Every finding on record at Rushville Nursing & Rehab CTR

Based on observation, record review, and interview the facility failed to care plan the level of assistance each resident requires for Activities of Daily Living (ADL).This effects all 68 residents residing at the facility. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 6/28/26 documents the facility census as 68 residents.The facility's Care Plan Policy dated October 2022 documents An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. The policy further documents the Comprehensive Care Plan has been designed to reflect the resident's needs and preferences.On 6/29/26 at 9:50 AM V12 (Registered Nurse) reported resident care needs are on the resident's individualized care plan. On 6/29/26 at 11:07 AM V6 (Restorative Nurse) reported V6 is responsible for the ADL (Activities of Daily Living) care plans and V6 only care plans the assistance resident requires for transfers. Bathing, dressing, bed mobility, eating, and mobility are not addressed on the residents' care plans.On 6/30/26 at 8:24 AM V1 (Administrator) confirmed none of the resident care plans address the resident's ADL (Activities of Daily Living) assistance needed with exception to transfers. On 6/30/26 at 11:02 AM V6 (Restorative Nurse) reported there is not a resident in the facility that is independent with all ADL's. V6 reported all residents require supervision or hands on assist with ADL's (Activities of Daily Living).

Based on observation, interview, and record review the facility failed to ensure garbage/refuse container lids are closed. This has the potential to effect all 68 residents. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 6/28/26 documents the facility census as 68 residents.The facility's undated Garbage Disposal Policy documents Keep dumpster closed at all times.On 6/29/26 at 7:00 AM the dumpster lid was not closed on one of the two dumpsters. V4 (CNA/Certified Nursing Assistant) verified dumpster lids are to be closed at all times and stated, Sometimes we need three of them.

Based on observation, interview, and record review the facility failed to maintain dignity for two (R5, R7) of two residents reviewed for dignity in a total sample of 68. Findings include: The facility's undated Assisting a Client with Eating Policy documents Sit with the person and assist with the meal as needed. The facility policy, Resident Rights Guideline, revised 10/2023, documents not in its entirety, Our facility will treat each resident with respect and dignity and care for each resident in a manner an in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility protects and promotes the resident of the residents. The right to be treated with respect and dignity. 1. On 6/29/26 at 8:54 AM V7 (CNA) was standing next to R7 feeding R7 breakfast . V7 stated, I'm the only one in here, so I'm going table to table to help the residents. I usually sit when I have help in here. On 6/29/26 at 12:50 PM V2 (Director of Nursing/DON) confirmed staff should be sitting with the resident when assisting residents with feeding. 2. R5's resident face sheet documents R5's date of re-admission to the facility was 3/23/26 and R5's diagnoses include but are not limited to Pressure Ulcer of Sacral Region Stage 4, Type 2 Diabetes Mellitus without complications, and Urinary Tract Infection site not specified-VRE (Vancomycin (Antibiotic)-resistant Enterococci (bacteria). R5's physician orders dated 6/25/26 documents that R5 has a treatment to coccyx of cleanse with wound cleanser, pat dry, apply Fibracol (medicated wound dressing) to wound bed and cover with dry dressing daily and as needed. On 6/29/26 at approximately 9:30am, V9 (Registered Nurse) and V8, V10 (Both Certified Nursing Assistants) observed doing wound care to R5's coccyx wound. V8 and V10 were noted to hold R5 over onto her right side facing the window in her room. R5 was without clothing from her waist down exposing her naked buttocks to the doorway of her room. Privacy curtain was not pulled around R5. V9 opened R5's door to her room to access the treatment cart while R5's naked buttocks were exposed to potential peers and visitors in the hallway outside her room for approximately 1 minute prior to V9 grabbing the treatment cart and pulling it to the doorway at which time V8 noted that R5's buttocks were exposed and covered R5 with a sheet. On 6/29/26 at approximately 10am, V8 and V10 (Both Certified Nursing Assistants) confirmed that the privacy curtain should have been pulled around R5 during cares. On 6/29/26 at approximately 10:30am, V9 (registered Nurse) confirmed that R5's naked buttocks were exposed to the hallway and confirmed that she (V9) should have made sure R5 was covered prior to opening the door.

Based on observation, interview and record review, the facility failed to attempt any nonpharmacologic intervention prior to using psychotropic medications for three residents (R17, R26, R27) and failed to GDR (Gradual Dose Reduction) for two residents (R17, R27) of 5 residents reviewed for unnecessary medications in total sample of sixty-eight. Findings Include: The facility's Psychotropic Medication policy dated 2/2025 documents Use of Anxiolytic/Sedative drugs for purposes other than sleep induction should only occur when 1. Evidence exists that other possible reasons for the resident's distress have been considered and ruled out. The facility's Psychotropic Medication policy documents Antipsychotic medications in persons with dementia should not be used if one or more of the following is/are the only indication: 1. Wandering 2. Poor self care 3. Restlessness 4. Impaired memory 5. Mild anxiety 6. Sadness or crying alone that is not related to depression or other psychiatric disorders 7. Insomnia 8. Inattention or indifference to surroundings 9. Fidgeting 10. Nervousness 11. Uncooperativeness (e.g. refusal of or difficulty receiving care). All of the above highlighted conditions/diagnosis where antipsychotic medications may be possibly be appropriate, but diagnoses alone do not warrant the use of an antipsychotic unless the following criteria are also met: The behavioral symptoms present a danger to the resident or others. The facility's Psychotropic Medication policy documents Unsuccessful reduction of medication must be substantiated by documentation, including a physician statement why the medication cannot be reduced farther. Clinically contraindicated means that a resident need not undergo a gradual dose reductions or behavior intervention if the resident has a specific condition and has a history of recurrence of psychotic symptoms which have been stabilized with a maintenance dose of an antipsychotic drug without incurring significant side effects. In residents with dementia, clinically contraindicated means that a greadual dose reduction has been attempted twice in one yuear and that attempt resulted in the return of symptoms for which the drug was prescribed to a degree that a cessation in the gradual dose reduction, or a return to previous dose levels was necessary. The resident's physician provides a justification that includes: a) diagnosis, but not simply a diagnostic label or code, but the description of the symptoms, b) a discussion of the differential psychiatric and medical diagnosis (e.g., why the resident's behavioral symptom is thought to be a result of a dementia with associated psychosis and/or agitated behaviors and not the result of an unrecognized painful medical condition or a psychosocial or environmental stressor) c) a description of the justification for the choice of a particular treatment, or treatments, and d) a discussion of why the present dose is necessary to manage the symptoms of the resident. This information need not necessarily be in the physician's progress notes, but must be a part of the resident's clinical record. Documentation confirming that previous attempts at dosage reduction have been unsuccessful. 1. R27's Medical Record documents that she was admitted on [DATE] with diagnosis to include but not limited to Unspecified Dementia with behavioral disturbance, Type II Diabetes Mellitus and Repeated Falls. R27's Medical Record documents that she is rarely/never understood. Throughout the survey R27 propelled self up and down hallways, into walls, into other residents. R27 did not speak when spoken to and did not acknowledge speaker. R27 appeared calm and confused. R27's Physician Order Sheet for April 2026 documents that she received Seroquel (Antipsychotic Medication) 25 mg (milligrams) for Dementia every night. R27's Pharmacy Recommendation accepting a Gradual Dose Reduction of the Seroquel to 12.5 mg every night was signed by V21 (R26's Doctor) was dated 4/2/26. R27's Behavior Monitoring Logs for April and May contain documentation of refusal of cares for 21 instances over the two months. No other behaviors were being monitored. R27's Physician Order Sheet documents a new order from V21 (R26's Doctor) on 5/18/2026 for Hydroxyzine (An antihistamine used primarily to treat anxiety, allergic skin reactions and itching. It works as a non-addictive sedative to calm the central nervous system) for Dementia. On 6/30/26 at 10:00 AM V18 (Registered Nurse/Psychotropic Nurse) stated that R27 is on an Antipsychotic medication for Dementia and anxiety. V18 stated that when she spoke with V21 (R27's Doctor) the plan was to use the Hydroxyzine to manage R27's anxiety and to get her off the Antipsychotic. This plan was not documented anywhere in R27's Medical Record. R27's Medication Record documents that R27 received Hydroxyzine 50 mg once on 5/19/2026. R27's Progress Notes dated 5/25/26 document that V21 (R26's Doctor) considered the GDR failed and returned her to the previous dose of Seroquel 50 mg every night. R27's Medication Record documents that R27 currently receives both the Seroquel 50 mg every night and Hydroxyzine 50 mg every 6 hours as needed. On 6/30/26 at 11:00 AM V5 (Social Services Director) stated that she did not believe any of R27's behaviors were harmful. V5 stated anxious? Yes, very. But she doesn't hurt anyone or herself. V5 stated that the Identified Behavior that V5 (SSD) decided to track for R27 was refusal of cares/combative with cares. V5 (SSD) stated A lot of residents with dementia don't like showers or changing their clothes. R27's current care plan does not contain any personalized interventions for R26 for any behavior issues. R27's care plan documents (R27) takes antianxiety medication. Approach: Implement a behavior management plan. 2. R26's Medical Record documents that he was admitted on [DATE] with diagnosis to include but not limited to Anxiety, Osteomyelitis and Type 2 Diabetes Mellitus. R26's Physician Order Sheet documents he was admitted on Ativan 1 mg twice daily as needed for anxiety. This as needed prescription did not have an end date. R26's Medication Administration Record documents that R26 takes his as needed Ativan almost daily for the month of June. On 6/28/26 at 1:00 PM R26 stated that he started the anxiety pill while hospitalized for osteomyelitis . My whole situation with maybe losing toes and having to be here (at facility) just makes me anxious. I get in my own head about things and over think them. R26 stated that he didn't know if counseling would help, but stated he would be open to other ways to manage his anxiety. No one has really offered anything else other than the pill. R26's Behavior Monitoring Logs for June documented zero instances of anxiety by R26. R26's Medication Administration Record documents that R26 received the Ativan 1 mg every day in June, sometimes twice a day. The reasoning for these medication administration ranged from pain other and behavior issue. R26's Progress Notes or Behavior Monitoring Logs do not contain any documentation of any nonpharmacologic interventions attempted prior to the administration of the Ativan. R26's current care plan documents (R26) takes anxiety medication Implement a behavior management program. Attempt non pharmacological interventions. On 6/30/26 at 9:30 AM V18 (Registered Nurse/Psychotropic Nurse/Care Plans) stated I don't do those (behavior management care plans) (V5/SSD) should be doing those. On 6/30/26 at 11:00 AM V5 (SSD) stated she has never done any kind of behavior management plan for any of the residents. V5 did confirm there were no personalized interventions on R26 and R27 current care plans. V5 also confirmed that both care plans stated attempt nonpharmacologic interventions and did not list what worked for this resident or what was available at this facility to attempt to manage behaviors/anxiety. 3. R17's Medical Record documents that he was readmitted on [DATE] with diagnosis to include but not limited to Schizoaffective Disorder Bipolar Type, Dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbances, Major Depressive Disorder, Generalized Anxiety Disorder and Chronic Obstructive Pulmonary Disease. R17's Physician Order Sheet documents he has an order for Olanzapine (antipsychotic) 5mg (milligrams) every 6 hours as needed for agitation. This as needed prescription did not have an end date. R17's Behavior Monitoring Logs for June documented one instance of agitation by R17 on 6/1/26. R17's Medication Administration Record documents that R17 received the Olanzapine (antipsychotic) 5 mg (milligram) on 6/4/26 one time with no documented agitated behavior. R17's Progress Notes or Behavior Monitoring Logs do not contain any documentation of any nonpharmacologic interventions attempted prior to the administration of the Olanzapine (antipsychotic). R17's current care plan documents (R17) currently receiving antipsychotic and anticonvulsant medications Implement a mood management plan to complement drug therapy. Quantitatively and objectively document behavior/mood. On 6/30/26 at 11:10 AM V5 (Social Service Director) stated she has never done a behavior management plan for any of the residents. V5 did confirm there were no personalized interventions on R17's current care plan. V5 also confirmed that care plan stated, Quantitatively and objectively document behavior/mood and stated, I've always been told if it's not documented then it did not happen. V5 confirmed there was no documentation in R17's medical record indicating behaviors had occurred for the month of June except the one occurrence documented on behavior log for 6/1/26.

Based on observation, interview, and record review the facility failed to provide documentation of communication with the dialysis facility for three residents (R1, R2, R42), failed to have appropriate physician orders for two residents (R1, R42), and failed to implement a care plan for one resident (R1) of three residents reviewed for dialysis in a sample of 68. Findings include: The facility policy, Hemodialysis Guidelines, dated 4/3/24, documents, Care interventions required when a resident is on hemodialysis may exceed the usual identified problems and interventions provided to residents in long-term care setting. The following information will provide additional direction in assessment, planning and provision of care to our residents. Residents receiving hemodialysis are transported routinely out of the facility. Communication is essential for continuity of care. Education surrounding the care of the unique needs of the resident on hemodialysis is also important. Communication between outpatient dialysis provider and facility should include written communication form with review of daily weights, any changes in condition or mood. Pre-Dialysis Protocol: Be cognizant of medications ordered and timing of administration. Be aware of any meals that may be missed and arrange for routine boxed lunches to be provided by dietary. Observe for lethargy, chest pain, headache, unsteady gait or nausea. Communicate symptoms to outpatient dialysis center and physician. Communicate/facilitate plan for preventative skin interventions. Post Dialysis Protocol: Review Communication Folder for any pertinent information. Remove fistula/graft-dressing evening of dialysis treatment and/ or as directed by the nephrologist. Check fistula for bruit (listening to fistula) or feel for a thrill (by touching the fistula.) This must be done daily, best after dressing is removed. If bleeding occurs any time after dialysis, apply pressure with clean gauze for 5-10 minutes. Repeat until the bleeding stops or call the dialysis unit (if open) or M.D. for further instructions. Blood pressure pm/daily or as the physician orders (do not take B/P on arm that fistula is in). Normal activity as tolerated. Observe skin/heels for any pressure areas from extended sitting/lying during dialysis. Emergency Protocol: Fistula/ Graft Daily Fistula/Graft Checks: Check for any signs of infection daily, these may appear as: redness, hardness, swelling, pain, drainage, and elevated temperature and body chills. Call the physician promptly. If bleeding occurs at needle sites any time after dialysis, apply pressure with clean gauze for 5-10 minutes. Repeat until bleeding stops. If this intervention does not control the bleeding a physician should be notified. Documentation on Treatment Sheets Includes: Fistula checks daily: Monitoring for presence of bruit and thrill. Checks for signs/symptoms of infection daily. Care of the Fistula/Graft: Residents should avoid lying or sleeping on the access arm. Avoid any tight clothing on the access arm. This may restrict the blood flow to access and increase the risk of clotting. Residents should avoid carrying a purse or heavy items on that arm. Avoid wearing a watch or bracelets on the access arm. No blood pressure is to be taken on the access arm. No blood is to be drawn from that arm or intravenous access to be placed in the access arm unless ordered by Dialysis Unit or resident's Physician. Keep dressings over exit sites clean, dry and in place. Emergency Protocol External Catheters: External Catheters-Avoid scissors or sharp objects around the catheter. Remind the resident not to pinch, poke, bend or pull at the catheter. Always have a smooth clamp at the bedside for use in emergency situations. Clamps should remain clamped and end caps should be tight on any temporary external catheter. Avoid getting these types of catheters wet while bathing. You may cover site with saran wrap or plastic covering during baths. If dressing becomes wet, falls off or pulled off by resident, you will need to replace the dressing. Cleanse the area in a circular motion using Betadine swabs or Hibiclens. Allow the area to dry and cover with a sterile gauze or Tegaderm type dressing. Use sterile technique with this dressing change. Make a note to the Dialysis Unit in the resident's folder that they bring to dialysis. If a catheter is accidentally cut or torn, immediately clamp the catheter near the exit site with a smooth clamp, you may also bend the catheter over and tape it tightly Assess the resident for signs of an air embolism, sob, chest pain or respiratory embolism, position resident on left side with head down and feet up- call 911. If catheter is pulled out, immediately apply pressure in the general area of the junction of the medial end of the clavicle and the sternomastoid muscle (internal jugulate vein). Applying pressure for 15-20 minutes will usually stop any bleeding. Check the catheter to be sure it is intact if not apply sterile gauze to exit site then notify M.D. at dialysis or primary physician if dialysis closed. 1. R1's Physicians Orders dated 6/1/26 by V21 R1's Physician includes the following order: Dialysis: Hemodialysis (local Dialysis Unit) in Rushville. Once a Day on Mon, Wed, Fri; Days; Dialysis: Check access site ____________for redness, bleeding and swelling. If any bleeding or oozing from site APPLY PRESSURE GAUZE DRESSING & NOTIFY PHYSICIAN. (Instructions for entering dialysis orders included in this order state the following: Special Instructions: enter the site above and select the correct dialysis days and delete this.) R1's Physicians Orders do not identify the R1's dialysis access site location or type of dialysis access utilized for hemodialysis. R1's dialysis access site was not identified or documented in Physicians Orders, Care Plan or Nursing Progress Notes. Additionally, there were no orders or parameters regarding laboratory monitoring for R1's dialysis treatments. On 6/30/26 at 9:55am, R1 indicated his dialysis access was a fistula, indicating a dressing which was in place on his left upper arm. 2. R3's EHR (Electronic Health Record) documents R3 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Gout, Anemia, Diabetes Mellitus, Hypertension, and Atrial Fibrillation. R3's Care Plan documents R3 receives hemodialysis twice a week at the dialysis center. The most recent dialysis communication form in R3's Electronic Health Record is dated 6/30/25. 3. R42's resident face sheet documents R42's date of admission to the facility was 2/11/25 and R42's diagnoses include but not limited to End Stage Renal Disease, Type 2 Diabetes Mellitus with Diabetic chronic Kidney Disease, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Essential Hypertension, and Chronic Systolic Congestive Heart failure. R42's physician orders dated 6/4/25 documents R42 has orders for Hemodialysis external to facility on Monday, Wednesday, and Friday days. R42's physician orders do not specify individualized dialysis prescriptions such as the length of treatment time, type of dialyzer, specific parameters of the dialysis delivery system [electrolyte composition of the dialysate, blood flow rate, and dialysate flow rate], anticoagulation or target weight. R42's dialysis communication forms dated 1/2/26, 4/8/26, 4/10/26, 4/15/26, 4/22/26, 5/25/26, 6/3/26, and 6/10/26 lack documentation by the facility prior to dialysis treatments. On 6/29/26 at 10:40am, V12 (Registered Nurse) stated that on dialysis days the resident's nurse is to send a dialysis communication sheet with the resident when they go to dialysis but was unsure if they are to fill out the top portion of the form. V12 stated, I know we have orders to do his (R42) blood pressure on off days but I am not sure if we are to be doing vital signs (blood pressure, temperature, respirations, pulse and weight) prior to him going to dialysis. He goes every Monday, Wednesday and Friday early in the morning before my shift. V12 also verified that R42's physician orders did not specify where R42 goes to dialysis, dialysis prescription, anticoagulation, or target weight. On 6/29/26 at 1:17pm, V2 (Director of Nursing) stated she has never seen the location of dialysis on the physician orders because they only have one location that the dialysis residents use and thought they only need what type of dialysis resident was receiving and the days of treatment on the orders. V2 also confirmed that the nurses are to fill in the top portion of the dialysis communication sheets prior to residents going to dialysis and the dialysis center is to fill in the bottom portions and return to the facility. On 6/30/26 at 7:40 AM V13 (Registered Nurse) reported the dialysis communication form does not return with the residents who go to the dialysis center. On 6/30/26 at approximately 10:40am V18 Care Plan Coordinator verified there was no documentation of R1's dialysis access site present in R1's current medical record, Care Plan or Physicians Orders. On 6/30/26 at approximately 10:45 am, V15 Transporter/Medical Records stated the Dialysis Communication Form has an area for the facility Nurses to fill out prior to the resident's transfer to the dialysis unit and an area designated for the dialysis unit staff to complete after the resident's dialysis treatment is completed and prior to transport back to the facility. V15 stated the lack of completed Dialysis communications Forms has been an ongoing issue. The facility was unable to provide completed Dialysis Communication Forms for R1, R3, and R42 documenting vital signs, weight and condition information by facility Nursing staff upon transportation to the local dialysis unit, nor the documentation by the dialysis unit staff for the facility Nursing staff, identifying the resident's condition and vital signs upon completion of the dialysis treatments.

Based on interview, observation and record review the facility failed to ensure staff utilized appropriate PPE/Personal Protective Equipment during mechanical lift transfer of one resident (R5) on Enhanced Barrier Precautions and failed to post Enhanced Barrier Precautions alert signage for one (R47) of 24 residents reviewed for Infection Control in the total sample of 68. The facility's Enhanced Barrier Precautions policy, dated 03/21/24 documents the following: It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms (MDRO). Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for .residents with wounds or indwelling medical devices. Initiation of Enhanced Barrier Precautions – b. Implement enhanced barrier precautions for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices.even if the resident is not known to be infected or colonized with a MDRO. High=contact resident activities include: c. Transferring; h. Wound care: any skin opening requiring a dressing. 1. R47 is a [AGE] year-old resident with diagnoses including: Lymphedema; Colostomy and Bilateral Lower Extremity (BLE) Venous Ulcers. R47's current Open-Ended Physicians Order by V21 documents: Enhanced Barrier Precautions related to Ostomy. R47's medical record included the following Open-Ended treatment orders by V14 NP/Nurse Practitioner & Wound Specialist: Colostomy: Empty bag. As Needed and Perform care Every Shift; Days, Nights, as well as extensive wound treatments and dressing change orders dated 6/18/26, by V14, for Left and Right Lower Extremity open wounds. R47's current Care Plan documents the following: Problem Start Date: 06/07/26: (R47) admitted to facility with venous ulcers to her BLE (Bilateral Lower Extremities). as well as the Problem: (R47) requires Enhanced Barrier Precautions d/t (due to) colostomy and open wound. On 6/28/26 at 10:00am no EBP signage was posted on or near R47's room door to alert staff and visitors to the need for PPE/Personal Protective Equipment during high-contact activities. On 6/29/26 at approximately 9:35am, V9 Wound Nurse stated R47 receives extensive daily treatments and dressing changes for multiple open ulcers on both lower legs. On 6/29/26 at 11:00am R47 was seated in her room with dressing wraps in place to both of her lower legs. Obvious drainage was present through both dressing wraps. R47 stated nursing staff change her dressings daily. There was no signage identifying the need for Enhanced Barrier Precautions present on or around R47's door. On 6/29/26 at approximately 11:25am, V9 removed the soiled dressing wraps from R47's legs exposing multiple open wounds present on R47's lower legs. On 6/30/26 at approximately 10:0am V3 Infection Preventionist verified there was still no EBP alert signage present on R47's door area and R47 should have EBP signage posted on or near the door in order to alert staff and visitors to the need for specific PPE for high-contact activities. 2. R5's resident face sheet documents R5's date of re-admission to the facility was 3/23/26 and R5's diagnoses include but are not limited to Pressure Ulcer of Sacral Region Stage 4, Type 2 Diabetes Mellitus without complications, and Urinary Tract Infection site not specified-VRE (Vancomycin (Antibiotic)-resistant Enterococci (bacteria).) R5's physician orders dated 3/23/26 documents R5 has an order for Enhanced Barrier Precautions, and strict isolation due to positive wound culture. R5's physician orders also document that R5 has an indwelling urinary catheter and treatment for coccyx wound to be completed daily and as needed. R5's current care plan documents that R5 has an indwelling urinary catheter, stage 4 (four) pressure ulcer to her coccyx and requires Enhanced Barrier Precautions due to indwelling medical device, open wound with intervention to wear gown and gloves when performing high-contact resident activities and transfers via sit to stand lift. On 6/29/26 at approximately 10:00am V8 and V10 (Both Certified Nursing Assistants) observed getting ready to transfer R5 per sit-to-stand mechanical lift. V8 observed placing mechanical lift sling around R5's upper torso wearing only gloves. On 6/29/26 at approximately 10:15am V8 confirmed she should have been wearing a gown and gloves when placing mechanical lift sling around R5 since it was a high contact activity.

Based on observation, interview, and record review, the facility failed to ensure staff respected R1's right to refuse care, failed to prevent staff from using physical force during care, and failed to protect R1 from abuse when staff held R1's arms and hands down and provided care against R1's expressed refusal while R1 repeatedly yelled No, Get off me, and Let go of me. These failures resulted in R1 being manually restrained during care, caused R1 fear, distress, and psychosocial harm, and created Immediate Jeopardy to resident health and safety.These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 10/28/25 when staff forced care on R1 despite R1's refusal and signs of distress. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 5/28/26 at 9:25 am. While the immediacy was removed on 5/30/26, the Facility's noncompliance remained at a Severity Level Two due to the need for additional monitoring to evaluate the implementation and effectiveness of the facility's plan of correction.Findings include:The facility's Abuse Prevention policy, dated 2/2020, documented the facility affirms the right of residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. The policy documented abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy further documented a physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to a resident's body that the resident cannot remove easily and that restricts freedom of movement.The facility's Resident Rights policy, undated, documented residents must not be abused by anyone physically, verbally, mentally, financially, or sexually. The policy documented the facility must make reasonable arrangements to meet residents' needs and choices.R1's Face Sheet documented R1 had diagnoses including vascular dementia, anxiety, depression, and chronic pain.R1's Care Plan documented R1 had behaviors including refusal of care, yelling/screaming out, harm to others/combative behavior with care, and difficulty falling or staying asleep. The Care Plan directed staff, when R1 became combative during care to the point staff safety was threatened, to ensure R1 was safe, remove themselves from the situation, and re-attempt care later. The Care Plan also directed staff to allow R1 to make decisions regarding the scheduling of care, redirect or intervene when R1 had increased agitation, and anticipate R1's needs to decrease agitation. Staff violated the Care Plan when they continued providing care after R1 repeatedly refused and became increasingly agitated, physically held R1's arms instead of removing themselves from the situation, and failed to stop and re-approach later as directed by the individualized interventions.On 10/28/25 at 10:17 AM, a video recording taken in R1's room showed V3, V4, and V7/Certified Nursing Assistants entered R1's room and stated R1 needed to be cleaned up. R1 immediately responded, no, several times. V3 stood on R1's right side of the bed and attempted to wash R1's face. R1 continued to state, no, and grabbed toward V3. V4 stood on R1's left side of the bed and held R1's left hand and wrist. R1 yelled, get off me, and attempted to pull his arm away from V4. V3 told R1 to stop and continued washing R1's face while holding R1's right arm with her left hand.Approximately two minutes and twenty-seven seconds into the recording, V6/Licensed Practical Nurse entered the room. V4 pulled the sheet off R1's groin area, exposing R1's penis. R1 stated, hey, get off of me, while V7 began washing R1's perineal area. R1 continued yelling, Hey, get off of me, and attempted to pull his arm away from V3. V3 told R1, stop, and you need to get cleaned up. R1 responded, no, I don't. As V7 continued washing R1's perineal area, R1 repeatedly yelled, let go of me, and attempted to pull his arm away from V3. R1 pulled against V3's hold with enough force that V3's upper body moved.Approximately eight minutes and four seconds into the recording, V3 and V4 released R1's hands. R1 then calmed, stopped yelling for staff to get off him, and the situation de-escalated. Throughout the recording, R1 remained lying flat during care and showed physical and emotional distress, including noticeable changes in breathing, use of accessory muscles, and abdominal breathing.On 5/26/26 at 11:59 AM, V5/R1's family member stated R1 had a video monitoring system in R1's room that V5 reviewed frequently to check on R1. V5 stated the video showed R1 saw V3/CNA, V4/CNA, and V7/CNA approach the door to R1's room to provide care, and R1 immediately began yelling, No, loudly before care began. V5 stated none of the staff listened to R1 or asked if it was okay to wash him. V5 stated staff told R1 they were going to clean him up and then held R1's arms and hands while he was naked, lying in bed, pulling away, and yelling out.V5/R1's family member stated V3 and V4 held R1's arms and hands down to prevent him from moving while V7 cleaned his perineal area. V5 stated R1 yelled out the entire time care was provided and continued to refuse, but staff did not stop or listen to him. V5 stated anyone could tell R1 was in distress and wanted them to stop. V5 stated V5 made V2/Director of Nursing aware of the incident and was told by V2 staff held R1's arms to keep him from swinging at them because they had to give him a bath, even if it meant holding his arms. V5 stated V2 then asked, at what point is it neglect if we don't make him get cleaned up? V5 stated, R1 was forgetful, but he was able to make his needs known. Do they think it's okay to do that to people who are forgetful or confused and they have no rights because of that? That is wrong, and what I saw on the video is the definition of physical assault and battery.On 5/27/26 at 11:25 AM, V1/Administrator stated V1 and V2/DON were made aware of the incident by V5/R1's family member in October 2025 and reviewed the video when V5 sent it to them. V1 stated V5 alleged staff held R1 down against his will during care. V1 stated, we did not think it was abuse. V1 confirmed V3/CNA and V4/CNA held R1's hands and arms during care to keep staff from being hit while they bathed him. V1 stated R1 was a terrible, terrible resident to care for and it was a very difficult situation all around. V1 stated facility staff did the best they could to care for him.During the survey, V1/Administrator provided an in-service record titled Caring for Residents with Dementia, dated 10/29/25. The in-service documented, Forcing a person with dementia to bathe is illegal, constitutes assault, and is a form of elder abuse. The in-service further documented resistance to bathing is common among persons with dementia and is often related to confusion, fear, discomfort, sensory sensitivity, anxiety, memory loss, pain, and loss of control and dignity.On 5/27/26 at 12:20 PM, V3/CNA (who was present in the room on 10/28/25 providing care) stated (staff CNAs and nurses) had to hold R1's hand and arms during cares because he resists and refuses most of the time. (Staff) have to provide care to him regardless of his refusals because (staff) would get reprimanded for not providing cares.On 5/28/26 at 9:25 AM, V2/Director of Nursing confirmed she saw the video and confirmed V5/R1's family member reported an allegation of abuse in October 2025. V2 stated V1/Administrator and V2/DON did not think the CNAs holding R1's arms and hands to provide care was abuse. V2 stated she was unsure when refusal of care became neglect for a resident like R1 because R1 always refused care, but staff had a responsibility to provide care. V2 confirmed the staff in the room should have left the room and re-approached R1 after R1 said no and began yelling.On 5/28/26 at 9:57 AM, V6/LPN (who was present in the room on 10/28/25) stated, I was pregnant, and the CNAs were concerned about me when providing cares for R1. They would hold R1's hands and arms down so R1 would not hurt me. There were times when we would leave the room and re-approach R1 and it did work. We should have left the room that day and re-approached him. I was not aware that holding someone's hands and arms to provide care while they're refusing is abuse. I would not do this to any other residents who refused.On 5/28/26 at 11:48 AM, V7/CNA (who was present in the room on 10/28/25) stated she was only employed for a short time at the facility and stated, that's why I am not there anymore in reference to the care provided to R1.On 5/28/26 at 12:10 PM, V10/Nurse Practitioner stated it was not appropriate to hold a resident's arms down while providing care. V10 stated staff should fully explain what they are going to do before and during each step of care for a resident with dementia. V10 stated staff should have stopped when R1 began yelling out and then re-approached him.V1/Administrator and V2/Director of Nursing were notified of the Immediate Jeopardy on 5/28/26 at 9:25 AM.Abatement plan was received on 5/28/26 at 12:58 PM and was not approved. Revisions were requested.Abatement plan was resubmitted on 5/28/26 at 3:13 PM and was not approved. Revisions were requested.Abatement plan was resubmitted on 5/29/26 at 12:28 PM and was not approved. Revisions were requested.Abatement plan was resubmitted on 5/29/26 at 1:59 PM and was approved.On 5/30/26 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:1. R1 no longer resides in the facility.2. On 5/28/26 an immediate facility-wide assessment was completed by V13 (Licensed Practical Nurse) to identify any residents at risk for abuse, inappropriate staff interventions, or improper handling of refusal of care. 3. On 5/27/26, all staff, including staff on leave or on vacation, were in-serviced by V13/LPN, V21, and V2 on the following: The facility Abuse & Retaliation Prevention Policy, to include assault by staff members if physically restraining a resident against their will while providing care. Resident rights and refusal of care include de-escalation of resident behaviors. All staff completed a post test on 5/28/26 to gauge their knowledge.4. On 5/28/26, pending an investigation, V22 (Corporate Director of Operations) suspended all staff (V1, V2 & V3) involved in the finding of Immediate Jeopardy. Completed 5/30/26

Based on interview and record review, the facility failed to ensure timely assessment, monitoring, physician notification, diagnostic evaluation, and intervention for significant changes in condition related to urinary catheter complications and signs and symptoms of urinary tract infection (UTI) for one (R1) of three residents reviewed for urinary catheters in the sample of three. The facility failed to recognize, investigate, escalate, and respond to repeated abnormal urinary findings and changes in condition despite R1's known history of recurrent UTIs, urosepsis, and rapid clinical decline requiring prior hospitalizations. The facility's repeated failure to identify and respond to ongoing signs and symptoms consistent with urinary tract infection and catheter complications resulted in delayed medical treatment and caused R1 to experience acute clinical deterioration, respiratory distress, sepsis secondary to urinary tract infection, supraventricular tachycardia requiring cardioversion, mechanical ventilation by bag-valve mask, positive airway pressure intervention, emergency hospitalization, and subsequent death on [DATE]. The facility's failure to recognize and respond to significant changes in condition related to infection created a situation likely to cause serious injury, harm, impairment, or death to residents. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when V16/Registered Nurse first documented abnormal urinary findings consistent with urinary tract infection and catheter complications and failed to initiate physician notification or intervention despite R1's history of recurrent urosepsis and hospitalizations. V22/Vice President of Operations was notified of the Immediate Jeopardy on [DATE] at 3:45 PM. The surveyor confirmed through interview and record review the Immediate Jeopardy was removed on [DATE]; however, noncompliance remained at a Severity Level Two due to the need for additional monitoring to ensure sustained implementation and effectiveness of corrective actions.Findings include: The facility's policy titled, Catheter Care, Urinary, dated 2005, documented the purpose of the procedure was to prevent infection of the resident's urinary tract. The policy further documented staff were to observe urine for unusual appearance including abnormal color and blood, observe the resident for signs and symptoms of urinary tract infection and urinary retention, and report findings to the supervisor immediately.The facility's policy titled, Urinary Tract Infections/Bacteriuria - Clinical Protocol, dated 6/2014, documented staff and practitioners were responsible for identifying individuals with signs and symptoms suggesting possible urinary tract infection. The policy further documented nurses were to observe, document, and report signs and symptoms including fever and hematuria in detail. Acute deterioration in previously stable chronic symptoms may indicate acute infection. Multiple concurrent findings, including fever with hematuria or catheter obstruction, were more likely to reflect a urinary source. The physician was to assist staff in identifying suspected sepsis related to urinary tract infection and determine whether hospitalization was warranted.The facility's policy titled, Change in a Resident's Condition or Status, dated 8/2008, documented the facility shall promptly notify the physician and resident representative of changes in the resident's condition or status. The policy defined a significant change as a decline or improvement that would not normally resolve itself without intervention, impacted more than one area of health status, and required interdisciplinary review or revision to the care plan. The policy further documented notification would occur as soon as possible and within 24 hours of the change.R1's Face Sheet documented R1 has diagnoses including history of UTIs, COPD (Chronic Obstructive Pulmonary Disease), urinary retention, depression, anxiety, and presence of indwelling urinary catheter. R1's Care Plan documented R1 requires an indwelling urinary catheter for urinary retention with interventions to assess drainage, change catheter as ordered, provide catheter care every shift and as needed, avoid obstruction in drainage, and report UTI symptoms (acute confusion, urgency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, and blood in urine).R1's progress notes were reviewed between [DATE] and [DATE], facility nursing staff documented ongoing abnormal urinary findings including blood-tinged urine, dark urine, thick sediment, mucus, orange urine, catheter obstruction findings, and decreased urinary output without documented physician or practitioner notification, nursing assessment, implementation of interventions, diagnostic testing, increased monitoring, or escalation of care. Multiple licensed nurses confirmed during interview they documented the abnormal urinary findings but did not notify the provider of a change in condition, nor were any interventions put in place until [DATE] when R1 was required emergency response.R1's labs were reviewed for this same time period and there were no lab results.V10/Nurse Practitioner progress notes between [DATE] and [DATE] were reviewed. There was no documentation addressing abnormal urinary findings despite nursing documentation during the same period identifying abnormal urinary symptoms. The progress notes documented diagnoses including recurrent urinary tract infections and urinary retention.On [DATE] at 11:59 AM, V5/R1's family member stated V5 maintained a video monitor in R1's room and repeatedly notified facility staff regarding concerns related to R1's urinary catheter and urine appearance including decreased output, blood, mucus, sediment, and lack of catheter irrigation on multiple occasions including [DATE], [DATE], [DATE], and [DATE]. V5 stated V5 was unaware if staff provided follow-up regarding interventions or further evaluation before R1's hospitalization on [DATE]. V5 stated, I am a registered nurse and was concerned he was septic because of all of these urinary symptoms and his history of urosepsis requiring hospitalizations.Interviews were conducted with V6/Licensed Practical Nurse, V12/Registered Nurse, V13/Licensed Practical Nurse, V14/Registered Nurse, V15/Registered Nurse, and V16/Registered Nurse regarding nursing progress notes documenting abnormal urinary findings for R1. All confirmed they documented abnormal urinary symptoms on multiple occasions and did not notify the provider regarding the change in condition.R1's nursing progress note, dated [DATE], documented bloody thick mucus discharge dried to R1's sheets and peri-area with blood-tinged urine noted in the urinary catheter tubing. There was no documentation of physician or practitioner notification, further assessment, diagnostic testing, intervention, or monitoring related to these findings.From [DATE] through [DATE], facility nursing staff entered 43 nursing progress notes documenting R1's abnormal urinary findings including dark urine, thick sediment, mucus, bloody or blood-tinged urine, and orange urine without documentation of physician notification, nursing assessment, diagnostic evaluation, implementation of interventions, or escalation of care.A nursing progress note entered by V6/LPN, dated [DATE], documented R1 was transferred to the emergency department by ambulance due to fever and respiratory distress.On [DATE] at 9:57 AM, V6/LPN stated the CNA working on [DATE] came and told her something was off with R1. V6 stated R1 was shaking, mumbling, and looked panicked when she entered R1's room on [DATE]. R1 had a fever and elevated respiratory rate. I didn't observe his catheter or urine that morning. V5 further stated V5 was not aware R1 had a significant history of UTIs with sepsis requiring hospitalizations. An attempt was made to call V10/Nurse Practitioner without success and EMS (Emergency Management Services) were called. R1 had dark urine, bloody urine, mucous, and malodorous often. It was always like that and V6 stated she did not report it to the physician. V6 stated she would report these symptoms for any other resident if symptoms persisted. R1's Ambulance Service Report dated [DATE] documented upon arrival emergency personnel found R1 in respiratory distress with cyanosis. Oxygen was initiated without improvement. R1 became less responsive and continued to decline. CPAP was initiated followed by bag-valve-mask ventilation due to worsening respiratory failure and unresponsiveness. Upon arrival to the emergency department, R1 was documented to be in supraventricular tachycardia with a heart rate of 236 while remaining unresponsive and requiring ventilatory support.R1's Emergency Department Provider Note dated [DATE] at 10:18 AM documented R1 arrived from the nursing facility in respiratory distress and altered mental status. The emergency department physician documented R1 had an indwelling Foley catheter with brownish sediments in the tube. Diagnoses included sepsis secondary to urinary tract infection, acute respiratory failure, and atrial fibrillation/supraventricular tachycardia refractory to cardioversion and medication intervention.R1's Hospital Genitourinary assessment dated [DATE] documented the Foley catheter tubing was obstructed in multiple areas with thick mucus and dried dark substances. Upon removal of the catheter, large amounts of brown, thick, mucous, foul-smelling drainage immediately expelled from the urethra saturating eight towels before slowing. Hospital documentation described the urine as brown, cloudy, concentrated, purulent, with mucus and sediment.R1's Hospital Emergency Documentation dated [DATE] documented after discussion regarding prognosis and sepsis diagnosis, R1's family elected to change R1's code status to comfort measures only.R1's Hospital Discharge Documentation dated [DATE] documented R1 expired on [DATE] at 12:28 PM.R1's death certificate documented the cause of death as respiratory failure secondary to sepsis.On [DATE] at 12:10 PM, V10/Nurse Practitioner stated R1 had a long history of recurrent urinary tract infections, urosepsis, and hospitalizations related to urosepsis and confirmed R1 declined rapidly when septic. V10 stated abnormal urinary findings including dark urine, sediment, blood, or mucus should have been reported to the provider for further follow-up and intervention. V10 confirmed there was no documented provider notification related to R1's urinary symptoms between [DATE] and [DATE]. V10 further confirmed if the provider had been notified regarding R1's urinary symptoms and change in condition, interventions could have been initiated sooner.On [DATE] at 2:20 PM, V9/Infection Preventionist stated symptoms of a possible urinary tract infection included foul-smelling urine, blood in the urine, sediment, mucus, and dark tea-colored urine.On [DATE] at 3:15 PM, V9/Infection Preventionist stated nursing staff should notify the physician regarding urinary abnormalities suggestive of infection and document physician notification in the medical record.On [DATE] the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:The abatement plan was submitted and accepted on [DATE] at 6:42 PM.R1 no longer resided in the facility.On [DATE], all licensed nurses, including those on leave or vacation status, received education regarding timely assessment, monitoring, physician notification, and intervention for urinary catheter complications and signs and symptoms of urinary tract infection. Education included assessment and escalation of changes in condition related to urinary abnormalities and infection. Post-testing was completed to evaluate staff understanding.On [DATE], all certified nursing assistants, including those on leave or vacation status, received education regarding signs and symptoms of urinary tract infection and the requirement to immediately report abnormalities to licensed nursing staff. Post-testing was completed to evaluate staff understanding.On [DATE], all residents with indwelling urinary catheters were assessed for signs and symptoms of urinary tract infection by facility nursing management and infection prevention staff.On [DATE], care plans for residents with urinary catheters were reviewed and updated to address monitoring and reporting of catheter-related complications and signs and symptoms of infection.All residents with indwelling catheter devices were assessed for a urinary tract infection.All Careplans for residents with catheters have been reviewed and updated as needed.The Medical Director was made aware.Quality Assurance monitoring was put into place.Completion Date: [DATE]

Based on interview and record review the Facility failed to notify medication changes to a Resident Representative for one of seven Residents (R1) reviewed for new medications in a sample of seven.Findings include:The Notification of Change Guideline Policy, dated 10/1/24, documents: it is the practice of the Facility that changes in Resident condition or treatment are immediately shared with the Resident or Resident Representative, according to their authority, and are reported to and consulted with the attending physician; resident/resident representative will be educated about treatment options and supported to make an informed decision; objective of the notification guidelines is to ensure Facility staff make appropriate and immediate notification to the Resident and/or Representative when there is a change in condition (significant treatment alteration including commencing a new form of treatment; document the notification and record any new orders in the Residents medical record; educate the Resident/Resident Representative about the plan to treat, risks and benefits of the proposed treatment.R1's Physician Order Sheet/POS, dated 2/1/26 through 2/28/26, documents R1's diagnoses including Vascular Dementia, with other behavioral disturbance, Major Depressive Disorder, Anxiety Disorder and Degenerative Disease of Nervous System. The POS also documents an order for an anti-depressant medication (Mirtazapine/Remeron) with a start date of 10/20/25 once a day at 5:00 pm and an insomnia medication (Rozerem/Ramelteon) with a start date of 12/8/25 at 8:00 pm.R1's current Care Plan documents: is at risk for adverse consequences related to receiving antidepressant medication (problem start date 09/02/2025); and displays long and short-term memory deficits as evidenced by Brief Interview for Mental Status/BIMS (score 7/15); and diagnosis of Vascular Dementia, moderate, with other behavioral disturbance (problem start date 09/02/2025).R1's Face Sheet documents V5 (R1's Power of Attorney/Sister) as R1's Emergency Contact and Power of Attorney.R1's Nursing Progress Notes, dated 10/20/25 and 12/8/25, do not document notification of medication changes to V5 (R1's Power of Attorney/Sister).R1's Informed Consent for Psychotropic Medications form for Remeron/ Mirtazapine, dated 10/20/25, does not document V5 (R1's Power of Attorney) signature.R1's Informed Consent for Psychotropic Medications form for Rozerem/Ramelteon, dated 12/8/25, does not document V5 (R1's Power of Attorney) signature.On 5/26/26 at 11:59 am, V5 (R1's Power of Attorney/Sister) stated, I am (R1's) power of attorney and I was not notified of any medication changes that they put my brother (R1) on, and they let him (R1) sign the consents, not me, for the phototropic medications. R1 is cognitively impaired, I am not sure how he was able to sign for consent and understand the medications.On 5/30/26 at 11:00 am, V2 (Director of Nursing) stated, It is our policy to notify a power of attorney and also have them sign required consents for medications changes especially when we have a cognitively impaired Resident.

Based on record review and interview the Facility failed to initiate appropriate fall interventions for one of four Residents (R6) reviewed for falls in a sample of six.Findings include:The Facility Fall Clinical Protocol Policy, revised 8/2008, documents: as part of the initial assessment, the Physician will help identify individuals with a history of falls and risk factors for subsequent falling; staff will continue to collect and evaluate information until either the cause of falling is identified, or it is determined that the cause cannot be found, or that finding a cause would not change the outcome or management of falling and fall risk; based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling; and staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.The Facility Resident Rights Policy, dated 2007, documents Personal Safety, the Resident has the right to expect safety as the Facility practice and environment are concerned.R6's current Care Plan, documents: diagnoses including Cerebrovascular Accident/CVA, Osteoarthritis, Depression, Diabetes and Depression; Activities of Daily Living performance deficit related to CVA and Hemiplegia affecting the right dominant side; and behaviors of agitation with difficulties falling/staying asleep; short term memory deficits. The Care Plan also documents the 2/14/25 fall interventions as educating on keeping wheelchair brakes locked; the 4/21/25 fall interventions as sign placed in room reminding to wear non-skid socks or shoes at all times; and the 7/5/25 fall interventions as non-skid strips placed on bathroom floor and a sign in room and bathroom reminding to lock wheelchair brakes.R6's Minimum Data Set/MDS documents: Section C (Cognitive Patterns), dated 3/18/25, documents moderate cognitive loss on R6's Brief Interview for Mental Status/BIMS (score 8/15); and Section GG (Functional Abilities) requiring substantial/maximal assistance with transfers.The Facility Fall Report, dated 2/1/25 through 2/28/25, documents R6's fall on 2/14/25 at 1:00 pm. R6 was found on the floor in the common area.The Facility Fall Report, dated 4/1/25 through 4/30/25, documents R6's fall on 4/21/25 at 2:20 pm. R6 was found on the floor in the common area.The Facility Fall Report, dated 7/1/25 through 7/31/25, documents R6's fall on 7/5/25 at 12:00 am, in R6's bathroom. R6's Event Report, dated 2/14/25 at 1:00 pm, documents R6 slid from unlocked wheelchair while trying to grab a boxed puzzle from the bottom shelf on the television stand in the common area (Day Room). The Event Report documents that R6 was screaming for help on right side, wheelchair unlocked and not near him; R6 stated that R6 slid from the wheelchair while trying to grab a puzzle.R6's Fall Details Report, dated 4/21/25 at 2:20 pm, documents R6 was found lying on right side on floor next to toilet, call light was off, wheelchair not in use and was off to side and R6 only wearing socks on feet. The Fall Details Report documents an intervention of a sign placed in R6's room to remind to wear non-skid socks or shoes at all times.R6's Event Report, dated 7/15/25 at 12:00 am, documents R6 had an unwitnessed fall in R6's bathroom. R6 was found sitting on the bathroom floor with wheelchair against the wall from R6. R6 stated that when R6 attempted to transfer back to wheelchair, the wheelchair rolled away from R6, causing R6 to land on the floor.On 8/14/25 at 11:50 am, V10 (Restorative Nurse/Licensed Practical Nurse) stated, I do understand that just educating (R6) or placing signs in (R6's) room was probably not the best intervention, given his cognition.On 8/14/25 at 1:00 pm, V2 (Director of Nursing) stated, We probably need different interventions for (R6) other than just educating or putting signs in (R6's) room. V2 verified that R6 is cognitively impaired and that the fall interventions were not appropriate for R6.

Based on observation, interview and record review the facility failed to perform hand hygiene after glove removal for two (R41 and R119) of 18 reviewed for infection control and failed to adhere to masking during an influenza outbreak. The failure of non-masking has the potential to affect all 71 residents currently residing in the facility. Findings Include: The Facility's undated Preventing and Controlling ARI (Acute Respiratory Illness) in Skilled Nursing Facilities and Other Facilities Providing Nursing Care documents Ensure everyone, including residents, visitors, and HCP (Health Care Providers) are aware of recommended Infection Prevention and Control (IPC) practices in the facility, including when specific IPC actions are being implemented in response to new infections in the facility or increases in respiratory virus levels in the community. Source control is recommended for individuals in health care settings who have suspected or confirmed respiratory infection or respiratory trends or observed trends). The facility Urinary Catheter Care policy and procedure, dated September 2005, documents The purpose of this procedure is to prevent infection of the resident's urinary tract. Staff are to wash and dry hands thoroughly, put on gloves, provide catheter care, discard disposable items, remove gloves, discard gloves, wash and dry hands thoroughly, reposition bed coverings, make resident comfortable, place call light, clean wash basin and bedside table, and to then wash and dry hands thoroughly again. The facility Hand-Washing/Hand Hygiene Policy, dated March 2020, documents It is he policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids. When hands are not visibly soiled, employees may use an alcohol-based hand rub (foam, gel, liquid) containing at least 60% alcohol in all of the foolwing situations: a. before direct contact with residents; b. after direct contact with a resident but prior to direct contact with another resident; c. before donning gloves; g. before moving from a contaminated body site to a clean body site during resident care; h. before and after putting on and upon removeal of PPE (personal protective equipment), including gloves; i. after contact with a resident's intact skin; j. after handling used dressings, potentially contaminated equipment; l. after contact with potentially infectious material; m. after removing gloves. The use of gloves does not replace compliance with hand-washing/hand hygiene procedures. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol, and wash with soap and water as soon as possible. The facility Personal Protective Equipment - Using Gloves policy and procedure, dated June 2005, documents Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) 1. On 4/6/25 at 6:00 AM a sign indicating the facility was in Flu (Influenza) Outbreak Status and Masking beyond this point is recommended, please see nurse with questions was on the entry doorway to the facility. On 4/6/25 at 8:00 AM V14 (Infection Preventionist) stated that the facility was in flu outbreak status due to a resident testing positive. We put all the residents on TamiFlu and are masking. On 4/8/25 at 10:30 AM V5 (Hairdresser) standing in the North hallway speaking with another staff member. V5 did not have a mask on. V5 stated No one told me we were wearing masks. All staff, including the staff member V5 was speaking to had masks on. V5 continued to walk from North Hall to South Hall with no mask on. On 4/8/25 at 10:35 AM V14 (Infection Preventionist) stated that anyone who walked through the entire building without a mask on during a flu outbreak status would be putting all residents at risk of getting the flu. Why do you ask? We do not have any families or visitors that I know of that refuse to mask when we ask them to. On 4/9/25 at 2:20 PM, V1 Administrator stated the facility recommends all staff, contracted staff, and visitors to wear masks during the facility flu outbreak. 30678 2. The current Care Plan for R41 documents R41 requires Enhanced Barrier Precautions due to indwelling urinary catheter and interventions including: Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures; Use Principles of infection control and enhanced barrier precautions; Teach resident/caregiver the chain of infection/methods of transmission; and Practice good handwashing. On 4/8/25 at 11:15 AM V18 CNA (Certified Nursing Assistant) performed indwelling urinary catheter care for R41. After completing care, with same soiled gloves on, V18 CNA assisted R41 with pulling up his pants, and threw garbage into R41's garbage can. V18 CNA then removed her gloves and applied a new set of gloves without performing hand hygiene, covered and positioned R41 with a bed sheet, moved R41's overbed table next to R41's bed, opened the window blinds, pulled back the privacy curtain, got into R41's nightstand retrieving a chocolate candy bar and handed it to R41. 3. The current Care Plan for R119 documents R119 requires Enhanced Barrier Precautions due to indwelling urinary catheter and interventions including: Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures; Use Principles of infection control and enhanced barrier precautions; Teach resident/caregiver the chain of infection/methods of transmission; and Practice good handwashing. On 4/8/25 at 10:52 am, V18 CNA (Certified Nursing Assistant) performed indwelling urinary catheter care for R119. After completing care, with same soiled gloves on, V18 CNA applied R119's clean brief and pulled up R119's pants. V18 CNA removed her soiled gloves and applied a new set of gloves without performing hand hygiene, placed call light in R119's hand, picked up R119's oxygen nasal cannula from the bed and placed it to R119's nares and wrapped around R119's ears. On 4/8/25 at 11: 35 AM, V17 LPN (Licensed Practical Nurse) and V18 CNA confirmed V18 CNA did not perform hand hygiene after removing her soiled gloves and should have. V17 LPN and V18 CNA confirmed V18 CNA should not have touched anything prior to washing her hands. V17 LPN stated she provided V18 CNA with hand sanitizer and V18 CNA stated she had hand sanitizer in her pocket.

Based on observation, interview and record review the facility failed to ensure food stays warm for six residents (R11, R12, R26, R47, R50, and R119) of six residents reviewed in a total sample of 33. Findings Include: The Facility's undated Hot Food Service Temperatures policy documents foods will be served to the residents at a temperature that is palatable to prevent injury such as burned mouth or lips. Food will be offered to be reheated if it is not within resident's preferred food temperatures or another tray will be offered. On 4/8/25 at 8:30 AM R11, R12, R26, R47, R50, and R119's breakfast trays were sitting out on the dining room tables with either a lid or other plates on top of the dishes. R11, R12, R26, R47, R50, and R119 were not in the dining room at this time. On 4/8/25 at 8:35 AM V4 (Certified Nurse Aid/Transportation) stated that these residents had not come out to the dining room yet and she wasn't sure how long the trays had been sitting at the tables without residents present. V4 stated that staff routinely deliver trays to the resident's regular spot whether the resident is present or not. V4 stated I told them (R26) was in the shower. She is going to be a while. The food back here (assisted area of dining room) is not always hot when I feed it to the residents because people put it on the table whether or not the person is here. On 4/8/25 at 8:40 AM V6 (Dietary Manager) entered the dining room and asked V4 (Certified Nurse Aid/Transportation) where R11, R12, R26, R47, R50, and R119 were. V4 stated she did not know. V6 picked up R47's tray and walked it to R47's room. R47 was sitting in her recliner with her eyes closed. V4 (Dietary Manager) sat meal tray on R47's bedside table and left the room. Food temperatures at that time were scrambled eggs 89 degrees Fahrenheit and sausage 88 degrees Fahrenheit. R47 was pleasantly confused and did not answer any questions in a sensical manner. On 4/8/25 at 8:50 AM R11, R12, R26, R50, and R119's trays were no longer in the dining room. V4 (Certified Nurse Aid/Transportation) stated she didn't know where the trays went. On 4/8/25 at 9:30 AM V6 (Dietary Manager) stated that food should only be served if the residents are present. We have a lot of food temperature complaints because once the food leaves the steam table it automatically starts to lose temperature.

Based on interview and record review the facility failed to identify, monitor, and review prophylactic antibiotic use for four of four residents (R17, R21, R38, R49) for antibiotic stewardship in the sample of 33. Findings include: The Infection Prevention and Control Program dated 2019 documented an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Antibiotic Stewardship and review including reviewing data to monitor the appropriate use of antibiotics in the resident population. The Infection Preventionist will oversee the facility Antibiotic Stewardship Program. review of the use of antibiotics is a vital aspect of the infection prevention and control program. Involve the consultant pharmacist with the oversight by identifying antibiotics prescribed for resistant organisms. Track antibiotic use monthly and completes an antibiogram yearly or as directed by the Medical Director and the Quality Assurance Committee. The Antibiotic Stewardship Policy dated 11/28/17 documented the physician, nursing and pharmacy are the leads responsible for promoting and overseeing antibiotic stewardship activities. The facility maintains a consultant pharmacist with antibiotic stewardship-specific drug expertise. The facility will utilize the McGeer's criteria when considering initiation of antibiotics. The Infection Control Log documented R17, R21, R8 and R49 had no signs or symptoms and received prophylactic antibiotics for urinary tract infections which were ordered by V13 (Urologist). 1. R17's Face Sheet indicated R17 was admitted on [DATE] with diagnoses of Chronic Respiratory Failure, Tubulo-Interstitial Nephritis and Personal history of Urinary (Tract) Infections. R17's Physician Order dated 4/4/25 and has no end date documented to administer an Antibiotic for Urinary Tract Infection Prophylaxis. 2. R21's Face Sheet documented R21 was admitted on [DATE] with diagnoses of Adjustment Disorder with Mixed Anxiety and Depressed Mood, Neuromuscular Dysfunction of Bladder, Infection and Inflammatory Reaction due to Indwelling Urethral Catheter, Stress Incontinence and Personal history of Urinary (Tract) Infections. R21's Physician's Order dated 11/27/24 through 2/27/25 for an Antibiotic medication was for a Personal History of Urinary Tract Infection. 3. R38's Face Sheet indicated R38 was admitted on [DATE] with diagnoses of Osteoarthritis, Major Depressive Disorder and Interstitial Cystitis. R38's Physician's Order dated 10/15/24 and had no end date documented to administer an Antibiotic and did not indicate a diagnosis/reason for the medication. 4. R49's Face Sheet indicated R49 was admitted on [DATE] with diagnoses of Polyosteoarthritis, Schizoaffective Disorder and Urge Incontinence. R49's Physician's Order dated 1/24/25 through 4/24/25 documented to administer an Antibiotic and did not indicate a diagnosis/reason for the medication. R49's Physician's Order dated 2/28/25 through 4/16/25 documented to administer an Antibiotic for Urge Incontinence. The QA (Quality Assurance) Committee meeting minutes for each quarter of 2024 were reviewed. The attendance sheets documented V15 (Pharmacist) attended the QA meetings on 2/6/25 and 8/6/24. The Consultant Pharmacist's Medication Regimen Review reports included psychotropic medications and did not include antibiotic usage. The Infection Report Summary did not include prophylactic antibiotic use surveillance data. On 4/8/25 at 2:00 PM, V14 (Infection Preventionist) stated Urge Incontinence was not a diagnosis that required an Antibiotic. V14 stated V13 (Urologist) was the only physician that ordered prophylactic antibiotics for urinary tract infections. On 4/9/25 at 2:30 PM, V1 (Administrator) and V2 (Director of Nursing) stated the Antibiotic Stewardship program was not all inclusice and needed improvement.

Based on observation, interview and record review the facility failed to ensure that a resident was treated with respect for one resident (R46) of 18 residents reviewed for respect and dignity in a total sample of 33. Finding Include: The Facility's undated Personal Cell Phone Use documents purpose: to assure that the resident privacy issues are maintained and to eliminate any distraction from responsibilities and duties. Personal cell phones must be turned off when reporting for work and stored in the employee's purse, car, or locker. They are not allowed to be carried on the employee's person while actively working. Employees may check/use their cell phones during break times only Please note employees may not bring the cell phone into any resident areas at any time regardless to break status. On 4/8/25 at 8:30 AM V4 (Transportation/Certified Nurse Aid) was in the dining room assisting R46 while eating. V4 had a utensil in one hand feeding R46 while looking at her phone and texting on her phone with her other hand. V4 stated she did not normally use her phone during cares. On 4/8/25 at 11:00 AM R46 did not answer any questions asked of her. R46's MDS (Minimum Data Set) dated 2/5/25 documents that R46 is rarely/never understood. On 4/8/25 at 2:00 PM V2 (Director of Nursing) and V1 (Administrator) both confirmed that staff should not be on their phones while giving any cares.

Based on observation, interview, and record review the facility failed to ensure chemical restraints were not utilized for one resident (R12) of five residents reviewed for psychotropic medication in a total sample of 33. This failure resulted in over sedation and physical functioning for R12. Findings Include: The Facility's Abuse Prevention Policy and Procedure, dated 2/2020, documents Chemical Restraint is any drug that is used for discipline or convenience and is not required to treat medical symptoms or behavior manifestations of mental illness. The Facility's undated Psychopharmacological Drug Use Procedure documents the procedure is to assure the appropriate monitoring is provided to residents receiving psychopharmacological drugs, that the lowest possible dose necessary for the benefit of the resident to improve or control mood, mental status and/or behavior is utilized, and to reduce or eliminate the usage of these medications. The Facility's undated Psychopharmacological Drug Use Procedure documents Antipsychotic medications in persons with dementia should not be used if one or more of the following is/are the only indication: 1. Wandering 2. Poor self-care 3. Restlessness 4. Impaired memory 5. Mild anxiety 6. Sadness or crying alone that is not related to depression or other psychiatric disorders,7. Insomnia 8. Inattention or indifference to surroundings 9. Fidgeting 10. Nervousness 11. Uncooperativeness (e.g. refusal of or difficulty receiving care). R12's Medical Record documents that she was admitted on [DATE] with diagnosis to include Conversion disorder with seizures or convulsions, generalized anxiety and unspecified dementia, unspecified severity, with other behavioral disturbance. R12's Physician Order Sheet dated March 2024 documents that R12 was admitted on Risperdal 2 mg (milligrams) every night for unspecified Dementia, unspecified severity, with other behavioral disturbance. R12's Medical Record documents that on 11/15/24 she was sent to a hospital for an increase in behaviors. R12's Psychiatric Evaluation from the hospital documented by V22 (Nurse Practitioner) dated 11/22/24 documents (R12)'s aggressive behavior has also continued to get worse, and she would have temper tantrums that would last one to three days with a daughter she was living with. She was continually aggressive with staff at the facility she was residing in. She does have severe Dementia. She also was continually refusing meds, and she was psychiatrically admitted on [DATE]. R12's Medical Record documents that she was readmitted to the facility after hospitalization on [DATE] with a new diagnosis of Bipolar Disorder and her Risperidone had been changed from 2 mg (milligrams) by mouth to Risperidone 125 mg subcutaneous once a month. R12's Behavior/Intervention Monthly Flow Record identified the following behaviors to be monitored for R12: easily agitated, cursing staff, restlessness, non-compliant/getting up by herself, insomnia, false allegations, yelling/screaming at others, crying/tearful, depressed/withdrawn, hallucinations and delusions. R12's Admission MDS (Minimum Data Set) dated 3/31/24 documents that R12 had no hallucinations, or delusions, no physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually), no verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing others), no other behavioral symptoms not directed towards others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), no rejection of care (e.g. blood work, taking medications, ADL (Activities of Daily Living) that is necessary to achieve the resident's goals for health and well-being. R12's MDS (Minimum Data Set) dated 12/25/2024 documents R12 had no hallucinations or delusions, No physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually), no other behavioral symptoms not directed towards others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds. R12's MDS dated [DATE] also documents had no instances of rejection care (e.g. bloodwork, taking medications, ADL (Activities of Daily Living) assistance) that is necessary to achieves resident's goals for health and well-being. R12's MDS documents that she had Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing others) 1 to 3 days out of 7 days. R12's MDS dated [DATE] documents R12 had hallucinations and delusions. R12's MDS documents that R12 had no physical behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing abusing others sexually), no verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others), no other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) and no instances of rejection of care (e.g. blood work, taking medications, ADL assistance)that is necessary to achieves resident's goals for health and well-being. On 4/7/25 at 11:30 AM V21 (Social Services) confirmed the behaviors listed on R12's Behavior/Intervention Monthly Flow Record. V21 stated that the false allegations being monitored for R12 is related to R12 stating that staff members are sleeping with her husband. V21 stated that R12 very easily agitated and can get very nasty when (staff) attempt to do anything (give cares). V21 stated that the yelling/screaming at others behavior can be described as R12 yelling when cares are being done or attempted and that R12 sometimes just yells for nothing. On 4/8/25 at 1:00 PM V7 (Registered Nurse) confirmed that after R12 was admitted in March 2024 she had an increase in aggression and agitation. V7 described the aggression and agitation displayed by R12 to be refusing cares, yelling out, cursing staff and hallucinations/delusions. V7 stated R12's hallucinations/delusions behaviors could be described as speaking in 3rd person, speaking as if she actually is her husband, believing that staff are sleeping with her husband who has been dead for years. V7 stated that R12 can be combative with cares also, but she is very hard of hearing and can't see very well, so that may be some of that. V7 denied any self-harming behavior by R12 stated I know she was putting herself on the floor sometimes, but from what I understood she would just lay on the ground, she did not throw herself on the floor. V7 denied any aggression or violence towards any other residents by R12. V7 stated R12's Risperidone was changed from pill form to shot form because R12 was refusing the pill. R12's Nurse's Note dated 4/2/2025 documents (R12) sleeping in recliner all this morning, was cleaned up and dressed by staff.(R12) would not rouse enough to take oral meds, scheduled insulin given. (R12) typically sleeps for a day or 2 post (Antipsychotic) injection. On 04/08/25 at 1:00 PM V7 (Registered Nurse) stated that R12 is very tired for a couple of days after her antipsychotic medication is administered via injection. V7 reported that R12 has had a significant decline in her physical condition related to her not being able to do as much for herself physically. R12's Admission MDS dated [DATE] documents that R12 used a cane previously, no wheelchair use. R12's MDS indicates that R12 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided through the activity or intermittently) for oral hygiene and toileting hygiene. R12's MDS documents that she required partial moderate assistance (Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for eating, shower/bathe self, dressing upper body and personal hygiene. R12's MDS documents that she required substantial/maximum assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for lower body dressing and putting on footwear. R12's MDS dated [DATE] documents that R12 used a wheelchair. R12's MDS documented that R12 required partial moderate assistance (Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for eating, upper and lower body dressing, putting on footwear and personal hygiene. R12's MDS documents that she required Substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for oral hygiene, toileting hygiene and shower/bathe self. R12's MDS dated [DATE] documents that R12 used a wheelchair. R12 required partial/moderate assistance (helper does less than half the effort. helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for eating and upper body dressing. R12's MDS documents that she required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for oral hygiene and personal hygiene. R12's MDS documents that R12 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene, shower/bathe self, lower body dressing and putting on footwear. On 4/9/25 at 11:00 AM V16 (Nurse Practitioner) stated that R12 was admitted on Risperidone 2 mg (milligrams) in pill form and has had increasing behaviors and has since been admitted to the hospital and her Risperidone was changed from pill form to shot form due to R12 refusing to take the medicine. V16 stated that R12 had many harmful behaviors which have led to V16 declining to reduce her antipsychotic medication. V16 described these behaviors as easily agitated and refusing cares. V16 confirmed that staff from the facility have informed her that R12 sleeps and refuses to participate in any cares for a couple days after she is given the antipsychotic injection. But she comes right back around in a couple of days and begins with the harmful behaviors again. 30678

Based on record review and interview the facility failed to obtain a Preadmission Screening and Resident Review (PASRR) after a significant change in condition for one resident (R12) of one reviewed for PASRRs in a total sample of 33. Findings Include: The Facility Admission policy dated November 2016 documents PASSR screens must be valid and reviewed on admission, annually and upon any significant change. All residents with a newly evident or possible serious mental disorder, intellectual disability, or a related condition should be referred for a level II resident review upon a significant change in status admission. R12's admission Physician Order Sheet dated March 2024 documents R12 was admitted with diagnoses that include but were not limited to conversion disorder with seizures, dementia and anxiety. R12's admission Physician Order Sheet did not include any serious mental illness diagnosis. R12's PASSR Level I dated 3/26/2024 did not document any serious mental illness diagnosis. R12's Nurse's Note dated 11/15/2024 document that R12 was sent to the hospital due to increased behaviors. R12's Nurse's Note dated 11/21/24 documents that R12 was transferred from the area hospital to an inpatient psychiatric hospital related to behaviors. R12's Nurse's Note dated 12/9/24 document that R12 returned to the facility from an inpatient psychiatric hospital stay. R12's Readmission Physician Order Sheet dated December 2024 documents that R12 was on subcutaneous Risperidone 125 mg (milligrams) every month for bipolar disorder. On 4/7/25 at 11:00 AM V21 (Social Service Director) confirmed that R12's bipolar diagnosis was new from her hospitalization in November/December 2024. V21 confirmed that no repeat PASSR had been done. On 4/9/25 at 2:00 PM V1 (Administrator) confirmed that no level II PASSR had been done after R12's significant change in mental health diagnosis and that it should have been done.

Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheters were placed securely off the floor in a sanitary manner for two (R41 and R119) of six residents reviewed for indwelling urinary catheters in the sample of 33. Findings include: The facility Urinary Catheter Care policy and procedure, dated September 2005, documents The purpose of this procedure is to prevent infection of the resident's urinary tract. Be sure the catheter tubing and drainage bag are kept off the floor. 1. The current Physician Orders for R41 documents a 7/29/24 physician order for R41 to use a 16 FR (french)/10cc (cubic centimeter) balloon indwelling urinary catheter for the diagnosis of Urinary Retention. The current Care Plan for R41 documents R41 requires an indwelling urinary catheter for a diagnosis of Urinary Retention and requires Enhanced Barrier Precautions due to placement of indwelling urinary catheter. The documented goals as follows: R41 will have catheter care managed appropriately with no signs of infection and to reduce the spread of infectious agents, minimize the transmission of infection, and reduce the risk of colonization. The interventions include Do not allow tubing or any part of the drainage system to touch the floor; Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures; Use principles of infection control and enhanced barrier precautions; and Teach resident/caregiver the chain of infection/methods of transmission. On 4/6/25 at 9:36 AM R41 was sitting in his wheelchair in the hallway with an indwelling urinary catheter bag hanging from underneath his wheelchair. The catheter was not in a protective dignity bag, urine visible in the catheter tubing, and the catheter tubing was dragging the floor. 2. The current Physician Orders for R119 documents a 4/2/25 physician order for R119 to use a 16 FR/10cc balloon indwelling urinary catheter for the diagnosis of Urinary Retention. The current Care Plan for R119 documents R119 requires an indwelling urinary catheter for diagnosis of Urinary Retention and requires Enhanced Barrier Precautions due to placement of indwelling urinary catheter. The documented goals as follows: R119 will have catheter care managed appropriately with no signs of infection and to reduce the spread of infectious agents, minimize the transmission of infection, and reduce the risk of colonization. The interventions include: Teach resident/caregiver the chain of infection/methods of transmission and Use principles of infection control and enhanced barrier precautions. On 4/6/25 at 7:30 AM R119 was lying in bed with an indwelling urinary catheter. The indwelling urinary catheter drainage bag was not in a protective dignity bag, urine visible in the catheter tubing and both the drainage bag and tubing were resting on the floor. On 4/9/25 at 2:30 PM, V1 Administrator and V2 DON (Director of Nursing) confirmed indwelling urinary catheter bags should be in protective dignity bags and catheter bags and catheter tubing should not be on the floor.

Based on observation, interview, and record review the facility failed to ensure oxygen tubing is changed weekly and ear pads are used for residents wearing oxygen for two (R25 and R119) of two residents reviewed for respiratory care in the sample of 33. Findings include: The facility Oxygen Administration policy and procedure, dated March 2004, documents The purpose of this procedure is to provide guidelines for safe oxygen administration. Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. Place ear protectors as needed for residents utilizing oxygen more than 8 hours a day. Observe the resident upon set up and periodically thereafter to be sure oxygen is being tolerated. If the resident refused the procedure, the reasons(s) why and the interventions taken are to be documented in resident medical record. Notify the supervisor if the resident refuses the procedure. 1. The Progress Note for R119, dated 4/2/25, documents R119 readmitted to the facility from the local hospital on 4/1/25 with diagnoses: Adult Failure to Thrive related to Influenza A, pneumonia, dehydration with renal failure and was having hypoxia with oxygen saturations in the 80's requiring supplemental oxygen to keep blood oxygen saturations between 88-94%. Staff will administer oxygen and assist with head of bed elevation to prevent shortness of breath. The current Physician Order Report for R119 documents the following orders dated 4/1/25: Oxygen via nasal cannula, titrate oxygen to keep blood oxygen saturations between 88-94% every shift; Use ear pads for continuous oxygen; Check oxygen saturation every shift; Change and label oxygen tubing and mask weekly and change as needed. The current Care Plan for R119 documents (R119) has a dx (diagnosis) of chronic lung disease and exhibits the following symptoms: easily fatigued, shortness of breath placing resident at risk for death. This plan of care does not address or list interventions regarding R119's use of oxygen or R119's behavior of removing his oxygen. On 4/6/25 at 7:20 AM, R119 was lying in bed on his left side without ear pads or nasal cannula in his nares and with a pillow partially covering R119's head. The oxygen concentrator next to R119's bed was running at 3.5 liters and R119's undated nasal cannula was resting on R119's bed under a blanket. On 4/7/25 at 10:13 AM, R119 was lying in bed without ear pads or oxygen on and nasal cannula oxygen tubing was resting across R119's overbed table. On 4/8/25 at 10:21 AM, R119 is lying in bed without oxygen in place with the nasal cannula resting next to R119, on the bed. There were no ear pads in place for the oxygen tubing and the oxygen concentrator was on and blowing three liters of oxygen into the air. On 4/8/25 at 10:53 AM, V17 LPN (Licensed Practical Nurse) and V18 CNA (Certified Nursing Assistant) entered R119's room to provide care. V18 CNA performed cares for R119 and at no time did V17 LPN or V18 CNA attempt to put R119's nasal oxygen cannula back in place and no education given to R119 regarding R119s' need for the oxygen. After the completion of R119's care, V18 CNA retrieved the nasal cannula from R119's bed and placed it on R119 without ear pads. On 4/8/25 at 10:53 AM, V17 LPN confirmed R119 did not have oxygen on, and oxygen tubing should not be on the floor. V17 LPN stated R119 is non-compliant with his oxygen and frequently takes it off and staff have to put it back on. V17 confirmed R119 has had oxygen since returning from the hospital on 4/1/25 for pneumonia, influenza A, and chronic lung conditions. 33970 2. R25's Treatment Administration Record dated March 2025 documents Oxygen: Change tubing and mask weekly and PRN (As Needed) once a week on Sunday. On 04/07/25 at 12:06 PM R25's Oxygen tubing and humidifier both had labels dated 3/23/25 and there was no ear pads placed on the tubing. On 4/7/25 at 2:00 PM V9 (Registered Nurse) confirmed that R25's oxygen tubing and humidifier was dated 3/23/25. V9 stated that the tubing and humidifier were overdue for change. On 4/9/25 at 2:30 PM, V1 Administrator and V2 DON (Director of Nursing) were unaware to confirm the facility oxygen policy and procedure documented residents with continuous oxygen are to have ear pads placed when used.

2. The current Physician Order Sheet for R119, documents a 4/1/25 physician order for Risperdal 0.25 mg (milligrams) daily at 8:00 AM for Vascular dementia with psychotic disturbance ordered by V16 NP (Nurse Practitioner). The Behavior/Intervention Monthly Flow Records for R119, dated March 13th through March 27th, 2025, and April 1st through April 8th, 2025, a total of 24 days, documents R119's targeted behaviors warranting the use of an antipsychotic as easily agitated and throwing food. These reports document R119 was easily agitated 13 of 24 days and throwing food on one of 24 days on 3/13/25. There are no other targeted behaviors listed for the use of R119's antipsychotic use. The Quarterly MDS (minimum data set) Assessment for R119, dated 3/25/25, documents R119 with moderately impaired cognition, moderate depression, and verbal behavioral symptoms occurring four to six times weekly. The facility facsimile communication form for R119, dated 3/19/25 was sent to V19 NP requesting diagnosis as: Antipsychotic Risperdal prescribed 3/19/25 for (R119) violent behavior. May we have dx (diagnosis) of (one) of the following: Brief psychotic disorder or Dementia with psychotic disturbance or Dementia with behavioral disturbance by V7 MDS (minimum data set) Nurse/Psychotropic Nurse. This form is signed and dated by V19 NP on 3/19/25 and documents Moderate vascular dementia with psychotic disturbance. On 4/6/25 from 6:30 am through 11:00 AM and on 4/7/25 and 4/8/25 from 9:00 AM through 3:00 PM R119 was lying in bed with no behaviors. R119's room was located across from the Nurses Station and R119 was lying in bed with no behaviors. On 4/8/25 at 10:20 AM, V17 LPN (Licensed Practical Nurse) stated R119 is extremely hard of hearing, does not see very well, so staff use a dry erase board to help communicate with R119. On 4/9/25 at 2:30 PM, V1 Administrator and V2 DON (Director of Nursing) confirmed R119 targeted behaviors for the use of Risperdal was easily agitated and throwing food. V1 and V2 stated R119 has been resistive to cares, yells at staff, and hit a therapy staff with his cane. The Quarterly Psychoactive Medication Evaluation for R119, dated 4/3/25, documents R119 continues to receive Risperdal and behaviors controlled. Based on observation, interview, and record review the facility failed to attempt gradual dose reduction for one resident (R12) and failed to have clinical indication for the use of an antipsychotic medication for one resident (R119) of five residents reviewed for psychotropic medications in the sample of 33. Findings include: The facility's Psychotropic Medication Policy and Procedure, dated February 2014, documents Policy: To establish the process for monitoring the use of and the reduction of doses of psychotropic medications without compromising the president's health and safety, ability to function appropriately, or the safety of others. 2. Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions listed in guidelines of recognized external review agencies. 3. Residents who receive antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated. The facility's undated Psychopharmacologic Drug Use Procedure, documents Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis including resident response to the medication. The following examples of antipsychotic drugs should not be used in excess of the listed doses for resident with organic mental syndromes unless higher doses (as evidenced by the resident's response or the resident's clinical record) are necessary to maintain or improve the resident's functional status. Risperidone is listed on the facility list as maximum dose of 4 mg (milligrams) in divided dose of 2 mg doses. When antipsychotic drugs are used outside these Guidelines, they may be deemed unnecessary drugs as a result of excessive dose. Antipsychotic medications may be considered for elderly residents with dementia but only after medical, physical, functional, psychiatric, social and environmental causes have been identified and addressed. Antipsychotic medications must be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review. Antipsychotic medications in persons with dementia should not be used if one or more of the following is/are the only indication: 1. Wandering, 2. Poor self-care, 3. Restlessness, 4. Impaired memory, 5. Mild Anxiety, 6. Sadness or crying alone that is not related to depression or other psychiatric disorders, 7. Insomnia, 8. Inattention or indifference to surroundings, 9. Fidgeting, 10. Nervousness, 11. Uncooperativeness (e.g. refusal of or difficulty receiving care. This policy and procedure also documents that diagnoses alone do not warrant the use of an antipsychotic unless: The behavioral symptoms present a danger to the resident or others; and one or both of the following: The symptoms are identified as being due to mania or psychosis (such as: auditory, visual, or other hallucinations; delusions, paranoid or grandiosity); or Behavioral interventions have been attempted and included in the plan of care, except in an emergency. 1. R12's Physician Order Sheet dated March 2025 documents that R12 receives the antipsychotic medication Risperidone 150 mg (milligrams) every month for bipolar disorder. R12's Medical Record documents that R12 was readmitted to the facility on [DATE] after a hospitalization with order for Risperidone 125 mg. R12's Behavior/Intervention Monthly Flow Record dated January, February and March 2025 documents the following identified behaviors being monitored for R12: Hallucinations, Delusions, crying/tearful, depressed/withdrawn, false accusations, yelling and screaming at others, restless, noncompliance by getting up by herself, easily agitated, cursing staff and difficulty falling and staying asleep. On 4/7/25 at 11:30 AM V21 (Social Services) confirmed the behaviors listed on R12's Behavior/Intervention Monthly Flow Record. V21 stated that the false allegations being monitored for R12 is related to R12 stating that staff members are sleeping with her husband. V21 stated that R12 very easily agitated and can get very nasty when (staff) attempt to do anything (give cares). V21 stated that the yelling/screaming at others behavior can be described as R12 yelling when cares are being done or attempted and that R12 sometimes just yells for nothing. V21 confirmed R12 had not had any attempts or documentation of any failed gradual dose reductions of R12's antipsychotic medications at any time. On 4/8/25 at 1:00 PM V7 (Registered Nurse) described the aggression and agitation displayed by R12 to be refusing cares, yelling out, cursing staff and hallucinations/delusions. V7 stated R12's hallucinations/delusions behaviors could be described as speaking in 3rd person, speaking as if she actually is her husband, believing that staff are sleeping with her husband who has been dead for years. V7 stated that R12 can be combative with cares also, but she is very hard of hearing and can't see very well, so that may be some of that. V7 denied any self-harming behavior by R12 stated I know she was putting herself on the floor sometimes, but from what I understood she would just lay on the ground, she did not throw herself on the floor. V7 denied any aggression or violence towards any other residents by R12. confirmed R12 had not had any attempts or documentation of any failed gradual dose reductions of R12's antipsychotic medications at any time. R12's Nurse's Note dated 3/27/25 at 4:08 PM documents response on res (resident) behaviors per (V16/Nurse Practitioner) increase (Risperdal) to 150 mg injection SQ (Subcutaneous). R12's Pharmacy Recommendation dated 3/11/25 documents a request to gradually reduce R12's antipsychotic medication Risperidone. V16 (Nurse Practitioner) marked patient is currently stable. Dose reduction is contraindicated because benefits outweigh risks, and a reduction is likely to impair the resident's function and/or cause psychiatric instability. On 4/9/25 at 11:00 AM V16 (Nurse Practitioner) stated that R12 had many harmful behaviors which have led to V16 declining to reduce her antipsychotic medication. V16 described these behaviors as easily agitated and refusing cares. V16 reported that she regularly meets with (V11/R12's Health Care Power of Attorney) when V16 comes to the facility to see R12. V16 reported that V11 is very supportive of R12 being on antipsychotic medications related to her behaviors.

Based on interview and record review, the facility failed to ensure the Hospice's coordinated communication and required documents were available and accessible to the facility staff. This deficiency affects one of one resident (R11) reviewed for Hospice care management in a sample of 33 residents. Findings include: The Hospice Services Policy not dated documented Hospice service will conduct assessments and develop a hospice plan of care which will be integrated with the resident's overall plan of care and maintained in the medical record or other location with the interdisciplinary care plan. All hospice service staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available in the medical record for all interdisciplinary staff to access. Hospice service staff will attend care plan conferences and participate in the resident's care planning process. The Long Term Care Hospice Service Agreement dated 5/19/2019 documented responsibilities of facility were to obtain the Hospice's Plan of Care, Medications, Orders, Election Form and the Certification of Terminal Illness. R11's Face Sheet documented R11 was admitted on [DATE] and elected Hospice benefits on 11/13/24 with a terminal diagnosis of Dementia, age-related Osteoarthritis with pathological fracture of Femur. R11's current Care Plan lacked specific Hospice responsibilities/interventions. R11's medical record lacked a Hospice Plan of Care, Election forms, Physician certification of terminal illness and/or copies of clinical notes. On 4/7/25 at 11:05 AM, V19 (Licensed Practical Nurse) stated the nurses assess on each resident at shift change and this is how staff know if a resident is on Hospice or not. V19 stated R11's Hospice Nurse Aide calls the day before they come to the facility and give a time. V19 stated The nurses don't call. We don't know when they (nurses) are coming. Sometimes they (Hospice nurses) come and go, and we don't even know they have been here. V19 stated there was not a Hospice binder for R11. On 4/7/25 at 11:15 AM, V21 (Social Services) stated there is a general Hospice binder with contact information located on each wing but not a specific one for R11. At 11:45 AM, V21 stated I found out that if hospice has a change (in cares/medications), they (Hospice staff) write on the POS (Physician's Order Sheet) and it should be scanned into the record. V21 reviewed R11's record and agreed there were no Hospice documents scanned into the computer. On 4/9/25 at 1:00 PM, V19 (Hospice Nurse) stated she does not leave R11's plan of care or visit notes at the facility.

Based on observation, interview, and record review the facility failed to utilize a gait belt during ambulation, for one resident (R2) of three residents, in a total sample of three residents reviewed for supervision. This failure resulted in R2 being hospitalized , with a femur fracture which required surgical intervention. Findings Include: Facility Policy, entitled Gait Belts, dated 4/13, document, Gait belts are used to help prevent injury of staff or residents during transfers and ambulation; 1. Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. R2's Electronic Medical Record/EMR document R2's diagnosis to include: Displaced supracondylar fracture with intracondylar extension of lower end of left femur, Muscle wasting and atrophy, Muscle Weakness, Chronic obstructive pulmonary disease, Heart Disease, Hypertension, Peripheral vascular disease, Displaced fracture of proximal phalanx of left lesser toe, Displaced fracture of proximal phalanx of right little finger, Legal blindness, and osteoporosis. R2's Quarterly, Minimum Data Set, dated dated [DATE] [seven days before R2's fall], document: Section GG The resident is dependent-helper does all of the effort. Resident does none of the effort to complete the activity [For transfers] chair/bed to chair transfer, toilet, transfer, and tub/shower transfer. [And the resident is a] partial/moderate assist to walk 10 feet and to walk 50 feet with two turns. Positioning sit to lying, lying to sitting on the side of the bed, and sit to stand, resident requires substantial/maximal assistance-helper does more than half the effort. R2's progress notes document: 10/29/24 3:35 p.m., Called to resident room. Resident noted to be sitting on floor left leg turned inward from hip to knee, Resident complaining of pain. Right ankle turned inward. Complaining of pain, no pulse noted. Aide to back of resident sitting behind her. States resident went to pivot and tried to sit too soon and fell to floor. Called for assistance. VS [Vital Signs] obtained. Called 911. POA [Power of Attorney] called. Resident to be transported to [hospital] for eval[uation]; 10/29/24 3:50 p.m., Ambulance left with resident to transport to [hospital]; 10/29/24 7:07 p.m., [hospital] called, and states resident is being flown out to [another hospital] for multiple fractures; 10/30/24 11:25 a.m., This nurse called [hospital] and had her x-ray reports faxed to the facility. X-ray reports resulted in resident having a left acute, comminuted fracture of the distal femur with intra-articular extension in the knee, and a right interval splining of the comminuted fractures of the distal tibia and fibula diaphysis; 11/4/24 4:16 p.m., [R2], an [AGE] year old female, was readmitted from hospital after her recent hospitalization for orthopedic surgery. During the resident's hospitalization , [R2] has experienced a decline in her ability to function. R2's x-ray result, dated 10/29/24, document findings as commuted, displaced distal, femoral shaft/metaphysis fracture. R2's hospital surgical report, dated 10/30/24, document the procedure performed was open reduction, internal fixation, left supracondylar distal femur fracture with intracondylar extension; and intramedullary fixation of a right tibial shaft fracture. On 11/26/24, at 11:55 a.m. V2/Director of Nursing confirmed a gait belt was not used while V4/Certified Nursing Assistant was ambulating R2 at the time of R2's fall. On 11/26/24, at 12:40 p.m., V5/Director of Rehabilitation confirmed R2 is blind and can only see shadows; ambulates with a front-wheeled walker; Requires one assist during ambulation; a gait belt was used during therapy and Everyone should have a gait belt used unless they are independent. On 11/26/24, at 12:50 p.m., V3/Assistant Director of Nursing confirmed R2 was not wearing a gait belt at the time of her fall; R2 is blind; R2 has a fear of falling; and R2 needs assistance ambulating. On 11/26/24, at 1:30 p.m., R2 confirmed not wearing a gait belt when she fell and fractured her leg. On 12/4/24, at 11:40 a.m., V1/Administrator confirmed, prior to R2 falling, R2 required one assist with a gait belt and walker. V1 also confirmed V4 was terminated for not following the facility Gait Belt Policy as V4 did not use a gait belt when assisting R2. On 12/4/24, at 12:07 p.m., V5 confirmed, prior to R2's fall, R2 required one assist, a gait belt, and a walker, for ambulation. On 12/4/24, at 12:25 p.m., and 12:35 p.m., V9/Certified Nursing Assistant and V10/Certified Nursing Assistant confirmed R2 required one assist/gait belt/walker when up ambulating.

Based on observation, record review and interview, the facility failed to implement pressure relieving interventions and perform daily Diabetic foot skin assessments for one of two residents (R47) reviewed for impaired skin integrity, in a sample of 27. These failures resulted in R47 developing unstageable pressure ulcers to the right and left heel after being admitted to the facility, which lead to osteomyelitis of the left heel and a delay in his discharge back to home. Findings include: The facility policy, titled Pressure Ulcer and Wound Prevention/Management Program (updated 12/05/2006) documents, Purpose: To identify residents who are at risk for pressure ulcers and skin breakdown. To prevent pressure ulcers and skin breakdown. To provide a guideline for the appropriate nursing management of skin breakdown when it occurs. Responsibility: Director of Nursing, Licensed Nurses, Certified Nursing Assistants, Restorative Nursing, Care Plan Coordinator, Dietitian, Physician and Medical Director. Policy: It is the policy of this facility to ensure that residents who enter the facility without pressure ulcers do not develop pressure ulcers unless the individual's clinical condition demonstrates that the pressure ulcers were unavoidable; ensure a resident who has been admitted with pressure ulcers or develops pressure ulcers in-house receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, when possible. The policy further documents, 3. Residents' skin will be inspected during daily bathing, dressing, showering, and incontinence care with special attention to bony prominences by CNAs (Certified Nursing Assistants) and staff nurses. Bony prominences include: Occipital, chin, scapula, elbow, sacrum, ischium, iliac crest, trochanter, knee, malleolus, and heel. Other common areas of breakdown include lower extremities and toes. 4. Weekly skin assessments will be completed for residents who are mild and moderate risk for breakdown. Daily skin assessments will be completed for residents who are high and severe risk for breakdown. Facility will determine where documentation of skin assessments will be completed. The Electronic Medical Record documents R47 was admitted to the facility on [DATE] for aftercare following a left total hip replacement, with the goal of returning to his home after completing Physical and Occupational Therapy. R47's admitting diagnoses include: Type 2 Diabetes Mellitus, Long Term (current) use of Insulin, Left Femur Fracture, Osteoarthritis and Anemia. An Initial/Baseline Care Plan dated 1/10/23 documents R47 required extensive assistance for bed mobility, was at risk for pressure sore/ulcer/skin injury and needed Positioning-turn and reposition every two hours and as needed. R47's Comprehensive Plan of Care, with a start date of 1/10/23, documents R47 is at risk for pressure ulcers (related to) weakness, related to (Diabetes Mellitus Type II), Folate Anemia, Primary Osteoarthritis, with a short term goal of (R47's) skin will remain intact. The Comprehensive Plan of Care instructs staff to do the following to prevent R46 from experiencing skin breakdown: Avoid shearing skin during positioning, transferring and turning; Keep clean and dry as possible, Keep linens clean, dry and wrinkle free, Pressure relieving device to chair and bed, Provide incontinence care after each incontinent episode, Report any signs of skin breakdown, Use absorbent, skin-friendly pads/briefs, Use moisture barrier product to perineal area. The Comprehensive Plan of Care failed to include instruction to staff for turning and repositioning R47 or frequency of R47's skin assessments. A Minimum Data Set assessment, dated 1/16/23, documents R47 as having a BIMS (Brief Interview of Mental Status) of 15, which indicates R47 is cognitively intact, requires the extensive assistance of 2+ staff members for bed mobility (turning/repositioning), and as at risk for developing pressure ulcers/injuries. The 1/16/23 Minimum Data Set assessments documents, under M1200. Skin and Ulcer/Injury Treatments the following marked as implemented: Pressure reducing device for chair and bed; however, Turning/repositioning program and Nutritional or hydration intervention were not marked as implemented at that time. A Braden Scale assessment (scores risk of pressure ulcer development), dated 1/25/23, documents R47 is at Moderate Risk for the development of pressure ulcers, based on his ability to respond meaningfully to pressure related discomfort, level of physical activity, limited ability to make changes in body position independently, inadequate oral/nutritional intake, and requiring moderate to maximum assistance to move his body. The 1/25/23 Braden Scale assessment checks off the following interventions as being implemented: Pressure relieving device for chair and bed and other preventative or protective skin care; again, turning/repositioning program and nutrition or hydration intervention was not checked off as being implemented by staff. Nursing Progress notes, dated 1/27/23, document R47 continues to require extensive staff assistance with bed mobility. On 2/01/23, R47 experienced weight loss when his weight decreased from 176.8 pounds (1/11/23) to 169.8 pounds in three weeks. A Nursing Progress note dated 2/06/2023 at 5:58 AM, documents (R47) noted to have (two) areas to right heel and one area to left heel. No (sign/symptoms) of infection noted. Heels offloaded. (Physician) notified via fax and will have wound doctor evaluate today. Skin Integrity Conditions reports, dated 2/06/23, documents R47 was found to have the following wounds: 1.) Right heel, facility acquired, unstageable wound measuring 1.0 cm (centimeters) x 0.5 cm; 2.) Right heel, facility acquired, unstageable Deep Tissue Injury, measuring 4.5 cm x 2.5 cm, with a black and purple wound bed; and 3.) Left heel, facility acquired, unstageable Deep Tissue Injury, measuring 5.0 cm x 4.0 cm, with a black and purple wound bed, and serosanguineous exudate. The 2/06/23 Skin Integrity Conditions report documents staff then implemented a turning and repositioning program, ulcer/wound care and treatment and a nutrition/hydration intervention for R47. On 2/06/2023, a Daily Diabetic foot inspection was initiated for R47 as well according to the documented Daily Skin Checks. On 2/09/23, Nursing Progress notes document, Resident was seen by wound physician via telehealth this afternoon for evaluation of bilateral heels. Left heel: diabetic wound. 3.4 (cm) x 5.0 (cm) Wound is closed. Cleansed and betadine applied and left (open to air). Placed off-loading boot on. Right heel: diabetic wound 4.0 (cm) x 4.0 (cm). Wound is closed. Cleansed and betadine applied and left (open to air). Placed off-loading boot on. Resident was having poor blood sugar control which contributed to the development of these wounds. He states that he rubs his heels on his sheets at night when he is trying to sleep. Wound doctor suggests to continue painting heels with betadine and leaving (open to air) and to continue with off-loading boots at all times except when bathing, transferring, ambulating, etc. Physician did order the following labs to be performed: CBC (Complete Blood Count), CMP (Complete Metabolic Pane), A1C (Hemoglobin A1C), pre-albumin. He also ordered a multivitamin daily, Vitamin C 500 mg (twice per day), and zinc sulfate 220 mg (orally for) 14 days as well as a protein supplement with meals or per dietary. Will have dietary manager ask dietician. Resident did state during rounds that he is not going to be taking any extra medications to help the healing process. Education provided. On 2/15/23, Nursing Progress notes document the following, This RN (Registered Nurse) sent fax to (Primary Care Physician) updating her on (R47's) wounds. She replies back: CBC, CMP, Sedimentation Rate, CRP (C-Reactive Protein) STAT (as soon as possible), MRI (Magnetic Resonance Imaging) bilateral heels- (to rule out) Osteomyelitis, -Schedule with (Wound Clinic as soon as possible) for debridement, (discontinue) Betadine to heels. (Begin treatment of) Calcium Alginate to bilateral heels and cover with ABD pad and kling/kerlix daily and (as needed), (start antibiotic) Augmentin 875 mg (orally every 12 hours for 14 days). On 2/16/23, Nursing Progress notes document R47's heel wounds had increased in size, with the left heel measuring 4.0 (cm) x 7.0 (cm) x 0.0 (cm) and the right heel measuring 8.5 (cm) x 11.0 (cm) x 0.0 (cm) and R47 was referred to the local Wound Clinic due to the facility's Wound Doctor only being able to do telehealth. A Wound Clinic Note, dated 2/20/23 by V10 (Wound Doctor), documents (R47) has a large wound of the right heel that measures 2.8 cm by 3.8 cm circumferentially, by 0.1 cm deep. A black eschar that is adherent occupies nearly the entire surface of the wound. No discharge. No surrounding Heat, erythema or fluctuance. There is a similar wound of the left posterior heel that measures 4.8 cm by 7.5 cm circumferentially, by 0.1 cm deep. It has the same characteristics as the wound about the right posterior heel. The Wound Clinic Note later documents, Assessment: 1. Large multifactorial unstageable pressure wounds of both heels. 2. Contributions from immobility, pressure, diabetes, diabetic neuropathy and arterial insufficiency. A 5/16/23 MRI of R47's lower extremities documents R47 had developed acute Osteomyelitis of the left heel. Wound Management Notes, dated 5/18/23, document R47's Left Heel wound as measuring 4.0 cm x 6.0 cm and Right Heel wound as measuring 2.5 cm x 5.5 cm. On 5/23/23 at 2:08 PM, V16 (Registered Nurse/Wound Nurse) and V17 (Licensed Practical Nurse) provided wound care to R47. At that time, R47 had a left heel wound, slightly larger than a golf ball, with a black center and a right heel wound, approximately the size of a quarter, with a black center. On 5/24/23 at 11:20 AM, R47 stated he needed the help of staff to turn over and change positions in bed when he was admitted to the facility from the hospital, and R47 indicated he still needs assistance to do so. R47 stated, When I came (to the facility), my heels would just lay flat on the bed, not up and off like now. When R47 was asked if staff would routinely help him turn and reposition on a scheduled or regular basis after he was admitted , R47 stated No, but they do more so now that I have sores on my feet. R47 stated, I want to go home, but now I can't because I have these (pointing to his feet) that need taken care of. On 5/24/23 at 11:27 AM, V2 (Director of Nursing) stated, facility protocol is for all residents that have Diabetes to be placed on a nightly foot skin check upon admission. V2 confirmed that R47's daily foot skin assessments were not implemented until his heel wounds were found on 2/06/23. On 5/25/23 at 12:29 PM, V16 stated she determines if a resident needs to be on a turning and repositioning program, based on their assessed risk for pressure ulcer development based and if they are able to turn and reposition themselves. V16 concluded that R47 was not able to turn and reposition himself independently when he was admitted to the facility and R47 did have multiple factors that put him at risk for skin breakdown. V16 stated it was unknown why R47 was not placed on a turning and repositioning program at the time of admission. On 5/25/23 at 8:41 AM, V10 (Wound Doctor) stated he saw R47 in his outpatient wound clinic about two weeks after R47's wounds initially developed. V10 stated R47's wounds are as a result of pressure to his heels, over a boney prominence, along with multifactorial contributions, such as his immobility, Diabetes Mellitus, nutrition, and arterial insufficiency. V10 stated, given R47's immobility and risk factors for pressure ulcer development at the time of his admission to the facility, nursing staff should have implemented basic interventions, like scheduled turning and repositioning and daily skin assessments. V10 stated The key to daily skin assessments is to identify skin breakdown early, as a Stage I, and to prevent progression. Routine skin checks would prevent wounds, like (R47's) from being first identified at the size and progression his were. V10 stated, resident wounds that are found to be necrotic on the initial assessment, indicate a lack of ongoing skin assessments by staff. V10 stated R47's left heel now has Osteomyelitis which could very likely lead to amputation of the left foot.

Based on record review and interview, the facility failed to ensure a resident identified as a fall risk was wearing proper footwear and was provided adequate supervision, and failed to conduct a fall investigation according to facility policy, for one of three residents (R1) reviewed for falls in a sample of three. These failures resulted in R1 falling in her room on 11/04/22 and sustaining a Left Femoral Neck Fracture (Hip). Findings include: The facility policy, titled Falls - Clinical Protocol (revised August 2008) documents, 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. The policy indicates, 3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. a. Risk factors for subsequent falling include: lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment and illness affecting the central nervous system and blood pressure. The policy advised that, 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. The policy further documents, 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. a. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke. b. Often, multiple factors in varying degrees contribute to a falling problem and 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The Electronic Medical Record documents R1 was admitted to the facility on [DATE] with Diagnoses of Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Muscle Weakness, and Difficulty in Walking. A Minimum Data Set assessment, dated 10/13/22, documents R1 had significant cognitive impairment, utilized a wheeled walker or a wheelchair for mobility, required an extensive assist of one person to ambulate in her room and the extensive assistance of two staff to toilet. A Fall Risk Assessment, dated 10/11/22, determined R1 was at high risk for falling, due to confusion, the use of Anti-depressants and Anti-hypertensives, and impaired neuromuscular function. R1's Current Plan of Care (initiated on 1/11/2022) documents, (R1) is at risk for falling (related to) Hallucinations, Unspecified Disorientation, Unspecified Muscle weakness (generalized) and Essential (primary) hypertension. (R1) is also receiving anti-hypertensive, antidepressant and diuretic medications which can increase (R1's) risk for falls, and instructs staff to Keep (R1's) personal items and frequently used items within reach and Provide (R1) with proper, well-maintained footwear. Nursing Progress Notes document R1 was found on the floor of her room on 7/02/22, 7/10/22 and 9/05/22, and sustained no injury from those falls. A Fall Details Report, dated 11/04/22 by V6 (Licensed Practical Nurse), documents at 8:20 pm, CNA (Certified Nursing Assistant) called writer to resident's room. Resident found sitting on floor with one slipper on and barefoot other foot. Resident was not using walker which was not near her. Resident sitting in lots of dried blood. Large hematoma noted to left side, back of head with dried blood. Resident lethargic and unable to get upright. The Fall Details Report documents, at the time of the fall R1's walker was not in use, she was wearing slippers. The Follow Up (Occurrence) Report completed by V2 (Director of Nursing), documents (R1) was observed sitting on the floor with one slipper on and barefoot on the other foot. (R1) was not using walker. (R1) noted to have a large hematoma to the left back of head. Upon assessment by nurse, resident lethargic and unable to sit upright. (R1) stated she was going to the bathroom. (R1) transferred to (Hospital) for evaluation. It appears that the resident got out of bed to go to the restroom without staff assistance. Resident was not using walker. Resident had one slipper on and barefoot on the other foot. Hospital Orthopedic Records, dated 11/05/22, document R1 was transferred to their hospital after sustaining a unwitnessed ground level fall in the Nursing Home trying to ambulate without her wheeled walker, that resulted in a Left Displaced Femoral Neck Fracture. The Final Reportable Investigation regarding R1's 11/04/22 fall, dated 11/05/22 at 1:50 pm documents, (R1) was found on floor in her room. Sent to (emergency room ) for evaluation. Investigation Initiated. Alert and moderately cognitive female resident got up out of bed and self ambulated to use the restroom and fell in room. (R1) admitted to Hospital with diagnosis of Left Femur Fracture. The Final Reportable Investigation, Fall Details Report and Follow Up Report fail to document any additional information, including witness statement of the timeline of events. On 12/07/22 at 1:42 pm, V5 (Certified Nursing Assistant) stated, on 11/04/22 she and V7 (Certified Nursing Assistant) were putting residents to bed a little after 8:00 pm. V5 stated when they got to R1's room, the door was closed, which was unusual because R1's door was usually open so she could be seen. V5 stated she opened the door and saw R1 on the sitting on the floor with a bloody head and blood on the floor next to her. V5 could not recall any other specific details regarding R1 at the time of the fall. V5 stated the the two nurses on duty came pretty quick and R1 was sent out by ambulance. V5 stated R1 was both continent and incontinent, and R1 would frequently take herself to the bathroom on her own. V5 stated R1 was always up and down, up and down, so she needed to be watched closely. V5 stated no one from Administration questioned her regarding the circumstances surrounding R1's fall. On 12/07/22 at 2:16 pm, R4 (R1's roommate) stated she was not in the room at the time of R1's 11/04/22 fall. R4 stated she was being taken to her room by V5 and V7, to be put to bed. R4 stated when they approached their room the door was closed, and it's never closed. R4 explained that staff needed to watch R1, because she'd get up on her own, so the door was to be open. R4 stated staff opened the door and she saw R1 sitting on the floor, facing the wall that is to the right when you enter the room, with the bedside table near her. According to R4, R1 kept saying I had an accident over and over. R4 stated R1 had dried blood on her head and there was dried blood on the floor, it looked like it had been there for a bit. R4 stated R1 would often take herself to the bathroom, even though she wasn't supposed to without help. On 12/07/22 at 3:32 pm, V6 (Licensed Practical Nurse) stated she had started her shift on 11/4/22 at 6:00 pm, received report and started her evening medication pass. While passing medications, the CNAs (Certified Nursing Assistants) told her there was an emergency in R1's room. V6 stated when she entered R1's room, R1 was sitting on the floor facing towards her bed, as if she had been walking back from the bathroom. R1 had dried blood on her head and there was dried blood on the floor, which made her conclude that R1 had been sitting there for awhile. V6 stated R1 was wearing one slipper, the kind you slide your foot into, with no back, which had a non-skid bottom, and the other slipper had come off R1's foot. According to V6, R1's walker was at the foot board of her bed and not near her. V6 stated staff were to keep her walker right next to her bed, because (R1) likes to get up on her own and use the bathroom, even though she is not supposed to. V6 stated R1 did not verbalized to her what she was doing when she fell , but was guarding her left side so she immediately called 911. V6 stated she was not questioned or interviewed regarding the details of R1's fall by V1 (Administrator) or any in Management, and she just completed an occurrence report. On 12/07/22 at 1:26 pm, V1 (Administrator) stated he was pretty sure he obtained witness statements when he did the investigation for R1's 11/04/22 fall, but does not know why those statements were not included in his final investigation details. Those statements were unable to be located. On 12/07/22 at 1:20 pm, V3 (Regional Administrator) stated, in order to determine what actually occurred, all fall investigations are to include witness accounts of what occurred just prior to and at the time of the resident fall, that's just part of your investigation. On 12/08/22 at 10:23 am, V2 (Director of Nursing) stated she started interviewing staff last night and this morning regarding R1's 11/04/22 fall. V2 stated it was determined after talking to Dietary Staff, R1 was observed in her bed in her room at approximately 7:00 - 7:30 pm on 11/04/22, and then was found on the floor at 8:20 pm. V2 stated that left approximately an hour to an hour and 20 minutes that the facility is unable to account for what R1 was actually doing. V2 stated staff should have been checking in on her (R1) as it was known that R1 frequently took herself to the bathroom independently, even though she required assistance. V2 concluded that a slipper sock or some type of non-skid footwear that can't slide off the foot would have been a safer option for R1 to have been wearing, rather than a traditional slipper.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent an injury for one of three residents (R2) reviewed for supervision in a sample of three. This failure resulted in R1 sustaining a fracture of the greater tuberosity. Findings include: R1's Facility Incident Report form dated 10/23/2021 documented the following under a section titled description of occurrence: R1 sustained a fall on 10/22/2021. R1 was standing up receiving medication. R1 was standing in dining room and did not see other resident in wheelchair in hallway and was bumped causing R1 to lose balance and fall to the floor. R1 did not have her walker in front of her using it for stability. R1's Nursing Progress notes dated 10/22/2021 at 6:40 PM documents the following: Writer (V3, LPN, Licensed Practical Nurse) was standing with (R1) in the dining room giving her medication and reminding her she needs to use her walker, she had her walker but not in front of her at the time, was at her table from eating supper. While writer (V3), was discussing this with resident, another resident (R2) was coming through the dining room in her wheelchair backwards and hit writer (V3), and (R1). (V3) reached for resident and both writer and resident fell to the floor. R1 landed on right side with back against the doors to the dining room. R1 denies pain except to left upper arm. Skin tear to left back of hand. Area cleansed and dressing placed to left hand skin tear. ROM (range of motion) completed to the best of R1's ability without pain to BLE, (bilateral lower extremity) RUE (right upper extremity). No shortening noted to BLE. R1 was assisted to wheelchair by write (V3), and CNA (V5, certified nursing assistant). M.D. Medical Director notified, and on-call supervisor notified. New order per M.D. to have left humerus x-ray. Mobile diagnostic contacted and will be at facility tomorrow before x-ray can be done. M.D. here and made aware, requisition made out and faxed. R1's physician clinical summary dated 10/22/2021 documents the following: (R1) had a fall this morning with a nurse who broke her fall as best she could when another resident (R2) knocked them both over. She fell on right side, no head injury. Has skin tear on left hand and c/o (complaints of) Upper left arm pain. R1's physician clinical summary dated 10/23/2021 documented the following: Plain film with left nondisplaced proximal humeral Fracture, placed in sling to wear at all times yet suspect she will not comply. R1 ' s 10/2/2021 MDS (minimum data set assessment) was reviewed and documented R1 has a BIMS (Brief interview for mental status) of 5 on a scale of 1-15, 15 being cognitively intact. R1 ' s Fall Risk Observation dated 10/22/2021 indicated R1 is at low risk for falls. R1's x ray report dated 10/23/2021 documents the following: Impression: Fracture of the greater tuberosity. R2's current care plan documents the following with a start date of 9/2/2021: Category: Behavioral Symptoms, Problem: (R2) has a history of pushing herself backwards in her wheelchair, she runs into other residents due to not seeing where she is going and becomes frustrated when asking her not to do that. This same care plan documents the following: (R2) has difficulty making self-understood R/T (related to) [CONDITION(S)] ([CONDITION(S)]) with [CONDITION(S)]. R2's progress notes dated 10/22/2021 at 1:20 pm document the following: Resident (R2) is alert and able to make needs known with gestures and some words. Resident propels her wheelchair, likes to go backwards and has to be reminded to watch and to turn around. On 11/7/2021 at 9:28 am V1, Administrator stated the following: On 10/22/2021 the residents were at dinner and V3, LPN (Licensed Practical Nurse) was giving R1 her medicine at the table, R1 was standing up, had her walker but did not have it directly in front of her. R2 backed her chair up and bumped in to R1 knocking R1 as well as V3, LPN down. On 11/7/2021 at 9:45 am V3, LPN (Licensed Practical nurse) stated on 10/22/2021 at dinner time, around 5 or 6 PM she was giving medications to R1 in the doorway of the dining room. V3, LPN stated, R1 had her walker angled to the left side of her, not directly in front of her. V3, LPN stated, R2 propels herself backwards in her wheelchair. V3 stated, R2 was propelling backwards in her wheelchair and ran in to V3, LPN and R1 knocking both down. V3 stated, she was not hurt but R1 was holding her left arm, saying it hurt. V3 stated, she completed a full body assessment, got R1 up with a gait belt and assistance. V3 stated, she called the doctor to report the fall. V3 stated, an x ray was ordered but the x ray company told V3 they would not be able to complete the x ray until 10/23/2021. On 11/7/2021 at 11:17 am R1 was sitting in her wheelchair at the dining room table fidgeting with Kleenex. On this same date and time R2 was in the dining room in her wheelchair at an opposite table. R2 then began to propel herself towards her room. Staff intervened and took her to her room. Staff asked R2 if she wanted to eat in her room and R2 replied yes. On 11/7/2021 at 11:25 am R2 was sitting in her wheelchair in her room. This surveyor attempted to interview R2, but she is not easily understood and appeared to get agitated because this surveyor could not understand her. On 11/8/2021 at 10:18 am V4, CNA (Certified Nursing assistant) stated, R2 tends to propel her wheelchair backwards but has gotten better. V4 stated they encourage her to go forward. On 11/8/2021 at 1:05 pm V3, Physician stated she assessed R1 the evening of 10/22/2021 after she was knocked down by R1. V3 stated, she ordered a non-urgent x ray to be completed the next day because she hates to send her older dementia patients to the emergency room at night V3 stated, she was aware R1 was having some pain but did not feel she was critical. On 11/8/2021 at 2:31 pm V6, LPN stated, R2 propels backwards in her wheelchair into other people and objects. V6, LPN stated, if you educate R2 she will stop for a short time, but she really must have constant reinforcement to propel forward. V6, LPN stated it is easier for R2 to propel backwards and she is fast if she goes backwards.

Based on interview, and record review, the facility failed to ensure the wound bed of a potentially deteriorating wound was observed and treated by a Physician for one of one resident (R1) reviewed for non-pressure related wound care in a sample of three. This failure resulted in R1's foul smelling wound with purulent drainage (containing or composed of pus) not being observed by a Physician or physician's surrogate for seven days at which time R1 was sent emergently to the hospital with a low blood pressure, a necrotic wound of the abdominal wall with surgical site dehiscence, fecal material draining into the surgical wound, and an intra-abdominal infection. Findings include: A Negative Pressure Wound Therapy policy dated 2/2014 under the heading of Reporting documents for staff to report, Marked changes in the wound condition from baseline or previous dressing changes. A Notification of Resident Change in Condition policy dated 11/2016 states, It is the policy of this facility to promptly notify the resident, their legal representative (s) and attending Physicians of changes in the resident's health condition. This policy states that, A licensed nurse shall promptly inform the resident and consults with the resident's Physician with A need to alter treatment significantly i.e. (that is to say) a need to discontinue an existing form of treatment due to adverse consequences or to begin a new form of treatment. This policy states, The licensed nurse is to use professional judgment in determining changes in condition based on assessment, and The licensed nurse will document in the Nurse's notes all assessment findings and all attempts to notify Physicians. R1's Face Sheet documents R1 was admitted to the facility 8/27/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospitalization records from prior to admission to the facility document that R1 had surgery to Repair Abdominal Wall and using an open approach and had an Inspection of the abdominal wall. These same records document that on 8/26/21 R1's wound vac (negative pressure) dressing was removed during a dressing change and that R1's wound was assessed as showing marked improvement. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nursing progress notes dated 9/7/21 at 6:38 AM, document that R1's, Wound vac dressing on abdomen is on and functioning set at 125mm/hg (millimeters of mercury) as ordered. Scant amount of serosanguinous drainage noted in vacuum tank. JP (Jackson-[NAME]) (drainage container) drain insertion site remains free of s/s (signs and symptoms) of infection less than 1 ml (one milliliter) of milky pink drainage noted in drain. R1's Nursing progress notes dated 9/8/21 at 9:50 AM, documented by V4 (Registered Nurse/RN) states, There appears to be a very foul odor to wound at this time. R1's Nursing progress notes dated 9/8/21 at 3:32 PM, and documented by V3 (Wound Nurse) state, This nurse assessed, measured, and treated R1's abdominal wounds per TAR (Treatment Administration Record). Right outer abdomen: 1.0 (cm/centimeters) x 1.5 (cm) x 4.1cm, tunnels towards midline wound. This area has purulent drainage and has a very foul odor. The surrounding skin is reddened. Midline abdomen: 5.7 (cm) x 9.5 (cm) x 3.2 (cm). There is a moderate amount of slough (dead or necrotic tissue yellow) noted to this wound and some necrotic (dead tissue brown/black) to the lower half. There is some bleeding noted, to left lower abdomen: This area was scabbed previously, but now has slough and is unmeasurable. A dry gauze was placed over the wound. A fax was sent to PCP (Primary Care physician) asking for an antibiotic due to the wound appearing to be infected. Will await response. A fax dated 9/8/21 documented by V3 and sent to the office of V8 (Nurse Practitioner), V9, and V10 R1's Primary Care Physician states, R1's abdominal wound is very malodorous and draining purulent drainage. I believe the wound is infected. May we have an antibiotic? And FYI (for your information) R1 goes to the wound clinic on Friday at 9:00 AM, on 9/10/21. R1's Nursing progress notes dated 9/8/21 at 4:30 PM, documented by V4 state, V9/Nurse Practitioner called facility in response to fax sent by V3 and she V9 stated, after talking to this nurse she would see resident on 9/9/2, no further orders received. R1's Nursing progress notes dated 9/13/21 at 7:45 PM, documented by V4 state, Wound appears to have a foul odor and wound bed appears to have brown slough with some red tissue, wound edges have some redness noted. This nursing progress note does not document that V8 R1's NP, V9, V10 or R1's wound clinic physician were notified regarding R1's wound condition or that R1's wound continued to have a foul odor. R1's Nursing progress notes dated 9/14/21 at 9:24 AM, documented by V4 state, (Jackson Pratt, JP), drain insertion site remains free of s/s of infection, emptied approximately 5 (five) ml (milliliters) of pinkish brown drainage, foul smell noted. This Nursing progress note does not include documentation that V8, V9, V10 or R1's wound clinic physician were notified regarding the foul odor to R1's wound drainage. R1's Nursing progress notes dated 9/14/21 at 5:46 PM, documents, Emptied approximately 5ml of pinkish-brown, foul smelling drainage from the JP drain. Insertion site looks to be free from s/s of infection however there is a small open area noted just to the right of and below drains insertion site, that has yellowish exudate/slough noted. Currently covered by drape/wound vac dressing. Notified PCP (Primary Care Physician). This same progress note does not document R1's wound clinic physician was notified regarding R1's wounds. R1's Nursing progress notes dated 9/15/21 at 8:58 AM, documents, JP drain patent and draining a brown thickened drainage. At 9:30 AM, R1's Nursing progress notes document, V8/Nurse Practitioner here at facility today and assessed resident, no new orders received and resident to f/u (follow up) with Wound clinic today. R1's Nursing progress notes dated 9/15/21 document, Fax from V8 in regard to R1's abdominal wound. Stated 'Received after hours on 9/14/21-was in facility AM (morning) doing rounds. Wound discussed with staff. F/U (follow up) appt (appointment) with wound clinic scheduled for today. R1's Complete Blood Count laboratory (CBC lab) findings dated 8/26/21, one day before admitting to the facility, document that R1's white Blood Count (WBC) was within normal limits at 6.3 thousand/ul (microliter). R1's CBC findings dated 9/2/21, after R1 was admitted to the facility under V8, V9, V10's care, documents that R1's WBC had risen to 12.0 thousand/ul with the normal range being 3.5-10.0 thousand/ul. R1's CBC findings dated 9/10/21 document R1's WBC had risen again to 14.7 thousand/ul. R1's hospital CBC findings dated 9/15/21, after being sent to the hospital by the wound clinic, had risen to 17.1 thousand/ul. V9's Progress notes dated 9/1/21 document V9 examined R1 on that date. This same note documents when V9 assessed R1's wound, R1's negative pressure wound dressing was in place and V9 did not visually inspect the wound bed of R1's wounds. V9 documented, Patient R1 is being managed by the wound clinic. V9's progress notes dated 9/9/21 document, Staff report per fax concerns of odor during dressing change of wound vac. Staff report some eschar (blackened dead tissue) to marginal edges of wound but without s/s (signs/symptoms) of infection. This progress note does not document that V9 evaluated R1's wound without the negative pressure dressing in place. This progress note also does not indicate any changes in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/20/21 at 9:18 AM, V11 Wound Clinic, NP stated, on 9/15/21, R1 was brought to the clinic by the facility for her wound care appointment. V11 stated nurses from her clinic provided wound care while R1 was hospitalized in 8/2021. V11 stated once R1 was brought into the exam room, the clinic nurse thought R1 did not look well and took R1's blood pressure (BP) which was in the 70's systolic blood pressure. V11 stated, nurse called V11 into the room to evaluate R1 and to also evaluate R1's wound. V11 stated, R1's wound appeared badly infected and appeared as though the abdominal wall had separated exposing a mesh material used to repair R1's abdomen during R1's surgery from 7/2021. V11 stated, there appeared to be fecal material in R1's wound and draining into the JP drain device. V11 stated, R1 was sent emergently to the hospital because of having a severely low blood pressure and because of a probable wound infection. V11 stated, she did not think R1's wound was treated appropriately by the facility. V11 stated, R1's wound, Did not deteriorate like that overnight. V11 stated, R1's wound must have been showing signs of deterioration for quite some time before coming to the wound clinic. V11 stated, this was R1's first wound clinic appointment since being discharged from the hospital 8/27/21. V11 stated, R1's wound did not open up into the bowel or drain fecal material at the time of her discharge from the hospital 8/27/2021, but when R1 arrived at the wound clinic 9/15/21, R1's wound appeared to be open into the bowel causing fecal material to drain from R1's wound. V11 stated, the facility should have been monitoring R1's wound for signs of deterioration and notified R1's Physician with that deterioration. V11 stated, she read through R1's hospital records and spoke with the hospital wound nurses who took care of R1 while she was hospitalized in 8/2021. V11 stated, R1's wounds had greatly deteriorated compared to the condition of R1's wounds at the time of hospital discharge 8/27/21. V11 stated, after she sent R1 to the hospital for treatment, she spoke with V9 regarding the condition of R1's wounds, including that fecal material was draining from R1's wounds. V11 stated, V9 told her V9 was not made aware by the facility that R1's wound had deteriorated to that extent. V11 stated, V9 also told her the facility did call V9 with some concerns regarding R1's abdominal wounds and V9 went to the facility to assess R1's wounds. V11 stated, V9 told her that V9 only looked around the outside of R1's wounds and did not remove the negative pressure dressing to see how the inside of R1's wound looked. V11 stated, the deterioration of R1's wounds should have been recognized sooner to prevent R1's low blood pressure, wound infection, and hospitalization . R1's hospital records dated 9/15/21 to 9/20/21 document that R1 was admitted to the hospital 9/15/21 with a low blood pressure, a necrotic wound of the abdominal wall with surgical site dehiscence, fecal material draining into the surgical wound, and an intra-abdominal infection. On 9/20/21 at 11:25 AM, and 2:16 PM, V3 (Wound Nurse) stated, R1's abdominal wounds were not infected when she was admitted [DATE]. V3 stated, V3 evaluates residents' wounds one time per week by inspecting the wound bed and measuring the wound. V3 stated, if she has concerns about a wound's appearance or if there are signs and symptoms of an infection, V3 will contact residents' Physicians for treatment orders. V3 stated, the first time she saw R1's wounds was on 9/1/21 and at that time R1's wounds did not have a foul odor. V3 stated, on 9/8/21 she changed R1's negative pressure dressing to R1's abdomen. V3 explained R1's negative pressure dressing is black the wound cannot be visualized through the dressing. V3 stated, only the areas outside the wound can be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 stated, she sent a fax to V9's office regarding R1's wound. V3 stated, V9 called the facility later that day and spoke with V4 (Registered Nurse) about the wound. V3 stated, V9 instructed V4 to go into R1's room and feel around the negative pressure dressing to see if her skin felt warm or if there were any other visible changes. V3 stated that V4 did not see any visible problems with R1's abdomen surrounding R1's negative pressure dressing. V3 stated, because of V4's assessment, V9 decided she would not come to the facility to evaluate R1's wound until the next day. V3 stated, V9 did not give any new treatment orders for R1's wound at that time. V3 stated, V9 came into the facility the next day 9/9/21 and evaluated R1's wound in person but without removing R1's dressing. V3 stated, V9 did not order for any changes to R1's wound treatment and did not order an antibiotic. V3 stated, R1 was supposed to go to the wound clinic to have her wound evaluated the next day on 9/10/21 but that appointment was canceled. V3 stated that R1's wound clinic appointment was rescheduled for 9/15/21. V3 stated that since V9 is the Nurse Practitioner for R1, she did not question why V9 did not make any changes to R1's treatment orders. V3 stated, even though R1's wound clinic appointment was rescheduled for 9/15/21, and no Physician or NP had actually seen R1's wounds since before R1's admission on 8/27/21, V3 did not reevaluate R1's wounds after V3 noted a foul odor and purulent drainage to R1's abdominal wound, despite knowing that V9 had only looked at R1's abdomen around the black negative pressure dressing. V3 stated she was not planning to assess R1's wounds until 9/15/21, the day R1 was sent emergently from the wound clinic to the hospital, and seven days after noting the foul odor and purulent drainage in R1's wound. On 9/20/21 at 3:06 PM, V4 (Registered Nurse) stated, she had cared for R1 several times since her admission. V4 stated, on 9/8/21 she reported to V3 that R1's abdominal wound had a very foul odor. V4 stated, R1's wound bed contained a brown slough. V4 stated, after V3 sent a fax to V8, V9, and V10's office with concerns over the condition of R1's abdominal wounds, V9 telephoned the facility and asked to speak to V4. V4 stated, V9 asked V4 to assess R1's wound around R1's negative pressure dressing and let her know if the wound had signs of infection. V4 stated, R1's abdomen around the negative pressure dressing looked ok, and R1 did not have a fever. V4 stated, after she reported that information to V9, V9 stated, she would be in the facility the next day to examine R1. V4 stated that she only reported concerns with R1's wound one time and that V4 reported those concerns to V3 (Wound Nurse). V4 stated, she was R1's nurse the morning of 9/15/21 when R1 went for R1's first wound clinic appointment. V4 stated, she believes she checked R1's blood pressure before sending R1 to the appointment and she thinks R1's vital signs were normal. V4 stated, she does not believe she documented those vital signs in R1's medical record. R1's Vital Signs log dated 8/27/21 to 9/15/21 document R1's weight was the only thing recorded under vital signs for that date (9/15/21). On 9/21/21 at 12:11 PM, V9 (Nurse Practitioner) stated, she had seen R1 two times since R1's admission. V9 stated, she had never assessed R1's wound without the dressing in place. V9 stated, after V3 sent a fax to her office with concerns over R1's abdominal wound, V9 called the facility and asked R1's nurse, V4, to evaluate R1's wound around the dressing to see if it had signs or symptoms of infection such as warmth or redness. V9 stated that V4 reported that R1's abdomen was not warm, had no redness, and R1's temperature was normal. V9 stated that she told V4 she would come to the facility the next day to evaluate R1's wounds. V9 stated that on 9/9/21, V9 examined R1's wound around R1's negative pressure dressing. V9 stated that, since the dressing had just been changed and V9 thought R1 was going to the wound clinic on 9/10/21, she would be able to determine if there were any signs or symptoms of a wound infection by looking at R1's abdomen around the black negative pressure dressing. V9 stated that she determined that R1 did not have an infection and, therefore, did not make changes to R1's abdominal wound treatment orders. V9 stated that R1's rising WBC level didn't mean R1 had an infection but that it could have meant that R1 had an [CONDITION(S)] process occurring. V9 stated that the facility did not notify V9 when R1's wound clinic appointment was canceled for 9/10/21. V9 stated, if she had known R1's appointment had been canceled; she would have examined R1's wound without the dressing in place. On 9/21/21 at 1:49 PM, V6 (Transportation Aide) stated, she drives residents to their appointments and schedules residents' Physicians' appointments. V6 stated, on 9/10/21 she was scheduled to take R1 to a wound clinic appointment. V6 stated, when she went to R1's room, she was not dressed and ready to leave. V6 stated, nursing staff caring for R1 stated, they did not know R1 had an appointment for that day. V6 stated, she called the wound clinic to see if she could reschedule the appointment. V6 stated, the wound clinic informed her the soonest they could schedule R1 was on 9/15/21. V6 stated, V4 received a call from a nurse from V8, V9 and V10's office who stated, R1 needed to be seen by the wound clinic that day. V6 stated, the nurse told V4 she would call and arrange for R1 to be seen by the wound clinic that day and would call V4 back with the details. V6 stated that V4 stated that the nurse for V8, V9, V10's office never called the facility back stating they were able to have R1 seen on 9/10/21, therefore, V6 took R1 to her wound clinic appointment 9/15/21. On 9/20/21 at 2:00 PM, V1 (Administrator) stated, she spoke with V10 (R1's Primary Care Physician) regarding the situation with R1's wound. V1 stated, V10 stated, he did not condone V9 examining R1's wound without removing R1's negative pressure wound dressing. V1 stated, that V10 told her that he would expect his colleagues to remove the dressing from a wound to examine it after staff report concerns there may be an infection.

Based on record review, and interview, the facility failed to obtain treatment orders in a timely manner and ensure a urinalysis was completed for a resident with symptoms of a Urinary Tract Infection, for one of three residents (R1) reviewed for Urinary Tract Infections, in a sample of seven. These failures resulted in R1 having symptoms of a Urinary Tract Infection from 2/11/21 to 2/18/21, without appropriate testing and R1 being hospitalized for Intravenous Antibiotic treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The electronic medical record documents R1 was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set assessment, dated 2/03/21, documents R1 as having no cognitive impairment and requiring the help of two plus staff for personal hygiene, and toileting. A Plan of Care, dated 2/05/21, documents R1 has an indwelling urinary catheter and instructs staff to report UTI (Urinary Tract Infection) (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine.) A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident Progress Notes, dated 2/11/21 by V2 (Director of Nursing), document Fax being sent to (Physician/Nurse Practitioner) in regards to (R1's) urine having a very foul odor and also having a thick consistency. Will await (Physician/Nurse Practitioner) response. There is no documented evidence in R1's electronic medical record that the Physician/Nurse Practitioner responded to V2's 2/11/21 fax notification regarding R1's urine. A Resident Progress Note, dated 2/14/21 by V4 (Licensed Practical Nurse), documents This nurse notified of dark amber colored urine in (catheter) bag. Fax sent requesting (urinalysis). A Fax Notification Sheet, dated 2/14/21 by V4, documents (R1's) Urine is dark and cloudy in (catheter) bag. (R1) believes it is due to increased intake of juice. I believe she needs a (urinalysis) completed. Can we please have orders for a (urinalysis with culture and sensitivity)? The same Fax Notification Sheet was returned to the facility on [DATE], with V11 (Nurse Practitioner) documenting No - (at) this time, awaiting (Hemodialysis evaluation of) 24 (hour) urine. Resident Progress Notes later, on 2/16/21 (5:00 pm), document, (R1) returned from [CONDITION(S)] lethargic, clammy, hard to arouse. A full assessment was completed and (vital signs) were (within normal limits). This nurse and another nurse on duty suspect [CONDITION(S)] (treatment) being the cause. On 2/17/21, Resident Progress Notes document, (R1) stated that she does not remember anything from the time [CONDITION(S)] hooked her up to their machine through to waking up in the middle of the night at the facility. The Electronic Medical Record contains no documented evidence that the physician was notified of R1's symptoms, on 2/16/21 and 2/17/21, that could have possibly been related to a Urinary Tract Infection. Resident Progress Notes on 2/18/21 document R1 left the facility for [CONDITION(S)] and R1 was sent to the local emergency room from [CONDITION(S)] facility at 7:00 am. The next Resident Progress Note, dated 2/21/21, documents R1 was ultimately admitted to the Hospital on 2/18/21 for Intravenous Antibiotic treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital emergency room notes, dated 2/18/21, describe R1's urine as grossly cloudy at the time she presented. Hospital Urine Cultures collected on 2/18/21 document R1 as having VRE infection of the urine, which required Intravenous Antibiotic (IV) Therapy. On 2/23/21 at 10:01 am, V2 (Director of Nursing) stated she and staff had to fax the Physician/Nurse Practitioner twice on 2/11/21 regarding R1's dark, thick urine with a foul odor. V2 stated they did finally get a response a couple days later, but the Nurse Practitioner instructed the staff to just wait for the 24 hour urine results that had been ordered previously (2/08/21-2/09/21). V2 indicated the [CONDITION(S)] staff had already reported to the facility that they had to dump R1's urine sample from 2/08/21, due to it being incorrectly collected; however, staff did not communicate that to the Nurse Practitioner when she advised them to just await those results to rule out R1 having a Urinary Tract Infection. V2 stated the Nurse Practitioner should have been notified that there were no pending urine tests for R1 on 2/15/21. Additionally, V2 stated staff should have made attempts to contact the Physician/Nurse Practitioner by phone, when they did not get a reply on 2/11/21. On 2/24/21 at 8:15 am, V16 (Registered Nurse/[CONDITION(S)] Facility) stated R1's urine specimen from 2/08/21 was not wasted and was actually tested ; however, they do not culture the urine to check for infection and only test kidney function. V16 stated, when R1 presented on 2/18/21 for [CONDITION(S)], she was very lethargic and even the transport bus driver stated something was very wrong with R1. According to V16, R1 would respond to commands, but had to be aroused, which was not her norm, her blood pressure was 69/43, urine was very dark, and cloudy. V16 stated they didn't even initiate [CONDITION(S)] and immediately called 911 to take her to the Hospital. On 2/23/21 at 2:57 pm, V15 (emergency room Registered Nurse) stated when R1 arrived at the emergency roiagnom on [DATE], her indwelling urinary catheter bag contained very dark, like watered down quicksand, urine that was full of sediment and had a foul odor. V15 stated R1 was diagnosed with a Urinary Tract Infection while she was there and given two different antibiotics, but was transferred to another hospital for continued treatment due to the seriousness of her condition. On 2/24/21 at 8:45 am, R1 stated she doesn't remember much from 2/16/21 -2/19/21, other than she just felt very ill. R1 stated that her daughter kept asking the nurses at the nursing home to test her urine for infection, but they kept putting it off. The facility policy, titled Notification of Resident Change in Condition Policy (November 2016), documents The licensed nurse is to use professional judgement in determining changes in condition based on assessment and findings or signs and symptoms of change which could lead to deterioration if not treated. The policy further documents, In the event the Physician cannot be reached or does not respond and the resident requires medical intervention or there are clinical complications in the judgement of the nurse, the alternate Physician will be promptly contacted. During the interim, appropriate nursing interventions and monitoring measures will be performed and documented.

Based on observation, interview, and record review the facility failed to identify and prevent abuse for one of three residents (R10) reviewed for abuse allegations. E5 C.N.A. (Certified Nurse Aide) and E6 C.N.A. were verbally, mentally, and physically abusive to R10and were allowed to continue to work. This has the potential to affect all 57 residents of this facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/06/14 at 6:30 pm, the facility remains out of compliance at a Severity Level II as the facility continues to monitor the effectiveness of training regarding abuse policy, updating of abuse policy, operationalization of the abuse policy and all seven components of the Abuse Neglect Policy. Findings include: (A) The facility's "Abuse Prohibition and Prevention Policies and Procedures" under the heading titled "E. Investigation" states "Any employee suspected of committing the above will be suspended pending the outcome of the investigation" and "Employees of the facility who have been accused of resident abuse will be suspended until the results of the investigation have been concluded." On 3/3/14 at 2:00pm E2, Director of Nursing, stated that the facility had "only one allegation of abuse" during the past 12 months. A facility "Incident/Accident Report"prepared by E2, Director of Nursing dated 11/7/13 documents a witnessed allegation of physical and verbal abuse occurred on 11/7/13 at approximately 1:30pm identifying E5, Certified Nurse Aid (CNA)as the perpetrator of the abuse. This Incident/Accident Report identifies R10, a cognitively impaired [AGE] year old resident as the recipient of the abuse and E12, CNA and E13, CNA are identified as the witnesses to the alleged abuse. R10's medical record documents that R10 has [DIAGNOSES REDACTED]. R10's Annual Minimum (MDS) data set [DATE] documents R10's Brief Interview for Mental Status (BIMS) score of 5 indicating R10 has significant cognitive impairment and that R10 requires extensive assistance with transfers, dressing, bathing and all activities of daily living. The description of the allegation included in the Incident/Accident Report and Investigation dated 11/7/13 documents the following occurred on 11/7/13 at 1:30pm: While changing R10's clothes, with E12, E5 "grabbed R10's nose and twisted it" after R10 "made inappropriate sexual statement" to E5. Two witnesses, E12 CNA(Certified Nurse Aide) and E 13CNA, documented in separate written witness statements dated 11/7/13 that after the mechanical lift transfer of R10 to R10's bed, E5 sat in R10's wheelchair with the mechanical lift handheld controller and continued to lower the metal bar on the mechanical lift into R10's abdomen. After being told to stop lowering the mechanical lift three times by the two other CNA's assisting in the transfer, E5 continued to lower the metal bar into R10's abdomen and stated that she should have " lowered the bar into (R10)'s chest in order to crush (R10), after what R10 said to me". E12, CNA also documented in the written statement dated 11/7/13, that after the transfer to R10's bed, while "picking up R10's room", E5 "said (E5) hates that f---ing bastard" and when R10 asked E5 for some chocolate milk E5 stated "(E5) was not giving that f---er nothing." A written statement by E3, Registered Nurse/Assistant Director of Nursing (RN/ADON), dated 11/7/13 documents that E3 was notified by E25, Licensed Practical Nurse (LPN), at 1:45pm on 11/7/13 that "E12, E13 and E5(CNA's) were in R10's room putting him to bed when E5 sat in R10's chair with the mechanical lift control in her hand pushing the down button."E12 told E5 three times to stop lowering the mechanical lift arm "before E5 finally stopped." "When she was pushing the button the (mechanical lift arm) was going down on (R10's) abdomen. After (E13) heard E5 tell E12 that E5 should have put it on his chest to crush him because he had told her early in the day to "suck his d--k and called her a b---h. E13 heard R10 ask for something E5 told R10 to "Shut the f--k up". E3, RN/ADON, documents that E3 notified E2, (Director of Nursing). (B) R10's current POS (Physician order [REDACTED]. R10's MDS (Minimum Data Set) assessment dated [DATE] indicates R10 is total dependent on staff for hygiene, dressing, and transfers. R10's MDS assessment also states R10's BIMS (Brief Interview for Mental Status) score is five, indicating R10 has severe cognitive impairment. R10's behavior flow sheet dated 3/01/14 shows R10 is monitored for the following behaviors: Actively engaged; One to one socialization; Sexually inappropriate to staff (verbally or physically); cursing; and Will not speak to staff. On 3/03/14 at 1:50 p.m., R10 was confused and sitting in a wheelchair next to R10's bed. R10 had a lap cushion in place and a personal alarm. E21 (CNA - Certified Nursing Assistant) and E22 (CNA) entered R10's room and transferred R10 from a wheelchair to the bed with a mechanical lift. An Accident/Incident Log dated 2013 documents on 9/15/13 at 2:50 p.m., R10 stated, "That girl that was just here (E6 CNA) twisted my left wrist." An Incident/Accident Report dated 9/15/13 at 2:50 p.m., indicates R10 reported to E7 (LPN - Licensed Practical Nurse), "That girl that was just in here (E6 CNA) twisted my left wrist." A Resident Accident and Incident Investigation Report dated 9/15/13 E7 (LPN) indicated R10 complained of left wrist discomfort at 2:50 p.m. and denied pain by 2:55 p.m. An Accident/Incident Log dated 2013 states on 9/15/13 at 2:50 p.m., indicates R10 had no obvious injury and reports E6 CNA stated, " I did not touch (R10's) hand, wrist, or arm. I used the pad to turn and reposition (R10)." A Resident Accident and Incident Investigation Report dated 9/15/13 at 3:00 p.m. includes a summary hand written by E2 (DON - Director of Nursing) stating, "Questioned (E6 CNA) and (E6) stated that (E6) did not touch (R10) or twist (R10's) wrist. (R10) may have thought (E6) did when (E6) turned (R10) with the pad. I explained to (E6 CNA) to always have two people in the room when taking care of (R10) because of (R10's) confusion and history of inappropriate measures with the staff. It protects everyone that way. When questioning (R10), (R10) had forgotten that (R10) had said anything about (E6 CNA)." On 3/10/14 at 9:05 a.m., E7 (LPN - Licensed Practical Nurse) stated, "I went in right away to (R10) and asked right at the first. (R10) told me someone twisted (R10's) arm. There was nothing visible on the arm. (R10) just said it was the girl that was just in (R10's) room (E6 CNA). It would have been the end of (E6's) shift because it was during last rounds and (E6 CNA) leaves at 3:00 p.m. I wrote what (E6 CNA) told me." E7 (LPN) indicated if an allegation of abuse occurs both the resident and the accused are to be questioned and the information reported to (E2 DON - Director of Nursing). Regarding staff being sent home after an allegation of abuse, E7 (LPN) stated, "That would be up to (E2 DON)." On 3/10/14 at 9:20 a.m., E6 (CNA) stated, "It was during 2:30 p.m. rounds. I was going in to change (R10's) pad real quick. I went in and I was rolling (R10) over trying to talk to (R10). You have to be careful what you say to (R10). (R10) gets sexual." E6 (CNA) stated, "(E7 LPN) and Z1 (R10's POA - Power of Attorney) called me back into the room and told me (R10's) wrist was hurting. I told them I didn't know anything about it." When asked if E6 (CNA) gave a written statement to E2 (DON) or E7 (LPN), E6 stated, "No, not that I recall." When ask if (E6 CNA) worked the following day (9/16/13) On 3/6/14 at 6:00 pm an Immediate Jeopardy was identified to have begun on 11/7/13 when R10 was witnessed to be physically, mentally and verbally abused while the alleged staff member was allowed to continue to work that shift and part of the following day. E1 (Administrator was informed of the Immediate Jeopardy on 3/6/14 at 6:00 p.m. The surveyor confirmed through observation, interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1) The Administrator,DON ( Director of ) or designated representative will report all allegations of abuse to the state agency immediately. All allegations will be thoroughly investigated with a completion date of 3/10/14 and continuing. 2) The DON (Director Of Nursing) and SSD (Social Service Director) assessed R18 and care planned for Abusive Behavior. Completion date of 3/13/14. 3) The Administrator, Director of Nursing and Administrative staff will follow the seven step plan in order to operationalize the Abuse and Neglect policies. Completion date of 3/10/14 and continuing. and 4) The Abuse Neglect inservices will be conducted by outside sources for all employees of the facility by an outside agency on 3/19/14 and an indiviual on 3/27/14. The DON and QA Coordinator will be responsible for monitoring and assuring ongoing compliance.

Based on observation, record review and interviews, the facility failed to report allegations of abuse to the state agency for three incidents involving one residnet (R10) reviewed for abuse on the sample of 15. The facility failed to thoroughly investigate allegations and failed to provide protection for all 57 residents residing in the facility. as those staff involved E5 C.N.A. (Certified Nurse Aide) and E6 C.N.A. were allowed to continue to work after witnessed allegations of verbal, mental and physical abuse were made and reported. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/06/14 at 6:30 pm, the facility remains out of compliance at a Severity Level II as the facility continues to monitor the effectiveness of training regarding abuse policy, updating of abuse policy, operationalize of abuse policy and all seven components of the Abuse Neglect Policy. Findings include: (A) The facility's "Abuse Prohibition and Prevention Policies and Procedures" under the heading titled "E. Investigation" states "Any employee suspected of committing the above will be suspended pending the outcome of the investigation" and "Employees of the facility who have been accused of resident abuse will be suspended until the results of the investigation have been concluded." On 3/3/14 at 2:00pm E2, Director of Nursing, stated that the facility had "only one allegation of abuse" during the past 12 months. A facility "Incident/Accident Report"prepared by E2, Director of Nursing dated 11/7/13 documents a witnessed allegation of physical and verbal abuse occurred on 11/7/13 at approximately 1:30pm identifying E5, Certified Nurse Aid (CNA)as the perpetrator of the abuse. This Incident/Accident Report identifies R10, a cognitively impaired [AGE] year old resident as the recipient of the abuse and E12, CNA and E13, CNA are identified as the witnesses to the alleged abuse. R10's medical record documents that R10 has [DIAGNOSES REDACTED]. R10's Annual Minimum (MDS) data set [DATE] documents R10's Brief Interview for Mental Status (BIMS) score of 5 indicating R10 has significant cognitive impairment and that R10 requires extensive assistance with transfers, dressing, bathing and all activities of daily living. The description of the allegation included in the Incident/Accident Report and Investigation dated 11/7/13 documents the following occurred on 11/7/13 at 1:30pm: While changing R10's clothes, with E12, E5 "grabbed R10's nose and twisted it" after R10 "made inappropriate sexual statement" to E5. Two witnesses, E12 and E 13, documented in separate written witness statements dated 11/7/13 that after the mechanical lift transfer of R10 to R10's bed, E5 sat in R10's wheelchair with the mechanical lift handheld controller and continued to lower the metal bar on the mechanical lift into R10's abdomen. After being told to stop lowering the mechanical lift three times by the two other CNA's assisting in the transfer, E5 continued to lower the metal bar into R10's abdomen and stated that she should have " lowered the bar into (R10)'s chest in order to crush (R10), after what R10 said to me". E12, CNA also documented in the written statement dated 11/7/13, that after the transfer to R10's bed, while "picking up R10's room", E5 "said (E5) hates that f---ing bastard" and when R10 asked E5 for some chocolate milk E5 stated "(E5) was not giving that f---er nothing." A written statement by E3, Registered Nurse/Assistant Director of Nursing (RN/ADON), dated 11/7/13 documents that E3 was notified by E25, Licensed Practical Nurse (LPN), at 1:45pm on 11/7/13 that "E12, E13 and E5(CNA's) were in R10's room putting him to bed when E5 sat in R10's chair with the mechanical lift control in her hand pushing the down button."E12 told E5 three times to stop lowering the mechanical lift arm "before E5 finally stopped." "When she was pushing the button the (mechanical lift arm) was going down on (R10's) abdomen. After (E13) heard E5 tell E12 that E5 should have put it on his chest to crush him because he had told her early in the day to "suck his d--k and called her a b---h. E13 heard R10 ask for something E5 told R10 to "Shut the f--k up". E3, RN/ADON, documents that E3 notified E2, (Director of Nursing). A document included in the investigation of the 11/7/13 incident titled "Timeline of (E5)" included in the Investigation packet for the abuse allegation of 11/7/13 involving E5 states "(E2) spoke with (E5) at 2:50pm, one and one-half hours later, on 11/7/13 at the facility explaining that an incident had been reported involving (R10) that had to be investigated." Also included in the same "Timeline on (E5)" is documentation by E2, Director of Nursing (DON), that E5 worked the following day from 7:00am to 12:00 noon on 11/8/13 for before being put on suspension. The facility's "CNA SCHEDULE" dated October 27, 2013 to November 9, 2013 documents that E5 was scheduled to work the 7am to 3 pm shift on 11/7/14 and on 11/8/13 from 7 am to 12 pm. The facility's Time Card for E5 documents that E5 worked on 11/7/14 from 7:01am through 3:14pm and on 11/8/13 from 7:01 through 12:08pm. On 3/4/14 at 1:00pm E2, Director of Operations verified that E5 did continue to work on 11/7/13 until "approximately 2:45pm" when E2 was notified of the allegation and arrived at the facility to begin the investigation of the allegation and E2 verified that E5 did work in resident care on 11/8/13 from 7am to 12pm. On 3/6/14 at 6:00pm, E2 verified that E5 should not have been allowed to work after the allegation of abuse on 11/7/13 was made. On 3/6/14 at 6:00 pm an Immediate Jeopardy was identified to have begun on 11/7/13 when R10 was witnessed to be physically, mentally and verbally abused while the alleged staff member was allowed to continue to work that shift and part of the following day. E1 (Administrator was informed of the Immediate Jeopardy on 3/6/14 at 6:00 p.m. The surveyor confirmed through observation, interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1) The Administrator, DON ( Director of Nursing) or designated representative will report all allegations of abuse to the state agency immediately. All allegations will be thoroughly investigated with a completion date of 3/10/14 and continuing. 2) The DON (Director Of Nursing) and SSD (Social Service Director) assessed R18 and care planned for Abusive Behavior. Completion date of 3/13/14. 3) The Administrator, Director of Nursing and Administrative staff will follow the seven step plan in order to operationalize the Abuse and Neglect policies. Completion date of 3/10/14 and continuing. 4) The suspicion of Crime Posters have been posted by Administrative staff with a completion date of 3/7/14. 5) The suspicion of Crime Policy is being completed by the Administrator and DON. Completion Date: 3/14/14 6) Abuse and Neglect inservices will be conducted by an outside agency and a contracted individual for all employees of the facility. The Don and QA (Quality Assurance) Coordinator will be responsible for monitoring and assuring compliance. Completion date for inservices: 3/27/14. (B) R10's current POS (Physician order [REDACTED]. R10's MDS (Minimum Data Set) assessment dated [DATE] indicates R10 is total dependent on staff for hygiene, dressing, and transfers. R10's MDS assessment also states R10's BIMS (Brief Interview for Mental Status) score is five, indicating R10 has severe cognitive impairment. R10's behavior flow sheet dated 3/01/14 shows R10 is monitored for the following behaviors: Actively engaged; One to one socialization; Sexually inappropriate to staff (verbally or physically); cursing; and Will not speak to staff. On 3/03/14 at 1:50 p.m., R10 was confused and sitting in a wheelchair next to R10's bed. R10 had a lap cushion in place and a personal alarm. E21 (CAN - Certified Nursing Assistant) and E22 (CNA) entered R10's room and transferred R10 from a wheelchair to the bed with a mechanical lift. An Accident/Incident Log dated 2013 documents on 9/15/13 at 2:50 p.m., R10 stated, "That girl that was just here (E6 CNA) twisted my left wrist." An Incident/Accident Report dated 9/15/13 at 2:50 p.m., indicates R10 reported to E7 (LPN - Licensed Practical Nurse), "That girl that was just in here (E6 CNA) twisted my left wrist." A Resident Accident and Incident Investigation Report dated 9/15/13 E7 (LPN) indicated R10 complained of left wrist discomfort at 2:50 p.m. and denied pain by 2:55 p.m. An Accident/Incident Log dated 2013 states on 9/15/13 at 2:50 p.m., indicates R10 had no obvious injury and reports E6 CNA stated, " I did not touch (R10's) hand, wrist, or arm. I used the pad to turn and reposition (R10)." A Resident Accident and Incident Investigation Report dated 9/15/13 at 3:00 p.m. includes a summary hand written by E2 (DON - Director of Nursing) stating, "Questioned (E6 CNA) and (E6) stated that (E6) did not touch (R10) or twist (R10's) wrist. (R10) may have thought (E6) did when (E6) turned (R10) with the pad. I explained to (E6 CNA) to always have two people in the room when taking care of (R10) because of (R10's) confusion and history of inappropriate measures with the staff. It protects everyone that way. When questioning (R10), (R10) had forgotten that (R10) had said anything about (E6 CNA)." On 3/10/14 at 9:05 a.m., E7 (LPN - Licensed Practical Nurse) stated, "I went in right away to (R10) and asked right at the first. (R10) told me someone twisted (R10's) arm. There was nothing visible on the arm. (R10) just said it was the girl that was just in (R10's) room (E6 CNA). It would have been the end of (E6's) shift because it was during last rounds and (E6 CNA) leaves at 3:00 p.m. I wrote what (E6 CNA) told me." E7 (LPN) indicated if an allegation of abuse occurs both the resident and the accused are to be questioned and the information reported to (E2 DON - Director of Nursing). Regarding staff being sent home after an allegation of abuse, E7 (LPN) stated, "That would be up to (E2 DON)." On 3/10/14 at 9:20 a.m., E6 (CNA) stated, "It was during 2:30 p.m. rounds. I was going in to change (R10's) pad real quick. I went in and I was rolling (R10) over trying to talk to (R10). You have to be careful what you say to (R10). (R10) gets sexual." E6 (CNA) stated, "(E7 LPN) and Z1 (R10's POA - Power of Attorney) called me back into the room and told me (R10's) wrist was hurting. I told them I didn't know anything about it." When asked if E6 (CNA) gave a written statement to E2 (DON) or E7 (LPN), E6 stated, "No, not that I recall." When ask if (E6 CNA) worked the following day (9/16/13). The facility policy titled ABUSE PROHIBITION AND PREVENTION POLICIES AND PROCEDURES no date, includes the following: E. Investigation: A thorough investigation will be conducted by the administrator or representative. 1. The investigation shall consist of: a. A review of the complaint. b. Interviews with person reporting c. Interviews with any witnesses f. An interview with staff members on all shifts having contact with the residents during the period of the alleged incident h. A review of the circumstances surrounding the incident. Protection: Appropriate action will be taken to protect a resident from harm during the investigation The resident census and condition report, dated 3/03/14, documents there are 57 residents in the facility.

Based on interview and record review, the facility failed to develop the abuse prohibition policies and procedures to include the reporting and identification components of abuse prevention as required. This has the potential to affect all 54 residents residing at the facility Findings include: On 4/28/14 the facility provided a policy titled, "Abuse Prohibition and Prevention Policies and Procedures" dated 4/3/14 which includes the following: "on page 3. D. Identification: 2. The Administrator or Director of Nursing Services must be immediately notified of suspected or (actual) incidents of abuse. G. Reporting: 2. Should the investigation reveal that abuse, neglect, theft or injury of unknown source occurred, the Administrator will report such finding to the (state agency)." E3 (DON/Director of Nursing) was asked on 4/30/14 at 11:30 am, what occurs when an allegation of abuse is reported? The facility policy regarding reporting allegations indicates staff have a choice of reporting to the Administrator or the Director of Nursing. The abuse policy also gives a choice of whether to report the allegation to the state agency based on what the investigation reveals. On 4/30/14 at 11:30 a.m., E3 stated, "We go down, look into it and investigate. We have 24 hours to get the paper work ready to report, if it is abuse." The Facility Data Sheet completed by E2 (Assistant Administrator) on 4/28/14 states there are 54 residents residing at the facility.

Based on Interview and Record Review, the facility failed to develop and operationalize abuse prohibition policies and procedures including the seven components of abuse prevention, for one of fifteen residents (R10), reviewed for abuse and neglect in a sample of fifteen, and failed to protect all 57 residents from potential abuse. These failures resulted in an Immediate Jeopardy While the immediacy was removed on 3/6/14 at 6:30pm, the facility remains out of compliance at a Severity Level II as the facility continues to develop and implement an updated abuse prohibition and prevention policy addressing all seven components of abuse prohibition and to effectively educate staff regarding the updated policy. Findings include: The facility's undated Abuse Prohibition and Prevention Policies and Procedures policy states that all staff will be trained in "The items that constitute abuse, neglect and misappropriation of property." A facility "Incident/Accident Report" prepared by E2, Director of Nursing (DON) dated 11/7/13 documents a witnessed allegation of physical and verbal abuse occurred on 11/7/13 at 1:30pm identifying E5, Certified Nurse Aid (CNA), as the perpetrator of the abuse. This Incident/Accident Report identifies R10, a cognitively impaired [AGE] year old resident, as the recipient of the abuse and E12, CNA and E13, CNA are identified as the witnesses to the alleged abuse. The description of the allegation included in the Incident/Accident Report and Investigation dated 11/7/13 documents the following occurred on 11/7/13 at 1:30pm: While changing R10's clothes, with E12, E5 "grabbed R10's nose and twisted it" after R10 "made inappropriate sexual statement" to E5. Two witnesses, E12 and E 13, documented in separate written witness statements dated 11/7/13 that after the mechanical lift transfer of R10 to R10's bed, E5 sat in R10's wheelchair with the mechanical lift handheld controller and continued to lower the metal bar on the mechanical lift into R10's abdomen. After being told to stop lowering the mechanical lift three times by the two other CNA's assisting in the transfer, E5 continued to lower the metal bar into R10's abdomen and stated that she should have " lowered the bar into (R10)'s chest in order to crush (R10), after what R10 said to me". E12, CNA also documented in the written statement dated 11/7/14, that after the transfer to R10's bed, while "picking up R10's room", E5 "said (E5) hates that f---ing bastard" and when R10 asked E5 for some chocolate milk E5 stated "(E5) was not giving that f---er nothing." A written statement by E3, Registered Nurse/Assistant Director of Nursing (RN/ADON), dated 11/7/13 documents that E3 was notified of the abuse allegation by E25, Licensed Practical Nurse (LPN), on 11/7/14 at 1:45pm. E3, RN/ADON, documents that E3 notified E2, Director of Nursing (DON), at approximately 2:15pm - 2:30pm on 11/7/14 after E2 came in to the facility and E2 then "went upstairs to talk to E5, CNA and investigate." A hand-written document by E2, DON, titled "Timeline of (E5)", included in the Incident Investigation packet for the abuse allegation of 11/7/13 involving E5 states "(E2) spoke with (E5) at 2:50pm", one and one-half hours after the abuse allegation had occurred. E2, DON, also documented that E5 continued to work on 11/8/13 for five hours, from 7:00am to 12:00 noon, before being sent home on suspension. The facility's "CNA SCHEDULE" dated October 27, 2013 to November 9, 2013 documents that E5 was scheduled to work the 7am to 3 pm shift on 11/7/14 and on 11/8/14 from 7 am to 12 pm. The facility's Time Card for E5 documents that E5 worked on 11/7/14 from 7:01am through 3:14pm and on 11/8/14 from 7:01 through 12:08pm. On 3/4/14 at 1:00pm E2, Director of Operations verified that E5 did continue to work on 11/7/13 until "approximately 2:45pm" when E2 was notified of the allegation and arrived at the facility to begin the investigation of the allegation and E2 verified that E5 did work in resident care on 11/8/13 from 7am to 12pm. On 3/6/14 at 3:30pm E2, DON verified that on 11/8/13, from approximately 7:00am to 12:00 noon, E5 worked in the facility doing resident care "with another CNA" "because (E2) did not want to falsely accuse anyone" and on the morning of 11/8/13 she had only one of two written witness statements and "was waiting for the second written witness statement in order to make the conclusion that there was substantial evidence of abuse." On 3/6/14 at 6:00pm, E2 verified that E5 should not have been allowed to work after the allegation of abuse on 11/7/13 was made. On 3/4/14 at 10:00am, E7, Licensed Practical Nurse (LPN), stated that when an employee is accused of abuse the employee is "talked to by (E2)" and "It would be up to E2 to decide whether the employee can stay at work or not." On 3/5/14 at 12:00pm E 27, CNA stated that she was "not sure if an employee could stay at work" when accused of abuse. E3, Assistant Director of Nursing stated on 3/5/14 at 11:30 am that an employee accused of abuse could continue to work in resident care in the facility if they were moved to the other resident hall and did not have contact with the resident that they had been accused of abusing. The facility's Abuse policy states: "Should the investigation reveal that abuse, neglect, misappropriation or theft of resident property, or injury of an unknown source occurred, the Administrator will report such finding to the local police department if necessary, and the Illinois Department of Public Health within 24 hours of the results of the completion of the investigation." On 3/5/14 at approximately 1:30 pm E2, Director of Nursing (DON), stated that she reported the allegation of abuse dated 11/7/13 involving R10 and perpetrator E5, to IP on 11/12/13, five days after the allegation of abuse was made. The facility's "Abuse Prohibition and Prevention Policies and Procedures" under the heading titled "E. Investigation" states "Any employee suspected of committing the above will be suspended pending the outcome of the investigation" and "Employees of the facility who have been accused of resident abuse will be suspended until the results of the investigation have been concluded." On 3/3/14 at 2:00pm E2, Director of Operations, stated that the facility had "only 1 allegation of abuse" during the past 12 months. The facility's abuse policy does not specify that an employee accused of abuse/neglect must be immediately suspended from duty. The facility's "Abuse Prohibition and Prevention Policies and Procedures" under the heading titled "E. Investigation" states "Any employee suspected of committing the above will be suspended pending the outcome of the investigation" and "Employees of the facility who have been accused of resident abuse will be suspended until the results of the investigation have been concluded." A facility "Incident/Accident Report"prepared by E2, Director of Operations dated 11/7/13 documents a witnessed allegation of physical and verbal abuse occurred on 11/7/13 at approximately 1:30pm identifying E5, Certified Nurse Aid (CNA)as the perpetrator of the abuse. This Incident/Accident Report identifies R10, a cognitively impaired [AGE] year old resident as the recipient of the abuse and E12, CNA and E13, CNA are identified as the witnesses to the alleged abuse. A written statement by E3, Registered Nurse/Assistant Director of Nursing (RN/ADON), dated 11/7/13 documents that E3 was notified of the abuse allegation by E25, Licensed Practical Nurse (LPN), on 11/7/14 at 1:45pm. E3, RN/ADON, documents that E3 notified E2, Director of Nursing (DON), at approximately 2:15pm - 2:30pm on 11/7/13 after E2 came in to the facility and E2 then "went upstairs to talk to E5, CNA and investigate." A hand-written document by E2, DON, titled "Timeline of (E5)", included in the Incident Investigation packet for the abuse allegation of 11/7/13 involving E5 states "(E2) spoke with (E5) at 2:50pm", one and one-half hours after the abuse allegation had occurred. E2, DON, also documented that E5 continued to work on 11/8/13 for five hours, from 7:00am to 12:00 noon, before being sent home on suspension. The facility's "CNA SCHEDULE" dated October 27, 2013 to November 9, 2013 documents that E5 was scheduled to work the 7am to 3 pm shift on 11/7/13 and on 11/8/13 from 7 am to 12 pm. The facility's Time Card for E5 documents that E5 worked on 11/7/13 from 7:01am through 3:14pm and on 11/8/13 from 7:01 through 12:08pm. On 3/4/14 at 1:00pm E2, Director of Operations verified that E5 did continue to work on 11/7/13 until "approximately 2:45pm" when E2 was notified of the allegation and arrived at the facility to begin the investigation of the allegation and E2 verified that E5 did work in resident care on 11/8/13 from 7am to 12pm. On 3/6/14 at 3:30pm E2, DON verified that on 11/8/13, from approximately 7:00am to 12:00 noon, E5 worked in the facility doing resident care "with another CNA" "because (E2) did not want to falsely accuse anyone" and on the morning of 11/8/13 she had only one of two written witness statements and "was waiting for the second written witness statement in order to make the conclusion that there was substantial evidence of abuse." On 3/6/14 at 6:00pm, E2 verified that E5 should not have been allowed to work after the allegation of abuse on 11/7/13 was made. On 3/4/14 at 10:00am, E7, Licensed Practical Nurse (LPN), stated that when an employee is accused of abuse the employee is "talked to by (E2)" and "It would be up to E2 to decide whether the employee can stay at work or not." On 3/5/14 at 12:00pm E27, CNA stated that she was "not sure if an employee could stay at work" when accused of abuse. E3, Assistant Director of Nursing stated on 3/5/14 at 11:30 am that an employee accused of abuse could continue to work in resident care in the facility if they were moved to the other resident hall and did not have contact with the resident that they had been accused of abusing. The facility's Abuse policy states: "Should the investigation reveal that abuse, neglect, misappropriation or theft of resident property, or injury of an unknown source occurred, the Administrator will report such finding to the local police department if necessary, and the Illinois Department of Public Health within 24 hours of the results of the completion of the investigation." On 3/5/14 at approximately 1:30 pm E2, Director of Nursing (DON), stated that she reported the allegation of abuse dated 11/7/13 involving R10 and perpetrator E5, to STATE AGENCY on 11/12/13. Also included in the same "Timeline on (E5)" is documentation by E2, Director of Nursing (DON), that E5 worked the following day from 7:00am to 12:00 noon on 11/8/13 for before being put on suspension. The facility's "CNA SCHEDULE" dated October 27, 2013 through November 9, 2013 documents that E5 was scheduled to work the 7am to 3 pm shift on 11/7/13 and on 11/8/13 from 7 am to 12 pm. The facility's Time Card for E5 documents that E5 worked on 11/7/14 from 7:01am through 3:14pm and on 11/8/14 from 7:01 through 12:08pm. On 3/4/14 at 1:00pm E2, Director of Operations verified that E5 did continue to work on 11/7/13 until "approximately 2:45pm" when E2 was notified of the allegation and arrived at the facility to begin the investigation of the allegation and E2 verified that E5 did work in resident care on 11/8/13 from 7am to 12pm. On 3/6/14 at 6:00pm, E2 verified that E5 should not have been allowed to work after the allegation of abuse on 11/7/13 was made. On 3/6/14 at 6:00 pm an Immediate Jeopardy was identified to have begun on 11/7/13 when R10 was witnessed to be physically, mentally and verbally abused while the alleged staff member was allowed to continue to work that shift and part of the following day. E1 (Administrator was informed of the Immediate Jeopardy on 3/6/14 at 6:00 p.m. The surveyor confirmed through observation, interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1) The Administrator, Director of Nursing or designated representative will report all allegations of abuse to the state agency immediately. All allegations will be thoroughly investigated with a completion date of 3/10/14 and continuing. 2) The DON (Director Of Nursing) and SSD (Social Service Director) assessed R18 and care planned for Abusive Behavior. Completion date of 3/13/14. 3) The Administrator, Director of Nursing and Administrative staff will follow the seven step plan in order to operationalize the Abuse and Neglect policies. Completion date of 3/10/14 and continuing. and 4) The Abuse Neglect inservices will be conducted by outside sources for all employees of the facility by an outside agency on 3/19/14 and a contracted individual on 3/27/14. The DON and QA Coordinator will be responsible for monitoring and assuring ongoing compliance. B) An undated policy titled Abuse Prohibition and Prevention Policies and Procedures states all potential employees will be screened. On 3/05/14 at 2:00 p.m., E5 (CNA - Certified Nursing Assistant's) personnel file shows E5 was hired on 2/23/10 and terminated on 11/12/13 for verbal and mental abuse. E5 (CNA's) employment applications dated 2/19/08 and 11/20/09 states E5 has work experience as a CNA in another state. E5 (CNA's) registry check dated 4/19/10 states E5 was deemed competent in this state from a program completed in a neighboring state. E5 (CNA's) personnel file does not contain verification the state registries were checked for both E5's documented work experience and the neighboring state where E5 received competency training. On 3/05/14 at 2:30 p.m., E15 (CNA's) personnel file shows E15 was hired on 7/24/13. E15 (CNA's) employment application dated 7/11/13 indicates E15 has been a CNA since 2007 but the work history provided by E15 only dates back to November 2011. E15 (CNA's) application also states E15 has resided in a neighboring state after the date of E15's certification. E15 (CNA's) personnel file contains no verification the neighboring state's nurse aide registry was checked before E15 was employed. On 3/06/14 at 9:30 a.m., E16 (Administrative Assistant) indicated (E16) is responsible to complete the nurse aide registry checks. Regarding registry checks for other state registries, E16 stated, "I didn't know I had to." E16 (Administrative Assistant) verified other state registries are not being checked when new CNAs are hired. The Abuse Prohibition and Prevention policy states " All staff will be trained through orientation and annually thereafter on this policy. Also included in the training will be: 1. Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. 2. Appropriate reporting of allegations related to this policy without fear of reprisal. 3. Recognizing the signs of burnout, frustration and stress that may lead to abuse. 4. The items that constitute abuse, neglect, and misappropriation or resident property. " The Abuse Prohibition and Prevention policy states " Identification: All incident reports will be reviewed by the Director of Nursing and the Administrator or designated representative, to identify events that may constitute abuse. Also, patterns of occurrences will be identified as potential abuse. Once alleged abused is determined, an investigation will be conducted. Any alleged violations of this policy must be reported immediately to the Administrator, Director of Nursing, or designated representative. R10's current POS (Physician order [REDACTED]. R10's MDS (Minimum Data Set) assessment dated [DATE] indicates R10 is total dependent on staff for hygiene, dressing, and transfers. R10's MDS assessment also states R10's BIMS (Brief Interview for Mental Status) score is five, indicating R10 has severe cognitive impairment. R10's behavior flow sheet dated 3/01/14 shows R10 is monitored for the following behaviors: Actively engaged; One to one socialization; Sexually inappropriate to staff (verbally or physically); cursing; and Will not speak to staff. On 3/03/14 at 1:50 p.m., R10 was confused and sitting in a wheelchair next to R10's bed. R10 had a lap cushion in place and a personal alarm. E21 (CNA - Certified Nursing Assistant) and E22 (CNA) entered R10's room and transferred R10 from a wheelchair to the bed with a mechanical lift. An Accident/Incident Log dated 2013 documents on 9/15/13 at 2:50 p.m., R10 stated, "That girl that was just here (E6 CNA) twisted my left wrist." An Incident/Accident Report dated 9/15/13 at 2:50 p.m., indicates R10 reported to E7 (LPN - Licensed Practical Nurse), "That girl that was just in here (E6 CNA) twisted my left wrist." A Resident Accident and Incident Investigation Report dated 9/15/13 E7 (LPN) indicated R10 complained of left wrist discomfort at 2:50 p.m. and denied pain by 2:55 p.m. An Accident/Incident Log dated 2013 states on 9/15/13 at 2:50 p.m., indicates R10 had no obvious injury and reports E6 CNA stated, " I did not touch (R10's) hand, wrist, or arm. I used the pad to turn and reposition (R10)." A Resident Accident and Incident Investigation Report dated 9/15/13 at 3:00 p.m. includes a summary hand written by E2 (DON - Director of Nursing) stating, "Questioned (E6 CNA) and (E6) stated that (E6) did not touch (R10) or twist (R10's) wrist. (R10) may have thought (E6) did when (E6) turned (R10) with the pad. I explained to (E6 CNA) to always have two people in the room when taking care of (R10) because of (R10's) confusion and history of inappropriate measures with the staff. It protects everyone that way. When questioning (R10), (R10) had forgotten that (R10) had said anything about (E6 CNA)." On 3/10/14 at 9:05 a.m., E7 (LPN - Licensed Practical Nurse) stated, "I went in right away to (R10) and asked right at the first. (R10) told me someone twisted (R10's) arm. There was nothing visible on the arm. (R10) just said it was the girl that was just in (R10's) room (E6 CNA). It would have been the end of (E6's) shift because it was during last rounds and (E6 CNA) leaves at 3:00 p.m. I wrote what (E6 CNA) told me." E7 (LPN) indicated if an allegation of abuse occurs both the resident and the accused are to be questioned and the information reported to (E2 DON - Director of Nursing). Regarding staff being sent home after an allegation of abuse, E7 (LPN) stated, "That would be up to (E2 DON)." On 3/10/14 at 9:20 a.m., E6 (CNA) stated, "It was during 2:30 p.m. rounds. I was going in to change (R10's) pad real quick. I went in and I was rolling (R10) over trying to talk to (R10). You have to be careful what you say to (R10). (R10) gets sexual." E6 (CNA) stated, "(E7 LPN) and Z1 (R10's POA - Power of Attorney) called me back into the room and told me (R10's) wrist was hurting. I told them I didn't know anything about it." When asked if E6 (CNA) gave a written statement to E2 (DON) or E7 (LPN), E6 stated, "No, not that I recall." When ask if (E6 CNA) worked the following day (9/16/13), E6 (CNA) stated, "I think so." Time card records for E6 (CNA) dated 9/15/13 indicates E6 clocked in at 6:52 a.m. and clocked out at 3:00 p.m. The time card information shows E6 did not clock in again until 9/17/13 at 7:00 a.m. On 3/10/14 at 9:20 a.m., E6 (CNA) denied (E6) ever being suspended for an abuse allegation investigation. On 3/10/14 at 10:26 a.m., Z1 (R10's POA - Power of Attorney) indicated (Z1) was aware of (R10's allegation of abuse on 9/15/13) and stated, "Yes, I just heard that it happened but there was no follow up. No one ever told me the outcome." On 3/03/14 at 2:00 p.m., E2 (DON) indicated there had been only one allegation of abuse on 11/07/13 involving R10 during the past year. On 3/10/14 at 11:10 a.m., E2 (DON) verified the 9/15/13 incident involving R10 and E6 (LPN) was not reported to the state agency as an allegation of abuse. E2 (DON) also indicated E6 (CNA) was not suspended until further investigation and resident and staff interviews were not conducted. On 3/10/14 at 11:10 a.m., regarding abuse allegations, E2 (DON) stated, "I'll need a full time person just to take care of that. Nobody is to work with (R10) without two staff ever. Not anymore." The Abuse Prohibition and Prevention policy states " A thorough investigation will be conducted by the administrator or designated representative and all other department supervisors who are considered important in the investigation. Any employee suspected of committing the above will be suspended pending the outcome of the investigation. Any employee found guilty of committing abuse will be immediately terminated ... The investigation shall consist of: a. A review of the complaint; b. An interview with the person(s) reporting the alleged incident; c. Interviews with any witnesses to the alleged incident; d. An interview with the resident; e. An interview with the resident's attending physician, if practicable, and review of the resident's medical record; f. An interview with staff members (on all shifts) having contact with the resident during the period of the alleged incident; g. Interviews with other residents to whom the accused employee provides care or services ; and h. A review of the circumstances surrounding the alleged incident. 2. Witness reports shall be in writing. Witnesses will be required to sign and date such reports. 3. Employees of the facility who have been accused of resident abuse will be suspended until the results of the investigation have been concluded. 4. The Administrator will keep the resident and his/her representative informed of the progress of the investigation. 5. The results of the investigation will be recorded in writing.... Any staff accused of resident abuse or neglect will be suspended pending the results of the investigation. " The Abuse Prohibition and Prevention policy states " Protection: Appropriate action will be take in order to protect a resident from harm during the investigation ...Any staff accused of resident abuse or neglect will be suspended pending the results of the investigation. The resident will be moved to another location in the facility if the alleged abuse was committed by another resident. The physician of the resident who committed the alleged abuse will be contacted and the resident will be transferred to the hospital if necessary. The facility policy titled ABUSE PROHIBITION AND PREVENTION POLICIES AND PROCEDURES no date, includes the following: E. Investigation: A thorough investigation will be conducted by the administrator or representative. 1. The investigation shall consist of: a. A review of the complaint. b. Interviews with person reporting c. Interviews with any witnesses f. An interview with staff members on all shifts having contact with the residents during the period of the alleged incident h. A review of the circumstances surrounding the incident. Protection: Appropriate action will be taken to protect a resident from harm during the investigation.

A. Based on observation, record review and interview, the facility failed to assess a resident's use of side rails, identify side rails as a potential entrapment risk, adequately investigate resident falls, and properly report a serious resident incident involving side rails, resulting in no investigation or amendment to the Plan of Care, for two of 10 residents (R8, R6) reviewed for use of siderails, in a sample of 15. This failure resulted in staff not identifying R8's inability to utilize side rails as an enabler, R8 being found with (R8's) body hanging from the bed and face against the side rail, and continued use of the side rails without concern of the potential for future entrapment. The facility failed to ensure staff safely transferred residents and followed operational Policies and Procedures for transfers, for two of seven residents (R1, R10) reviewed for transfers, in a sample of 15. This failure resulted in skin tears to R10's hand, shin, and great toe as well as bruising to the eye. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 3/04/14, the facility remains out of compliance at a Severity Level II as the facility continues to monitor the effectiveness of training regarding resident safety, incidents that are to be reported and the appropriate staff to report incidents to, side rail use and identification of residents at risk for entrapment. Findings include: 1. On 3/03/14 at 10:00 a.m. and 2:00 p.m. and on 3/04/14 at 9:10 a.m., R8 was lying in bed with the right side of the bed against the wall and the left half-siderail in the upright position. On 3/04/13 at 10:35 a.m., E9 (Certified Nursing Assistant) and E8 (Certified Nursing Assistant) provided incontinence care to R8. E8 stated R8 was unable to reposition independently. E8 and E9 had to physically roll R8 from the right to the left side during cares. A physician's orders [REDACTED]. A Minimum Data Set, dated dated [DATE], documents R8 has moderate cognitive impairment, with disorganized thinking, fluctuating altered level of consciousness, psychomotor retardation, and requires the extensive assistance of two staff for transfers and bed mobility. The Minimum Data Set identifies R8 utilizes a bed rail as a physical restraint on a daily basis. A Plan of Care, last updated 8/01/13, documents R8 as high risk for falls with a long history of falls at home and while residing at the facility, often making unsafe transfers, trying to ambulate independently, making poor decisions, and having poor balance control. The Plan of Care instructs staff to utilize bilateral half side rails while R8 is in bed, as an intervention to the falls. A Side Rail Assessment, dated 11/16/10, documents R8 had requested a side rail for "enhanced bed mobility" and identified R8 as having a history of weakness, balance deficit, and falls. The Side Rail Assessment documents the side rails are recommended for use when R8 is in bed and is to be assessed in 30 days "or sooner, if there is a significant change in condition." The last documented assessment of R8's ability to use the side rails is dated 8/01/13, and indicates R8 "requests to keep (R8's bilateral) half rails." A Incident/Accident Report, dated 12/22/13 at 6:30 a.m., documents R8 as "trying to get up to go to (bathroom). (Resident) on knees beside bed, holding on to side rail." The Incident/Accident Report documents R8 sustained "(right) elbow bruises (and) skin abrasions." The Incident/Accident Report instructs staff to conduct visual checks of R8 every 15 minutes as a new intervention to prevent falls. R8's most current Plan of Care (dated 8/01/13) failed to document staff were to monitor R8 every 15 minutes as an intervention. A Incident/Accident Report, dated 12/27/13 at 1:05 a.m., documents R8 as laying on the floor next to the bed, with the side rails in the upright position. The Incident/Accident Report documents R8 was moved to a room closer to the nurses station, as an intervention to prevent further falls. However, according to E2 (Director of Nursing), on 3/11/14 at 3:00 p.m., R8 was not relocated to a room closer to the nurses station at that time. Nursing notes, dated 2/18/14 at 2:00 p.m., document, "Housekeeping yelling for C.N.A. (Certified Nursing Assistant). (Resident) attempting to get out of bed. (Resident) sitting on edge of bed (with bilateral lower extremities) dangling. Personal (and) pad alarm intact. (Not) sounding. (Resident states) 'I'm going to get my wallet.' C.N.A.s remind (resident)....hasn't had (wallet) for a long time. (E3-Assistant Director of Nursing) notified staff can't hear alarms during the day with (televisions), etc." Nursing notes, dated 2/18/14 at 2:50 p.m., document, "Alarms sounding. (Resident's) body hanging out of bed (with) face against siderail. (Resident) repositioned. (E3) notified and asked to move (resident) closer to nurses desk or for a low bed." On 3/04/14 at 3:17 p.m., E7 (Licensed Practical Nurse) stated (E7) was caring for R8 on the afternoon of 2/18/14. E7 stated R8 was restless, trying to get out of the bed, and exhibiting unusual behavior. E7 stated R8 was found with (R8's) body scooted down the bed, (R8's) body was on the far left side of the bed with (R8's) feet just over the edge. E7 stated R8's face was pressed up against the half-side rail at the midpoint of the rail. E7 stated, "The side rail was preventing (R8) from falling." E7 stated, since R8's feet were not touching the floor, E7 did not consider the incident a "fall." E7 stated it was conveyed to E3 that R8 was acting unusual and repeatedly trying to get out of bed. E7 stated (E7) discussed with E3 putting R8 into a low bed or moving R8 closer to the nurses station. E7 stated the facility had "no low beds available" and "would have loved to put (R8) in a low bed", but R8 was moved to another room to be more closely monitored. On 3/04/14 at 4:01 p.m., E3 stated E7 did report to (E3) on 2/18/14 that R8 was "anxious and wanting to climb out of bed." E3 stated (E3) was unaware of R8's position in the bed, with (R8's) face against the siderail. E3 stated the incident should have been accurately reported and investigated. E3 concluded R8 originally had half-side rails for bed mobility. However, E3 stated R8 now has the half-side rails as a safety measure to prevent (R8) from "falling out of bed", as (R8's) condition has declined. On 3/04/14 at 3:44 p.m., E2 (Director of Nursing) stated E7 did not explain to (E2) how R8 was found with (R8's) face against the siderail and body positioned. E2 stated, had the incident been properly reported, an investigation would have been completed and the side rails would have been evaluated. E2 stated that all restraints and side rails are to be assessed on a quarterly basis, at least. On 3/05/14 at 3:00 p.m., E17 (Medical Director) stated (E17) was unaware of the 2/18/14 incident with R8's face in the side rail. E17 stated, had the nurse who found (R8) reported the incident, "I'm sure a change in the Plan of Care would have occurred." E17 further stated, "accidents happen" and the facility has "only so many low beds." E17 stated, "To me, it sounds like that side rail kept (R8) from falling." E17 concluded, by stating, "Maybe I need some education on the regulation and what options are available besides side rails, to prevent falls." The facility's "Consent for Use of Side Rails" form, documents "....the use of side rail(s) may involve risks such as: getting caught in the rails, getting caught between the rail and mattress, strangulation, hitting against the rail(s) causing skin tears and/or bruising and crawling over the top of a rail risking a fall from a higher level with a risk for greater injury or death. It is the policy of this facility to use side rail(s) only after assessment and care planning deem it appropriate to treat the resident's medical symptoms and assist the resident in attaining or maintaining his or her highest practicable physical and psychosocial well-being, and other methods or interventions are in adequate. In all instances, the least restrictive device, which is effective, will be used. The facility will monitor the resident's status and adjust care, as necessary. The facility will have a systematic and gradual process to reduce the use of side rail(s) to ensure the resident's safety while treating the resident's medical condition." On 3/04/14 at 5:09 p.m., the measurable width between the lower half of R8's side rail and the mattress was 4 and 3/4 inches at the widest point. On 3/04/14 an Immediate Jeopardy was identified to have begun on 12/22/13 when R8 fell from bed, hanging onto the side rails, and staff failed to assess the potential safety risks involved with R8's continued use of side rails. E2 (Director of Nursing) was informed of the Immediate Jeopardy on 3/04/14 at 4:40 p.m. The surveyor confirmed through observation, interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1.) On 3/04/14 at 5:15 p.m., R8 was immediately placed on a low bed with no rails and a fall mat. 2.) On 3/04/14, E2 and E3 assessed other residents to identify those who may be at risk for entrapment and measures were taken to correct those concerns immediately. 3.) On 3/05/14 by 2:00 p.m., all staff received an inservice regarding resident safety, reporting of incidents, and appropriate fall prevention interventions. 4.) A process has been implemented to ensure ongoing assessment, monitoring and oversight regarding appropriate and effective interventions regarding resident safety. 5.) A plan to ensure the Director of Nursing and Quality Assurance Coordinator will conduct ongoing evaluation of all residents to determine potential risk for entrapment and for developing appropriate fall prevention interventions for each resident at risk. 2. 3. R6's current POS (Physician order [REDACTED]. R6's MDS (Minimum Data Set) assessment dated [DATE] indicates R6 requires extensive assistance of one for transfers and hygiene. R6's MDS assessment also states R6's BIMS (Brief Interview for Mental Status) score is three, indicating R6 has severe cognitive impairment. On 3/03/14 at 10:00 a.m., R6 was lying in bed with the bed positioned at standard height and both side rails in the raised position. R6 was confused and had a personal alarm in place. On 3/03/14 at 2:30 p.m., R6 was sleeping soundly with the bed positioned at standard height and both side rails raised. R6's care plan dated 11/20/13 states, "Makes poor decisions. Intermittent confusion, weakness. At risk for falls, Score of 10. Use of antidepressant and (history of) falls. (R6) tends to move the edge of the bed and causes risk for falls." No new interventions have been added to R6's fall care plan since 11/20/13. A Side Rail assessment dated [DATE] states "(R6) continues to use (siderails) for mobilities". There is no documentation indicating R6's siderail use was assessed after R6's fall on 2/27/14. An Incident/Accident Report, dated 2/18/14 at 9:45 a.m., states R6 fell and was found partially off the bed. A Resident Accident and Incident Investigation Report dated 2/18/14 recommends R6 be toileted every two hours and the call light be kept within R6's reach. An Incident/Accident Report, dated 2/27/14 at 4:15 a.m., states R6 was found on the floor beside R6's bed and between the bed and the window. A Resident Accident and Incident Investigation Report dated 2/27/14 recommends discontinuing R6's air mattress "Due to concerns about it causing (R6) to slide out of bed no pressure areas. Consider pad alarm." 2. R10's current POS (Physician order [REDACTED]. R10's MDS (Minimum Data Set) assessment dated [DATE] indicates R10 is total dependent on two staff for transfers. R10's MDS assessment also states R10's BIMS (Brief Interview for Mental Status) score is five, indicating R10 has severe cognitive impairment. R10's Care Plan dated 1/07/14 states "All transfer with (mechanical) lift, gait belt, and two assist." On 3/03/14 at 1:50 p.m., R10 was sitting in a wheelchair next to R10's bed. R10 had a lap cushion in place and a personal alarm. E21(CNA - Certified Nursing Assistant) and E22 (CNA) entered R10's room to transferred R10 from a wheelchair to the bed. E21 (CNA) and E22 (CNA) secured the mechanical lift sling positioned under R10 to the mechanical lift and transferred R10 from the wheelchair to the bed. An Accident/Incident Log entry for R10 dated 8/04/13 states, "CNAs (Certified Nursing Assistants E18 and E19) using lift with two assist, slid out of lift hitting right shoulder in wheelchair and sliding to floor on right side. ROM (Range of Motion) per usual, skin tears noted to left hand, right shin, and great toe. Right outer corner of eye bruised." An Incident/Accident Report completed by E20 (RN - Registered Nurse) dated 8/04/14 at 6:45 p.m. states, "Using lift with assist, slid out of lift hitting right shoulder in wheelchair and sliding to floor on right side." A Resident Accident and Incident Investigation Report completed by E2 (DON - Director of Nursing) at 7:00 p.m. states, "The lift and sling were checked and all was in working order at the time. Instructed staff to check and double check everything when using a lift. Called to assess resident after the incident... When questioning staff about the incident , they said it happened so quickly that they aren't sure of what or how it happened. They stated they hooked the lift up as usual, and as they were lifting (R10) out of the wheelchair, (R10) slid out of the wheelchair and onto the floor. The lift was in low position at the time, so (R10) did not fall." On 3/10/14 at 4:15 p.m., regarding R10's fall from the lift on 8/04/13, E18 (CNA - Certified Nursing Assistant) stated, "(E19 CNA) was hooking (R10) up to the lift. I'm assuming, but not sure because (R10) likes to move things around, but when we were getting him up the sling was still on and (R10) was hooked up to the machine. But it was off (the sling loop not connected to the lift arm) or not all the way on....(R10's) really grabby and I was trying to watch (R10) from grabbing me... (R10) was probably off the wheelchair an inch and the sling came off at the bottom and (R10) slid out of the bottom. We tried to catch (R10). I happened quick. I'm pretty sure (R10) hit (R10's) head on the wheelchair and slid to the floor." E18 (CNA) verified R10 fell to the floor during the transfer on 8/04/13 at 6:45 p.m. and received injuries. On 3/10/14 at 4:05 p.m., E19 (CNA) stated on 8/04/13 R10 was hooked up to the mechanical lift and "(R10) grabbed a hold of the sling and unhooked it while we were lifting (R10) up. (R10) will do that sometimes. We've caught (R10) doing it even since then. (E18 CNA) was in front. I was in back. From my angle it looked like it was connected... (R10) was just above the wheelchair 3 inches and (E18 CNA) gasped. I guess that's what you'd call it. I tried to catch (R10) but couldn't get to him fast enough. (R10) fell and landed into the wheelchair, hit the chair and then we eased (R10) to the floor." E19 verified the incident resulted in R10 falling and receiving injuries. On 3/10/14 at 9:05 p.m., E7 (LPN - Licensed Practical Nurse) verified (E7 LPN) and E20 (RN - Registered Nurse) assessed R10 on 8/04/13 but neither E7 or E20 witnessed R10's transfer. E7 (LPN) stated, "I got this from them (E18 and E19 CNAs). (R10) was having behaviors that day and somehow (R10) had unhooked the lift sling. (R10) had to have done it before they started the lift. I would say (R10) has done it before but they've never lifted him without putting it back on. (E2 DON - Director of Nursing) knows about it cause (R10's) done it right in front of (E2) when (E2) was on the floor. I don't believe it's one of the behaviors we chart on." On 3/10/14 at 11:10 a.m., E2 (DON) stated, "(R10's) good hand is everywhere. (R10's) grabbing at them or something all the time. It should be on the care plan." The current Behavior Flow sheet for R1 dated 3/01/14 does not include behaviors regarding R10's transfers. R10's Care Plan dated 1/07/14 does not include interventions regarding R10's behaviors during transfers or safety interventions for staff providing R10's care. 2. A Minimum Data Set, dated dated [DATE], documents R1 requires the extensive assist of two people to transfer. A Plan of Care, dated 2/10/14, documents R1 has the current [DIAGNOSES REDACTED]. On 3/04/14 at 9:55 a.m, R1 was wheeled into a community bathroom located adjacent to the Activity Room/Dining Room, by E11 (Certified Nursing Assistant). E11 pivot transferred R1 independently, from the wheelchair to the toilet, without using a gait belt and holding R1 under the arm. On 3/04/14 at 10:00 a.m., E11 stated R1, "does o.k. with out using a gait belt." The facility policy, titled "Transfer or Gait Belt", documents, "Purpose: To promote patient safety when walking or making a transfer." The "Transfer or Gait Belt" policy instructs staff to "fasten the transfer belt securely around the patient so that the belt does not slide up the patient's body" and "using the transfer belt, pivot the patient to the bed or chair."