an electric wheelchair but the facility "apparently needs to evaluate me" to make sure I "need" an electric wheelchair. R8 said "I can't get around in this one. Someone has to take me everywhere." R8 appeared to have limited arm movement but did attempt to move his right leg by tugging at the top of his pant leg with his right hand to move the lower extremity to the right as if to put it on the leg rest. The right leg slid back to the central position. R8 had only socks to his feet. Both legs between the end of the pant leg and the top of the sock were dark purple in color with [MEDICAL CONDITION] noted. R8 stated he had not had restorative therapy in weeks because the facility was short of staff. R8 said when a CNA call's off, the CNA's from restorative are pulled to work the floor. R8 said the facility is so short of staff that the staff "take short cuts" and hurry to get things accomplished. R8 stated one example of a "short cut" was when he received a "gash" on his lower leg because the aides didn't remove the leg rests from the chair "before transferring me. I am on [MEDICATION NAME] (clot prevention agent) so they couldn't get it to stop bleeding." R8 stated the ambulance was called and he required 10 sutures to the wound in the emergency department and subsequent daily treatments/wound care. R8's medical records/incident reports show R8 did sustain a laceration on 10/5/13 which required treatment/sutures at the local emergency room after his leg came into contact with the leg rest of a wheelchair during a mechanical lift transfer. The POS dated 10/13 showed R8 was ordered [MEDICATION NAME] 4.5 mg and [MEDICATION NAME] 5 mg daily in alternating doses. The 10/15/13 lab report showed R8's PT ([MEDICATION NAME] Time) as 25.1 (normal range is 9.5-13) and an INR (International Normalized Ratio) was 2.3 (normal range is 0.8 - 1.1). These results show R8 is at a higher risk for bleeding concerns. R8 has no care plan to identify his potential for injury or bleeding risks. During the 10/17/13 interview with R8, he also stated that he has had to sit in a soiled incontinent brief for an hour because there was not enough staff members working to assist him. R8 stated because he is transferred by use of a mechanical lift, 2 staff members are required to be present to transfer him. R8 stated when a CNA calls off and is not replaced, it leaves one CNA on the wing and that CNA must wait for someone else to become free from another assigned area before a mechanical transfer can be completed. R8 said the staff shortages result in extended wait times for toilet use, getting up for meals, laying down, going to the bathroom, and just a general "rush" to get cares completed. R8 could not give dates or times when he remained in his soiled garments. R8's MDS of 8/11/13 identified R8 as being continent of bowel with occasional bladder incontinence episodes. The care plan dated 8/20/13 with a revision of 10/17/13 documents R8 is to be given peri care after each incontinent episode by the CNA's. On 10/17/13 at 10:00 AM, E2 (Director of Nursing) said she is in charge of the CNA scheduling. E2 said she schedules 2 nurses and 4 CNA's for the first and second shifts for each of the two floors and 1 nurse and 2 CNA's for each of the floors on the night shift. E2 said if someone calls off, in an effort to prevent overtime situations, she will pull one or both of the restorative CNA's to the floor to assist. E2 stated the facility has a CNA that works in the billing department she will pull if necessary. When asked at what point would replacements be called in to cover for the CNA's, E2 stated "if the numbers drop to 2 CNA's per floor on the day or evening shift, that; would not be allowed, so at that time someone would be called in." E2 verified if their were 3 per floor on the day and/or evening shift (1 below facility scheduling for each floor) the staff would work with those numbers without replacements. Schedules were reviewed for 10/1/13 through 10/16/13. On 10/5/13, when R8 received his leg laceration, the incident report showed a nurse was assisting a CNA with his transfer. The 10/5/13 schedule showed the restorative CNA was pulled to the floor to cover duties, however, even with her assistance, the staffing fell below the facility's 4 CNA's per floor. On 10 of the 16 days reviewed, CNA's had been pulled from restorative and/or billing duties to cover the floor requirements. On 8 of the 16 days, the schedule showed no restorative CNA's. With use of the restorative and billing CNA's, the facility had 8 of 16 days where the CNA's still numbered 3 or below on one or both floors of the facility. On 10/17/13 at 10:45 AM, R9 was asked about her cares. R9 stated she has had to sleep in soiled pants until someone could come. R9 said she is transferred by a mechanical lift and "2 staff have to do that". R9 said she has had bowel movements in her pants waiting for enough staff to complete the transfer. On 10/16/13 at 11:40 AM and 12:00 PM, R5 and R4 were interviewed respectively. Both stated the facility is always short CNAs and cares are late or not given. Both residents stated when a CNA call's off, no one else is called in to replace them. R5 stated "today" (10/16/13) "I just got tired of waiting so I had to dress myself without help." R4 stated "my roommate (R8) has had to lay in his own feces." On 10/17/13 between 10:00 AM and 10:45 AM, E14, E16, E17 and E18 (CNA's) were interviewed. The following comments were made: "We work short a lot"; "Turns get missed"; "People wait longer than they should to get cares"; "We tell the residents they will have to wait and we will get back to them and it is 20 minutes or longer and they get upset"; "There is a delay in toileting, transfers of residents who require use of a (mechanical lift)"; "(R9) has wet and soiled herself waiting"; "(R13) left yesterday but he was always mad and yelling because he wasn't getting his turns"; "There is no time for extras like shaves, showers, cleaning nails, bedmaking, etc."; "When they pull the restorative CNA's we only have them for a limited time because they have work to do too"; "Passing water by 11:00 AM and obtaining vital signs for the nurse by 10:00 AM don't get done because we are assisting residents"; "If we don't get to the resident's on time they will try to do things themselves and then fall and we have a bigger mess" (R11 & R12 given as examples that will try to do tasks on their own and fall.)

Based on observation, record review, and interview, the facility failed to protect residents (R5, R4, R16) from verbal and physical abuse by a resident with a known history of physical and verbal aggression. The facility failed to have behavioral interventions in place to protect other residents. This failure resulted in 3 residents (R5, R4, R16) being physically abused by R1. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy situation was identified on 9/24/13. The Immediate Jeopardy began on 8/17/13 when R1 began displaying verbal and physical aggression toward other residents. The Immediacy was removed on 9/24/13 at 9:30 PM when R1 was removed from the facility. The facility remains out of compliance at a severity level 2 due to the need to assess all residents for their potential for abuse, review and revise care plans with behavioral interventions, and evaluate the implementation of their policy and procedure for agressive behavior. This applies to 4 of 17 residents reviewed for abuse. (R1, R5, R4, R16) in the sample of 17. The findings include: 1. R1's Face Sheet shows that R1 was admitted to the facility on [DATE]. R1's September, 2013 physician's orders [REDACTED]. R1's Minimum Data Set (MDS) assessment of 8/25/13 shows that R1 has a Serious Mental Illness and other related conditions. R1 has moderate cognitive impairment. The same assessment shows that R1 has had no behavioral symptoms. R1 requires only supervision in most of his Activities of Daily Living. R1 is 6 feet tall and weighs 156 pounds. R1's Abuse Risk Indicator assessment dated [DATE] documents a score of 2 (0-2 = low) for possible abuse. R1 is scored as 1 (0-2 = low) for risk for possible aggressive behaviors. A hospital Social Work Consult dated 6/20/13 documents that R1 has a history of aggressive behavior and [MEDICAL CONDITION]. R1's aggressive behavior was physical and verbal. The report shows that R1 hit his room mate three times. The same report showed that R1 had a history of [REDACTED]. R1's [DIAGNOSES REDACTED]. It is documented that Z4 reported R1 was threatening to kill other residents. (previous facility) R1 has had approximately 15 Psychiatric hospitalization s, and multiple facility placements in which R1 threatened or physically assaulted other residents. The hospital History and Physical for 6/22/13 documents that R1 has past [DIAGNOSES REDACTED]. R1 had [AGE] years of living for the most part in institutions or group homes. The previous facility said that R1 can not return, he has no where to go. He is a potential danger to himself and others and will be admitted involuntary to the Psychiatric ward. He will need long term hospitalization or a residential facility. R1's (nursing notes) showed that from 8/16/2013 until 9/24/13, R1 refused medication 13 days. R1's Nursing Notes document numerous verbal and physical aggressive behaviors beginning one day after his admission to the facility. (8/17/13) On 8/17/13 R1 cursed and screamed at a male resident in the shower room. R1 got into a second altercation with a different resident when that resident got to close to R1 and touched his leg. R1 said " Look [***] , I will kick your Ass. What the F..k are you doing touching me. Keep your f..cking hands to yourself. I'm going to kick your f..cking ass [***] ." Other residents were yelling, "Don't you touch that man, don't hit him, nurse, nurse help him." 8/23/13 R1 continues to have behaviors of cursing and being verbally aggressive to other residents. 8/25/13 R1 struck another resident in the head. because he was sitting in his chair. 8/26/13 Verbal altercation with another resident. R1 very agitated after the resident (R17) pulled up her clothes exposing her body to R1. 8/27/13 R1 constantly cursing, difficult to redirect when "mad." 8/30/13 Cursed at staff because there was no chocolate milk. 9/4/13 R1 was yelling and cursing staff unable to understand what he was saying. 9/5/13 Yelling and cursing at another resident. (two occurrences) 9/11/13 R1 is verbally abusive to staff and constantly angry and swearing. 9/13/13 R1 verbally abusive to another resident at lunch. 9/12/13 R1 very hostile, wants to go to the hospital. R1 says he will call 911. R1 was transferred to the hospital, and returned the same day. 9/16/13 If anyone made eye contact with R1 he would start yelling and cursing as if to start a fight. 9/16/13 3:00 PM, R1 had an altercation with another resident called her a [***] and said to get out of his chair. R1 sat down next to her and kept yelling and the other resident slapped R1 in the face. R1 then struck that resident in the back of the head. R1 has been walking around all day cursing at everyone he sees. 9/17/13 while on the first floor R1 hit another resident. R1 struck the resident on the face and head. (12:45 AM) 9/17/13 Nursing Note shows "Per E1 (Administrator) resident (R1) is to return to the second floor to his room. He spent the night downstairs the nurse from downstairs said that R1 was very agitated downstairs" 9/18/13 R1 began yelling "F.ck You" to the staff. 9/18/13 7:00 AM, R1 yelling and screaming "F..ck this, F..ck that." R1 started toward another resident swinging, very hard to redirect. 9/20/13 5:45 AM CNA entered R1's room to get room mate ready for [MEDICAL TREATMENT]. R1 got up out of bed and said to the CNA "What are you doing in here [***] ?" 2:00 PM R1 walking throughout the facility swearing at staff and other residents. 2:30 PM R1 sat at dining room table and called the other resident at the table a "[***] ", R1 was threatening the other resident. When staff told R1 to stop he said "F..ck You." R1's Care Plan dated through 12/3/13 documents that R1 has a behavior problem. Resident swears and strikes out at other residents. The goal is that R1 will have no evidence of behavior problems. The approaches include: administer his medications as ordered. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention, remove from the situation. On 9/24/13 at 9:30 AM, E6 (Psycho/Social) said that R1 initiates aggression toward others. He (R1) thinks people are talking about him. He hit R16, he said she was in his chair. R1 was arguing with R4 (second floor) so they sent him (R1) to first floor and put him in the room with R5 and R1 hit him. E6 said that they just try. On 9/24/13 at 2:00 PM, E3 (Registered Nurse) said on the day that R4 egged on R1, they brought R1 to the first floor and put him in in the room with R5. R1 can be helpful, but "when he flips, he flips." On 9/24/13 at 5:45 PM, R1 was observed pacing rapidly back and forth in the dining room during the dinner meal. R1 was talking to himself, and going up to residents and standing by them.( very close) R1 pulled the phone out of the hand of another resident (R4) while she was talking to someone. E10 Certified Nursing Assistant was assigned to do 1:1 with R1. E10 could only follow R1 around, he did not respond to her verbal redirection. 2. R5's [DIAGNOSES REDACTED]. The resident startles easy and has intermittent periods of lethargy. The MDS notes R5 requires supervision with transfers, ambulation, dressing, hygiene and bathing. He ambulates using a walker. R5's careplan of 4/2/2013 shows the resident has impaired individual coping related to Depression and Paranoia. On 9/17/2013, Nursing Notes document at 12:45 AM, R5 was in his bed. R1, who had been placed in his room, began yelling at R5 and started to repeatedly strike R5 on his face and head. Nursing notes state R1 was very vulgar and combative. On 9/24/2013 at 11:30 AM, R5 said, "I was trying to sleep. They moved (R1) from the 2nd floor to my room. I wasn't paying any attention, I thought it was strange they moved him in the middle of the night. He (R1) came over on my side of the curtain screaming, hollering, and hammered me on the head. I had no idea why he was so mad. I hadn't even spoken to him. I don't know know why he would be violent against me. I hollered for help, he was hammering on me. I couldn't do anything, I couldn't move, I just hollered and the aide came in to help me. They put him in my room because he was fighting upstairs. He is extremely violent. I still have a headache. He (R1) pounded my head with his fists. They knew he was violent before they brought him down (to my room). I don't want those violent people in my room in the middle of the night. He has trouble with more than one person." 3. R4 was admitted to the facility on [DATE], according to her Face Sheet. A 10/26/2013 Subpart S Screening Form documents R4's [DIAGNOSES REDACTED]. An Abuse and Aggressive Behavior Screening of 8/9/2013 showed R4 is at medium risk for possible abuse and is at high risk for aggressive behavior. On 9/24/2013 at 9:30 AM, E6 (Psychosocial Director) said on 9/17/2013, R4 and R1 were arguing and fighting. R1 slapped R4 in the head during the argument. 4. R16's September, 2013 physician's orders [REDACTED]. R16's Face Sheet documents R16 was admitted on [DATE]. R16's MDS Assessment of 8/7/13 documents that R16 has moderate cognitive impairment. R16 has behavior that includes verbal abuse directed at others. R16 requires extensive assistance of 2 or more persons for transfer. R16 does not ambulate and uses a wheel chair for mobility. A Psychiatric Progress Note of 8/13/13 documents that R16 has [MEDICAL CONDITION]. The same report shows that R16 has been aggressive toward staff. R16's Behavior Care Plan dated through 11/20/13 shows that R16 has potential to be physically aggressive by scratching and hitting others. R16 has poor impulse control and a history of harm to others. The goal is that R16 will have less than two episodes of aggressive behavior per day through the next review. R16's care plan for Verbal Abuse dated through 11/20/13 documents the goal for R16 is she will verbalize understanding of need to control verbally abusive behavior through the next review. The approaches include when R16 becomes agitated intervene before agitation escalates. The Incident Report dated 9/16/13 shows that R1 was involved in a verbal and physical altercation with R16. R1 kept yelling at R16 and she "made contact" with R1 and he "made contact back." R16 reported that R1 hit her in the head. According to the Abuse Prevention Program Policy: Physical Abuse is defined as hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The same policy shows that residents who allegedly mistreat another resident will removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as, the safety of other residents and employees of the facility. E1 Adminstrator was informed of the Immediate Jeopardy on 9/24/13 at 5:07 PM related to the facility failure to protect other residents from verbal and physical aggression. Through interview and record review the surveyor confirmed that the facility took the following steps to remove the immediacy of the situation: 1. R1 was removed from the facility on 9/24/13 at 9:30 PM. 2. All mentally ill residents will be reviewed for potential of physical aggressive/explosive behaviors and the care plans will be revised. Completion date of 9/30/13. 3. Actions to be taken when dealing with a physical aggressive and/or explosive behavior resident: Inservicing completion on 9/30/13. a. Stay Calm. b. Move the resident into a private room away from other residents. c. Use a team approach by getting staff to help. d. Have a one to one with the residents. e. Call the psychiatrist and have the patient seen with in 24 hours. f. Call the Administrator, Director of Nursing, Doctor and family. g. Call the police if you feel your safety is in danger. 4. All staff will be inserviced prior to working the floor on proper policy and procedures in handling residents that display physical aggressive and/ or explosive behavior.Inservicing of staff will be completed by 9/30/13.

Based on observation, record review, and interview, the facility neglected to follow thier policies related to Admission, Violence Prevention, and the Management of Aggressive and Combative Behaviors. These failures resulted in R1 physically assaulting three residents. (R5, R4, R16 ) R1 exhibited verbal and physical aggression toward others from 8/16/13 until 9/24/13. As a result of these failures an Immediate Jeopardy was identified on 9/24/13. The Immediate Jeopardy began on 8/17/13 when R1 began displaying verbal and physical aggression toward other residents. The immediacy was removed on 9/24/13 at 9:30PM when R1 was removed from the building. The facility remains out of compliance at a severity level 2 due to the need to assess all residents for their potential for abuse, review and revise care plans with behavioral interventions, and evaluate the implementation of their policy and procedure for aggressive behavior. These failures apply to 3 residents who were physically assaulted by R1 (R5, R4, R16) in the sample of 17. The findings include: The facility admission policy documents that applicants whose primary need is nursing care, but who also have a [DIAGNOSES REDACTED]. Residents with serious mental illness will be screened for aggression, self harm, substance abuse, refusal of treatment/medications and prior criminal history. No resident who is destructive of property, himself, or others shall be admitted to or kept within the facility. 1. R1's September, 2013 physician's orders [REDACTED]. Pre- admission, hospital records for R1, entitled Social Work Consult of 6/20/13, shows that that R1 has a history of aggressive behavior and [MEDICAL CONDITION]. R1 had struck his room mate 3 times. R1 has physical and verbal aggression, and refuses his medications. The same report shows that R1 made threats to kill other residents at his previous facility. R1 has history shows approximately 15 Psychiatric hospitalization s. R1 had been in multiple facilities, in which he threatened and physically assaulted other residents. The facility Risk Indicator Assessment for R1 dated 8/23/13, documents a score of 2 (0-2 = low) for possible abuse. R1 is scored as 1 (0-2 = low) for risk for possible aggressive behaviors. R1's (nursing notes) showed that from 8/16/2013 until 9/24/13, R1 refused medication 13 days, and displayed repetitive display of verbal and physical abuse toward other residents. .8/25/13 R1 struck another resident in the head. because he was sitting in his chair. On 9/16/13 R1 struck R16. R1 kept yelling at R16 and R16 slapped R1. R1 then slapped R16. 9/17/13 R1 was on the first floor and hit another resident. R1 struck R5 on the face and head. (12:45 AM) R5 said on 9/24/13 at 11:30 AM that he was trying to sleep and they moved a man (R1) into his room in the middle of the night. R5 said that R1 came on his side of the curtain and was screaming, hollering, and hammering me on the head. I had no idea he was so mad. I didn't even speak to him. I had nothing to do with him, I was minding my own business. I don't know why he was violent against me. I hollered for help, I couldn't do anything, I couldn't move. R5 said that R1 was "off balance." R5 said it seems that recently residents are annoyed all the time, getting mad, cussing, and hateful. R1 got to me because he was fighting upstairs and they moved him downstairs with me. I still have a headache. R1 pounded my head with his fists. They knew he was violent before they put him in with me. I don't want any more of those violent people in my room. I know that R1 has trouble with more than one person. On 9/24/13 at 9:30 AM, E6 (Psych/Social) said R1 initiates aggression toward others. He (R1) thinks people are talking about him. He hit R16, he said she was in his chair. R1 was arguing with R4 (second floor) so they sent him (R1) to first floor and put him in the room with R5 and R1 hit him. E6 said that they just try to intervene with R1's behaviors as needed. On 9/24/13 at 2:00 PM, E3 (RN) said on the day that R4 egged on R1, they brought R1 to the first floor and put him in the room with R5. R1 can be helpful, but "when he flips, he flips." E3 said she had no training in how to deal with residents exhibiting physical and verbal aggression. The facility Violence Prevention Policy shows that the Administrator is responsible for the implementation of the violence prevention program. The same policy shows that residents with potential to become physically aggressive during care shall have an interdisciplinary care plan to address consistent approaches to these behaviors. Caregivers will be trained to minimize potentially violent behaviors. On 9/25/13 at 1:30 PM, E1 (Administrator) said " At the end of the day I'm the final say on who will be admitted to the facility. I turn down residents with tracheostomies, ventilators, bad behaviors, too young, no payor source, bad wounds, and if there is not official criteria for long term care." R1's Care Plan dated through 12/3/13 documents that R1 has a behavior problem. Resident swears and strikes out at other residents. The goal is that R1 will have no evidence of behavior problems. The approaches include: administer his medications as ordered. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention, remove from the situation. The facility policy on Resident Aggression shows that following procedure will be implemented during aggressive behavior: Staff will remove other residents from the immediate area. Staff will attempt to redirect the resident. If resident is resistant to redirection from one staff member they will step back and let another staff member attempt to redirect. A staff member will notify the resident's nurse of the situation. If the resident cannot be controlled, his/her MD will be notified and an order requested to sent out of the facility for an evaluation. The same policy shows that combative residents will have a thorough assessment beginning with a review of the patient's medical, social, and work history, and a search for behavior patterns that may be present. E6 said on 9/24/13 at 9:30 AM that he thought the staff had an hour of training. E6 said the training was done by E12. (PRSC) Psychiatric Rehabilitative Services Coordinator. Inservice Training Materials were reviewed and showed that acting out is defined as: The total loss of rational control that results in a physically acting out episode. Examples include presenting a danger to self or others by hitting, kicking, throwing objects. The intervention is a safe, non- harmful restraint position to control the individual until he can regain control of his own behavior. On 9/24/13 at 5:45 PM, R1 was observed pacing rapidly back and forth in the dining room during the dinner meal. R1 was talking to himself, and going up to residents and standing by them.( very close) R1 pulled the phone out of the hand of another resident (R4) while she was talking to someone. E10 Certified Nursing Assistant was assigned to do 1:1 with R1. E10 could only follow R1 around as he walked, he did not respond to her verbal redirection. Multiple staff were in the dining room at the time of the occurrence and were watching R1's behaviors without intervening. A confidential interview on 9/24/13 at 3:00 PM it was said that a 30 minute training was provided. We don't always know about the residents behaviors until they get her. We do the best we can. E1 Administrator was informed of the Immediate Jeopardy on 9/24/13 at 5:07 PM related to the facility failure to protect other residents from R1's verbal and physical aggression. Through interview and record review the surveyor confirmed that the facility took the following steps to remove the immediacy of the situation: 1. R1 was removed from the facility on 9/24/13 at 9:30 PM. 2. All mentally ill residents will be reviewed for potential of physical aggressive/explosive behaviors and the care plans will be revised. Completion date of 9/30/13. 3. Actions to be taken when dealing with a physical aggressive and/or explosive behavior resident: Inservicing completion on 9/30/13. a. Stay Calm. b. Move the resident into a private room away from other residents. c. Use a team approach by getting staff to help. d. Have a one to one with the residents. e. Call the psychiatrist and have the patient seen with in 24 hours. f. Call the Administrator, Director of Nursing, Doctor and family. g. Call the police if you feel your safety is in danger. 4. All staff will be inserviced prior to working the floor on proper policy and procedures in handling residents that display physical aggressive and/ or explosive behavior. Completion 9/30/13.

A. Based on observation, record review, and interview the facility failed to supervise a resident with known physical and verbal agression directed toward others. Between 8/16/13 and 9/24/13 R1 physically assaulted three residents (R4, R5, R16). The facility failed to supervise behaviorally at risk residents to prevent self harm (R13, R3). These failure resulted in an Immediate Jeopardy that was indentified on 9/24/13 and began on 8/17/13. Although the Immediacy was removed on 9/24/13 the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policies and staff training on the management of agressive behavior. This applies to 4 residents (R4, R5, R16, R13) reviewed for safety and supervision in the sample of 17. The findings include: I. R1's Face Sheet shows that R1 was admitted to the facility on [DATE]. R1's September, 2013 physician's orders [REDACTED]. R1's Minimum Data Set (MDS) assessment of 8/25/13 shows that R1 has a Serious Mental Illness. A hospital Social Work Consult dated 6/20/13 documents that R1 has a history of physical and verbal agression. R1 had approximately 15 Psychiatric hospitalization s, and multiple facility placements in which R1 threatened or physically assaulted other residents. The hospital History and Physical for 6/22/13 documents that R1 has past [DIAGNOSES REDACTED]. R1 had [AGE] years of living for the most part in institutions or group homes. R1's Nursing Notes document numerous verbal and physical aggressive behaviors beginning one day after his admission to the facility. (8/17/13) R1's Nursing Notes show that from 8/17/13 until 9/24/13 R1 had 3 episodes of physical assault and residents, and 15 occurences of verbal agression. R1's Nursing Notes show: On 8/25/13 R1 struck another resident in the head. because he was sitting in his chair. On 9/16/13 3:00 PM, R1 struck a resident in the back of the head. On 9/17/13 R1 struck a resident on the face and head several times. R1's Care Plan dated through 12/3/13 documents that R1 has a behavior problem. Resident swears and strikes out at other residents. The goal is that R1 will have no evidence of behavior problems. The approaches include: administer his medications as ordered. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention, remove from the situation. There have been no revisions to R1's care plan following these occurrences. On 9/24/13 E6 (Psycho/Social) said they just try to intervene with R1's behaviors as needed. On 9/24/13 at 5:45 PM, R1 was observed pacing rapidly back and forth in the dining room during the dinner meal. R1 was talking to himself, and going up to residents and standing by them (very close). R1 pulled the phone out of the hand of another resident (R4) while she was talking to someone. E10 Certified Nursing Assistant was assigned to do 1:1 with R1. E10 could only follow R1 around, he did not respond to her verbal redirection. 2. R5's [DIAGNOSES REDACTED]. The resident startles easy and has intermittent periods of lethargy. The MDS notes R5 requires supervision with transfers, ambulation, dressing, hygiene and bathing. He ambulates using a walker. R5's careplan of 4/2/2013 shows the resident has impaired individual coping related to Depression and Paranoia. One of the interventions of the careplan is to initiate a trusting relationship with R5. On 9/17/2013, Nursing Notes document at 12:45 AM, R5 was in his bed. R1, who had been placed in R5's room due to behaviors, began yelling at R5 and started to repeatedly strike R5 on his face and head. Nursing notes state R1 was very vulgar and combative. On 9/24/2013 at 11:30 AM, R5 said, "I was trying to sleep. They moved (R1) from the 2nd floor to my room. I wasn't paying any attention, I thought it was strange they moved him in the middle of the night. He (R1) came over on my side of the curtain screaming, hollering, and hammered me on the head. I had no idea why he was so mad. I hadn't even spoken to him. I don't know know why he would be violent against me. I hollered for help, he was hammering on me. I couldn't do anything, I couldn't move, I just hollered and the aides came in to me. They put him in my room because he was fighting upstairs. He is extremely violent. I still have a headache. He (R1} pounded my head with is fists. They knew he was violent before they brought him down (to my room). I don't want those violent people in my room in the middle of the night. He has trouble with more than one person." 3. R13 was admitted to the facility on [DATE], according to the resident's face sheet. Her [DIAGNOSES REDACTED]. A History and Physical of 8/20/2013, documents R13 had been admitted to a hospital after having been found in a retail store bathroom cutting herself. A hospital Crisis Assessment form, dated 8/20/2013, documented R13 was found in a retail store bathroom with multiple cuts to her arm and abdomen. She also cut the skin over her pubic area and inserted a razor into her vagina. Upon admission to the facility, Nursing Notes show R13 was placed on 15 minute checks. On 9/7/2013 at 4:45 PM, Nursing Notes document, "Activity staff reported that this resident (R13) reported that this resident (R13) told her that she swallowed 4 batteries. The batteries were out of her remote control from her room...received new order to send resident to a near-by medical facility. Staff instructed to do 1:1 (one on one supervision) until ." Nursing notes of 9/8/13 shows the facility received a report from the hospital stating 2 triple A and 2 Double A batteries were removed from the resident, and she was returning to the facility. Nursing notes of 9/8/2013 at 5:30 PM state, "Staff reported that this resident told her that we can watch her all we want, but if she wanted to cut herself she would find something in her room to do that..." A 9/6/2013 careplan showed R13 has a history of self injury. The interventions do not include the resident's need for continuous monitoring. The plan just directs staff to check on the resident resident every 15 minutes. R13 was not to have any sharp objects. There is no interventions in place to keep the resident from sharp objects such as silverware. On 9/24/2013 at 3:00 PM, E7 (Licensed Practical Nurse/Careplan Coordinator) said she was aware of R13's history of self mutilation. She said she initiated 15 minute checks for R13 prior to her arrival, to ensure her safety. 4. R4 was admitted to the facility on [DATE], according to her Face Sheet. A 10/26/2013 Subpart S Screening Form documents R1's [DIAGNOSES REDACTED]. She has a history of substance abuse disorders. The 9/2013 POS shows R4's medical [DIAGNOSES REDACTED]. A Social Service Note, written by E8 (Social Service Director) states, "(R4) has an open wound on her knee, leg, and ankle which requires nursing care. This resident is reported to have a history of drug abuse and a [DIAGNOSES REDACTED]. The facility could not present a plan showing R4's potential for being abused or being abusive toward others. There are no interventions on how the facility will keep R4 safe from harm or how they will supervise her to ensure the safety of other residents. Facility incident reports show R4 was involved in multiple incidents. On 8/17/2013 and 9/16/2013 R4 was involved in verbal and physical altercations with other residents. On 9/10/2013, R4 tipped her wheelchair over. On 9/14/2013, R4 was found on the dining room floor. She said she didn't lock her wheelchair. On 9/21/2013 at 12:10 AM, R4 became verbally abusive after being told it was not time for the pain medication, she was asking for. At 2:20 AM, the Nursing Notes state R4 told staff she was leaving the building. The resident left the building at 2:20 AM. The nursing notes document staff watched the resident, from a window, until the resident could not be seen. The facility staff did not attempt to stop the resident from leaving the building or talk with her to try and calm her down and convince her not to leave. The documentation states R4 told the nursing assistants she "needed to get out of here and get high." On 9/25/2013 at 3:30 PM, Surveyors saw R4 at a local restaurant. At 3:35PM, E9 (Front door receptionist) said R4 left the building. He said he was not certain if she had privileges to leave the facility. On 9/25/2013 at 3:45 PM, E6 (Psychosocial Director) said R4 was not to be off of the facility campus. He said she has not been screened for community skills and safety. E6 verified the facility has multiple residents with behavior problems. Many of the residents can be abusive. E6 said, "We intervene when incidents occur. We need to try to keep our Geriatric residents safe. On 9/24/2013 at 2:15 PM, E3 (Registered Nurse) said R4 was always "egging" on R1. There are times when E3 acts out to get certain things. She changes her personality frequently. One time she pulled the fire alarm because she wanted an order for [REDACTED]. On 9/24/2013 at 12:00 PM, R4 said, "I'm so scared of (R6). He always lies about me. He torments me. I'm not perfect, I've cussed him out. He keeps calling me a whore and roly poly. It was a non-stop process. He comes to the 2nd floor and laughs at me." A facility letter (2/20/2009) written to the families, Power of Attorneys, and Guardians of facility residents states, "We have a long-standing admission process designed to prevent the admission of any resident considered to be potentially harmful to themselves or to others..." E1 Administrator was informed of the Immediate Jeopardy on 9/24/13 at 5:07 PM related to the facility failure to ensure the safety and supervision of all residents. 1. R1 was removed from the facility on 9/24/13. 2. All mentally ill residents will be reviewed for potential of physical aggressive/explosive behaviors and the care plans will be revised. Completion 9/30/13. 3. Actions to be taken when dealing with a physical aggressive and/or explosive behavior resident: Staff inserviced by 9/30/13. a. Stay Calm. b. Move the resident into a private room away from other residents. c. Use a team approach by getting staff to help. d. Have a one to one with the residents. e. Call the psychiatrist and have the patient seen with in 24 hours. f. Call the Administrator, Director of Nursing, Doctor and family. g. Call the police if you feel your safety is in danger. 4. All staff will be inserviced prior to working the floor on proper policy and procedures in handling residents that display physical aggressive and/ or explosive behavior. Completed by 9/30/13.

Based on Observation, Interview and Record Review the facility failed to provide safety for residents by leaving insulin syringes unattended on top of a medication cart in the hallway. The facility failed to provide safe hot water temperatures for residents. This is for 3 of 15 residents (R50, R55 & R75) reviewed for safety in the sample and 25 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R17, R18, R19, R20, R21, R22, R23, R42, R43, R44, R45, R46, R65, R66, R76 & R84) in the supplemental sample. The findings include: 1. On 12/10/13 at 10:55am, E8 (Licensed Practical Nurse - LPN) had a container with several vials on top of the cart. E8 was filling another open container on top of the cart with insulin syringes. R8 left the containers on top of the cart and went into a locked medication room to return a basket of supplies. At 10:59am, E8 took the cart down to R84 ' s room to check his blood glucose level. When E8 finished checking R84 ' s blood sugar she put the cart over by the entrance of the short hall on the second floor. The cart had insulin syringes in an open container on top of the cart. The syringes were observed to be left unattended by staff from 11:08am to 11:21am and 11:29am to 11:55am. On 12/10/13 at 11:24am, E8 was observed getting a wound culture for R89. At 11:48am, E8 got on the elevator and took the culture downstairs. At 11:53am, E8 returned to the second floor with R75 to check the resident ' s blood glucose level. At 11:55am, E8 took the cart, with the syringes that had been left out, to R75 ' s room to check her blood glucose level. R50, R55, R75 and R85 are residents on the second floor with histories of substance abuse and/or suicidal attempts in the past. The Nursing Facility Placement Assessment Summary Information screening dated 8/16/12 for R50 showed a [DIAGNOSES REDACTED]. The Nursing Facility Placement Assessment Summary Information screening dated 3/13/13 for R55 showed [DIAGNOSES REDACTED]. The Nursing Facility Placement Assessment Summary Information screening dated 11/23/12 for R75 showed, " R75 reports she was residing at another nursing facility and tried to leave. R75 states she was having suicidal ideations and began to cut herself with a plastic knife on the table. R75 then states she tried to use the pin in her watch to " stab her vein " in her arm. R75 reports feeling like all the staff and Emergency responders were laughing at her. R75 states she was in the hospital from 9/22/13 to 9/30/13 after trying to suffocate herself with the garbage liners while at the nursing home. R75 states the certified nursing assistant found her with the bag over her head. " The Nursing Facility Placement Assessment Summary Information screening dated 10/12/11 for R84 showed [DIAGNOSES REDACTED]. The Psychosocial and Psychiatric Rehab Group Members List dated November 2013 showed 4 residents (R48, R54, R76 & R82) as members of the Substance Abuse Support Group. On 12/11/13 at 11:30am, E1 (Director of Nursing - DON) stated, " I don ' t know if I have a specific policy for the syringes being left on the medication cart. I have a policy and procedure for safety for falls. They should not have left the syringes out. E1 stated leaving the syringes out on top the medication cart was a safety concern. 2. On 12/11/13 at 9:15am, an environmental tour of the facility was conducted with E10 (Maintenance Supervisor) and E15 (Maintenance). The hot water temperatures were taken at resident handwash sinks on the 1st and 2nd floors of the facility. The hot water temperature in the 1st floor long hall common bathroom measured 113.3F (degrees Fahrenheit) at the handwash sink used by R1-R15 and R17-R23. The hot water temperature at handwash sink for R65 and R66 measured 114.6F. The hot water temperature measured 114F at the handwash sink used by R42, R43, R44, R45 and R46. E10 said, "The mixing valves needed to be adjusted."

Based on observation, interview, and record review the facility failed to prevent residents at high risk for skin break down from developing pressure ulcers, failed to prevent these areas from worsening, failed to track wound characteristics, failed to apply the ordered treatment, and failed to ensure pressure relieving devices were present. These failures contributed to R1 and R2 developing unstageable pressure areas. This is for 2 of 3 residents (R1 & R2) reviewed for pressure ulcers in the sample of 4. The findings include: 1. R2 ' s 2/19/13 and 5/17/13 Minimum Data Set Assessment shows R2 is totally dependent on staff for bed mobility, transfers, dressing, and hygiene/bathing. R2 is at high risk for developing pressure ulcers. On 6/26/13 at 10:30 AM, E2 (Director of Nursing) said skin assessments and wound documentation is done on the Treatment Administration Record (TAR) for each resident. R2 ' s February 2013 TAR ' s show from 2/7 to 2/21, R2 developed skin breakdown going from intact skin to a stage II, 5 x 3 CM (centimeters) coccyx wound, and a 2 x 0.7 CM open area " to distal wound " . The 2/24 entry shows an open skin abrasion (no measurement) to right buttock under treatment with Santyl and foam dressing daily. The manufacturer's specifications for Santyl ointment state that Santyl ointment is indicated for use in [MEDICATION NAME] (removal of dead tissue) chronic dermal ulcers. Santyl is an enzymatic [MEDICATION NAME] ointment. It possesses the ability to digest collagen in necrotic (dead) tissue. An [DIAGNOSES REDACTED] (redness) can occur in the surrounding tissue when Santyl ointment is not confined to the wound. Therefore, the ointment should be applied within the area of the wound. Use of Santyl should be terminated when debridement of necrotic tissue is complete. R2 ' s March 2013 TAR shows between 3/7 and 3/28, R2 developed a stage I wound on the right buttock that progressed to two open areas on each buttock. No measurements were taken of the four wounds on the buttocks. R2 ' s coccyx developed a second open area. On 3/13/13 the coccyx wounds measured 1 x 2 CM and 2 x 1 CM. On 3/20/13 the coccyx wound was 3 x 2 CM and had a " small dark purple area by the coccyx, not open. " R2 ' s April 2013 TAR shows on 4/1 R2 had a 0.5 x 0.5 open area on the coccyx, pink in color and had no drainage. On 4/17 R2 had a purple area (no measurement) on the coccyx that was not open and was being treated with Santyl and covered with a foam dressing. Between 4/4 and 4/21 no measurements were taken of the " open areas to the coccyx and the left buttock. " R2 ' s May 2013 TAR shows an undated entry, " coccyx is red with black center and not open. Right thigh is open (2 x 1.5) using Santyl and foam dressing. " On 5/24 R2 continued to have " open areas to the buttock/coccyx and right hip. The black spot to the center of the buttock wound remains unchanged. " (no measurements) R2 ' s Physician order [REDACTED]. On 5/28/13 wound treatment orders were to cleanse with normal saline, apply [MEDICATION NAME] Ag (absorbent, antimicrobial pad that maintains a moist environment) and cover with a foam dressing. Change every 3 days and as needed to facilitate drainage. Turn and reposition patient every 2 hours and as needed. R2 ' s June 2013 TAR shows on 6/13 R2 had 3 open areas. " 1. Coccyx is necrotic, 3 x 3 CM. 2. Left buttock is stage II, 1 x 1 CM. 3. Right thigh has a large amount of drainage, 2 x 2 x 0.5 CM. " On 6//18 the coccyx wound increased in size to 6 x 5 CM. R2 ' s 6/10/13 results of a wound culture of the right thigh wound showed growth of proteus mirabilis and was treated with the antibiotic Bactrim DS, twice a day for 7 days. On 6/26/13 at 10:25 AM, E5 (Licensed Practical Nurse- LPN) & Z1 (hospice LPN) changed the dressing to R2 ' s coccyx pressure ulcer. R2 ' s coccyx wound was approximately 5 x 4 CM with a large black necrotic tissue center surrounded by yellow slough. Z1 applied Santyl ointment and covered R2 ' s coccyx wound with a foam dressing. R2 ' s right lower buttock area had a white dressing covering it. Z1 said he had just completed the treatment of [REDACTED]. R2 ' s 6/26/13 Treatment Administration Record (TAR) shows the current orders are to apply [MEDICATION NAME] to the right lower buttock area, change every 3 days and as needed. R2 ' s Physician order [REDACTED]. R2 ' s 6/26/13 Treatment Administration Record (TAR) shows the current orders are to cleanse the coccyx with wound cleanser, apply Santyl, and cover with foam dressing daily and as needed. On 6/26/13 at 12:05, 1:00, 2:15, & 2:30 PM, R2 was sitting in a reclining wheelchair in the same position. On 6/27/13 at 11:20 AM, Z2 (Regional Registered Nurse for the hospice) said Z1 put the wrong treatment on R2 ' s right lower buttock. Residents can be repositioned while sitting in reclining wheelchairs to redistribute pressure. On 6/26/13 at 10:25 AM, R2 ' s right foot had 3 dry dark scabs (dime size) on the top of and near the 2nd, 3rd, and 5th toes. R2 ' s left foot had a moist pink open area (nickel size) with a flap of thin skin at the base of the 1st toe. R2 had no scabbed areas on the left foot. Z1 said the areas on the right foot were being left open to air. The left foot was a new blister from today that opened. R2 ' s June 2013 TAR, Nurses Notes and hospice Nursing Visit Record do not mention the scabs on R2 ' s right foot. R2 ' s June 2013 POS show no orders for the right foot scabbed areas. R2 ' s 6/7/13 TAR entry states, " Scabbed area noted to top of left foot. " No measurements or other description was documented. R2 ' s TAR entries of 6/7, 6/11, 6/14, 6/21, & 6/25 do not mention the right foot wounds. On 6/26/13 at 12:35 PM, E4 (Certified Nursing Assistant) said R2 slides down in the bed and his toes press against the footboard. There are usually pillows at the foot of the bed, but not always. R2 ' s 2/26/13 Potential for Skin Impairment care plan states, R2 will maintain current intact skin integrity by next review date. Turn and reposition every 2 hours and as needed. The facility ' s 7/11/05 Pressure Ulcer Prevention policy states, Mechanical Loading and Support Surfaces: Bed-bound residents will be repositioned at least every two hours, chair-bound residents every hour. Devices such as pillows and foam wedges or bath blankets will be used to keep bony prominences from direct contact with each other, stabilize postural alignment, provide pressure relief when positioning in a chair, and to relieve pressure on the heels. The facility ' s undated Assessment and treatment of [REDACTED]. Type of Ulcer; Ulcer Characteristics- location ..., staging, size ..., exudates ..., wound bed ..., description of wound edges and surrounding tissue ..., the presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection ..., pain ...; The resident ' s physician and responsible party will be notified. Treatment orders will be obtained from the physician. The charge Nurse will ensure that all treatments and dressings are applied, dated and initialed. " " If a pressure ulcer fails to show progress toward healing within 2-4 weeks, the overall clinical condition will be reassessed and the physician and family will be notified. " " Based upon the assessment and the resident ' s clinical condition, choices and identified needs, basic care should include interventions to: redistribute pressure (such as repositioning, protecting heels, etc.) ... " The facility ' s undated Stages of Pressure Ulcers policy fails to include the 2007 updated staging system from the National Pressure Ulcer Advisory Panel that includes a definition of deep tissue injury. Suspected Deep Tissue Injury is purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 2. R1 ' s 1/19/13 Minimum Data Set Assessment shows R1 needs extensive assistance of 2 staff for bed mobility, transfer, hygiene, and toilet use. R1 ' s January 2013 Treatment Administration Record (TAR) shows on 1/12 R1 developed a blister to the left heel with clear fluid drainage. A foam dressing and heel protector was applied. On 1/25 R1 ' s right heel developed a blister that was intact. A foam dressing and heel protector was applied. No measurements were done. R1 ' s February 2013 TAR ' s had no wound assessments. R1 was discharged to the hospital on 2/13 and was readmitted to the facility on [DATE]. R1 ' s 2/20/13 Resident Admission Assessment shows Unstageable pressure areas to both heels. The left heel wound was 3.5 x 4.8 CM and dry. The right heel wound was 2.6 x 3.0 CM and dry. R1 had an open area noted between the gluteal folds. The coccyx wound was 3 x 2 CM and pink in color. R1 ' s March 2013 TAR shows on 3/8 R1 ' s left heel wound was 8 x 7 CM with a moderate amount of drainage. R1 ' s right heel wound was 5 x 3 CM. R1 ' s coccyx wound was 0.5 x 0.5 CM. R1 ' s 4/2/13 hospital Operative Report shows that R1 had both heels surgically debrided. The left heel had osteo[DIAGNOSES REDACTED]. R1 ' s May 2013 TAR shows on 5/21/13 R1 ' s coccyx wound was 2.5 x 3.5 CM. R1 ' s June 2013 TAR shows on 6/2/13 R1 developed a 2 x 2 CM black, dry eschar area on the left posterior foot below the big toe. R1 ' s 5/2/13 Pressure Ulcers care plan has a goal that pressure ulcers will be healed by next review (3 months). R1 ' s care plan has 5 approaches: assess for pain; administer treatment per physician order; bi weekly skin checks; bilateral heel protectors, remove for skin care only; & monitor for sign and symptoms of infection. R1 ' s June 2013 Physician order [REDACTED]. " The left planter foot and the coccyx wound had orders to apply [MEDICATION NAME] Ag and cover. On 6/26/13 at 2:30 PM, E2 said R1 had been followed by the wound clinic since February. The osteo[DIAGNOSES REDACTED] that developed in R1 ' s left heel made healing of the wound difficult.