Every finding on record at Sandwich Living & Rehab Center

Based on observation, interview and record review the facility failed to maintain a safe environment by ensuring a resident's previous room was locked while being repaired. This applies to 1 of 3 residents (R2) reviewed for safety in the sample of 8. The findings include: On 6/15/26 at 9:29 AM, R2 was sitting up in her wheelchair in her room. She stated, she has had a couple of falls out of her wheelchair. The facility's May fall log shows, R2 had a fall on 5/13/26. She attained an abrasion for sliding out of the wheelchair. On 6/15/26 at 9:55 AM, V3 Licensed Practical Nurse (LPN) stated, she was the nurse working 5/13/26. She heard R2 screaming but she was 1:1 with another resident and couldn't leave. V7 housekeeping was walking by so she asked her to please go see why R2 was screaming. V7 came back saying, R2 had fallen. At that time, she was able to go check on R2. V6 Certified Nursing Assistant (CNA) was with her. They found R2 in a different room down the hall from her own room. She had fallen into a hole in the floor. Her legs were in the hole. She had a small rug-burn like abrasion that was not opened and some bruising to her knee. She stated, maintenance had been working on the floor in that room. He had left the room and did not lock the door. The resident was able to get into the room. She was not able to say the exact size of the hole but it was a good size hole, big enough for R1's feet/legs to be in it. On 6/15/26 at 10:49 AM, V6 CNA stated, she heard R2 screaming but was helping another resident. When she was done, she went with V3 LPN to see what was going on. They found R1 in another room that had a hole in the floor. R2 had banged her knee. She stated, the door was not locked and it should have been. They had been working in that room but nobody was in it at the time R2 went in there. On 6/15/26 at 9:45 AM, V4 Maintenance stated, he had a room that he had to replace the subfloor and tiles in. He did it early May 2026. It took him 2 days to fix the floor. He could not recall anyone falling in that room while he was working on it. The room that this incident took place had 42 tiles measuring 12x12 that were replaced on the floor right in the doorway. There were no locks on the door to lock the room. On 6/15/26 at 1:19 PM, V1 Administrator stated, the room was R2's old room. She was trying to get in the room to go to the bathroom. R2's progress notes dated 5/13/26 by V3 LPN shows, Resident observed sitting on her buttocks on the floor. Head to toe assessment completed. Resident denies hitting her head. Range of motion is within normal limits. Resident noted with abrasion to left knee/shin. R2's care plan dated 4/25/26 shows, Falls: At high risk for falls related to incidence of fall in the past 60 days. Fall 4/25/26 (no injuries), Fall 5/13/26 (no injuries). Interventions: 4/25/26: Re-education on the importance of using call light to have assistance with toileting. Maintain safe environment by ensuring that floor is free from clutter. The facility's maintenance policy dated 1/2025 shows, Guideline: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Process: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: b. Maintaining the building in good repair and free from hazards.

Based on observation, interview and record review the facility failed to ensure catheter care was completed in a manner to prevent contamination for a resident with a history of urinary tract infections (R4), for 1 of 3 residents reviewed for indwelling urinary catheters in the sample of 4.The findings include: R4's Face Sheet shows she has diagnoses including dementia and neuromuscular dysfunction of the bladder.R4's Physician Order summary and active Care Plan show R4 has an indwelling urinary catheter and catheter care should be provided every shift and immediately after an incontinent episode. A facility provided list of residents who had Urinary Tract Infections (UTI's) shows that R4 had UTI's requiring antibiotic treatment on 1/3/26 and again on 2/18/26.On 3/4/26 at 11:13 AM V4 and V5 both Certified Nursing Assistants (CNA's) were providing catheter care to R4. V4 had a basin of soapy water and a basin of plain water, V4 said one basin was for washing and the other was to rinse after they clean the area. R4 had stool present so V4 took a washcloth and cleaned the stool from R4's buttocks. R4 without washing her hands and using the same gloves and basins of water, obtained a new washcloth and dipped it in the basin and cleansed the tubing of R4's urinary catheter from the urethra in a downward motion on the drainage tubing. On 3/4/26 at 12:10 PM V2 (Director of Nursing) said R4 has a chronic indwelling urinary catheter and a history of UTI's. V2 said when catheter care is provided if there is stool present the CNA's should change their gloves and water after they clean the stool, before they provide the catheter care to prevent contamination of the catheter tubing which could contribute to UTI's. The facility provided, not dated, Catheter Care policy shows to prevent contamination of the urinary catheter hands should be washed, gloves should be changed and new equipment used for catheter care if there is feces/stool present.

Based on observation, interview and record review the facility failed to ensure water in resident rooms and a shower room used by residents was at a safe temperature. On 2/2/26 at 10:42 AM the bathroom sink in R3's room had a water temperature measuring 149.5 degrees. The South Shower Room shower water measured 146.5 degrees and the water in R17's bathroom sink measured 145.5 degrees. This has the potential to affect all 13 of 13 residents (R1, R3, R4, R5, R7, R13, R15, R17, R19, R21, R24, R30, R36) residing on the South Hall of the facility reviewed for safety.The Immediate Jeopardy began on 2/2/26 when the water temperatures on the South Hall measured between 145 and 153.5 degrees Fahrenheit. V1 (Administrator) was notified of the Immediate Jeopardy on 2/3/26 at 12:30PM. The surveyor confirmed by observation and interview that the Immediate Jeopardy was removed on 2/2/26 but noncompliance remains at Level Two because additional time is needed to evaluate the effectiveness of changing the settings on the hot water heater, scheduling repairs on the hot water heater to prevent reoccurrence of extreme temperature fluctuations, evaluating the process by which water temperatures are taken and educating the staff regarding monitoring of water temperatures. The findings include: On 2/2/26 the facility roster/census showed 13 residents residing on the South Hall of the facility, R1, R3, R4, R5, R7, R13, R15, R17, R19, R21, R24, R30 and R36.On 2/2/2026 at 10:42 AM R3 asked Surveyor to check the handles on his bathroom sink as he feels they are difficult to turn on. Surveyor turned on the hot water and let the water run for about 2 minutes. The water began to steam. R3 stated, The shower is the same- it gets really hot and then it gets cold. My skin is pretty sensitive. The water is hotter than it should be I know that. 104-105 should be pretty good. The Surveyor left the room and returned a short time later with a thermometer. The temperature of the water measured 149.5 degrees.Surveyor then went to the South Shower Room (next to R3's room). The water from the shower head measured 146.5 degrees.At 10:50 AM Surveyor went to the other end of the hall and checked the water in R17's room. The water measured 145.5 degrees.On 2/2/2026 at 11:17 AM V3 (Maintenance Director) stated, We got a brand-new gas fired water heater on March 8, 2025. I tested this hall (South) water temperatures last week (1/26/26). I switch halls each week. I try to keep them at 100-110 degrees. V3 then accompanied Surveyor to R3's room with a facility thermometer. V3 turned on the hot water, waited a few seconds and then put the thermometer under the water, it read 106 degrees. Surveyor asked V3 to keep the thermometer under the water longer. V3 stated, Oh, that is hot, 108 degrees. Surveyor asked V3 when was last time V3 calibrated his thermometer. V3 stated it was brand new. V3 left the room to get another thermometer. Surveyor turned the water back on and let it run. V3 returned with another thermometer and put it under the running water. The thermometer read 153.5 degrees. The water was steaming and visibly hot. Surveyor asked V3 if he was able to put his hand in the running water and V3 stated No, it is too hot. V3 left the room and returned in a minute or two.V3 stated, The Water Heater is set to hot- I turned it down to blank notch (medium) I may even have to turn it to low. It may be a bad mixing valve. It may take about 5 minutes to cycle through. At 11:30AM Surveyor and V3 went to the Hot Water Heater Room on the South Wing and observed the Hot Water Heater. The Water Heater was set to Hot and the thermometer on the Hot Water Heater pipe was reading 150 degrees.On 2/2/2026 at 12:37 PM V3 stated, Each building is independent. No one has looked at the water heater. I adjust it sometimes based on the temperature outside, but I don't know what would account for the 40 degrees jump in temperature in a week. I was going to call my supervisor and see if he wants me to call the vender and have him come out and take a look at it. I have it set now to Low- I figured I would start at the baseline and work my way up. On 2/3/26 at 9:05AM V3 stated that he last adjusted the hot water heater on the south hall (prior to 2/2/26) about 6 months ago. V3 also stated that he contacted his Maintenance Consultant, and he is going to come and change the mixing valve when he can as he is a licensed plumber.The facility policy entitled Hot Water Temperature dated 1/2025 states, The water temperature to residents' rooms, washrooms and showers will be taken daily and logged on the water temperature log form. and The water temperature must be maintained at the acceptable range of 100 degrees- 110 degrees Fahrenheit.The facility Water Temp Log shows the last time the South Hall water temperatures were checked was on 1/26/26. (7 days prior to findings of high temps)The Facility Floor Plan shows that the facility has 4 water heaters. One for each hall, North and South, one for the kitchen and one for the laundry room.The facility presented an abatement plan to remove the immediacy on 2/3/26. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned 2/4/26 at 9:45AM and a revised abatement plan as presented by the facility on 2/4/26 at 10:45AM. The abatement plan was accepted on 2/4/26 at 11:15AM.The Immediate Jeopardy that began on 2/2/26 was removed on 2/2/26 when the facility took the following actions to remove the immediacy.When the hot water temperatures were identified on 2/2/26, the hot water heater was turned off and drained immediately. After the hot water heater was drained, the temperature valve was readjusted, temperatures were tested thereafter throughout the day. Contractor has been called and will be there on 2/5/26 to inspect the Facility's hot water heater and mixing valves and immediately correct any issues he finds at that time.Staff on duty were immediately in-serviced by the Maintenance Director (see sign-in sheet). All staff will be in-serviced by the Maintenance Director on the Facility's Hot Water Policy on or before 02/06/26.Residents will be kept safe with water temperatures in all resident accessible areas kept at 100 F - 110 F.Facility's Hot Water Temperature Policy will be followed:1. The water temperature to residents' rooms, washrooms and showers will be taken daily and logged on the water temperature log form.2. The water temperature must be maintained at the acceptable range of 100 F - 110 F.3. The hot water temperature that exceeds 110 F, the following steps must be taken: the mixing valve will be adjusted and temperature retaken before residents' use of water.4. The hot water temperature that's below the acceptable range of 100 F, the following step must be taken: the hot water tank will be adjusted and temperatures retaken before resident use of water.5. The retaken water temperature will be reflected on the temperature log form.6. If water is unable to be sustained at acceptable range, Administrator or designee will refer to emergency plan if needed.Charge Nurses and/or their designees (as the persons responsible for the safety of the residents) will perform spot checks every Friday for three months (and longer if any issues identified in these spot checks) to determine level of staff compliance with temperature logs and Facility's Hot Water Policy.Maintenance Consultant will review temperature logs and any maintenance issues weekly for three months. Any irregularities will be clarified and noted on a Quality Assurance report.QAPI will review these reports and others at its next regularly scheduled meeting (to be held 04/22/26) and make any further changes to policies or procedures it deems necessary.The Medical Director will be advised of this issue and the corrections that have been and are being undertaken.Administrator and/or his designee will monitor for overall compliance through his general supervision and reports from Charge Nurses and staff compliance.Completion Date: 02/02/2026

Based on observation, interview, and record review the facility failed to maintain a safe walking environment for a resident at risk for falls for 1 of 3 residents (R3) reviewed for falls in the sample of 11. The findings include:On 4/16/25 at 12:07 PM, R4 was sitting on her bed. R4 said she usually goes to the dining room for meals, but was feeling a little irritated today. R4 said she usually sits in a table closer to the sliding, glass door. R4 said the floor is messed up in the dining room and she saw a male resident fall about a month ago because of it. R4 stated, The floor is coming up in some places and the leg of her chair gets caught up in it. I've told everyone about it because I don't want anyone to get hurt. R4 said the facility told her that the floor was going to be replaced, but nothing has happened and it's been a month. R4's facility assessment dated [DATE] showed she was cognitively intact. On 4/16/25 at 12:09 PM, the surveyor toured the dining room area. The room has a small half wall at one end and a sliding, glass door at the opposite end. There were 2 visible seams in the laminate flooring that ran the length of this room. Along the visible seams there were random patches of a brown, sticky substance (floor glue combined with floor debris) and tiny nails that were run along both sides of the seams in other areas. Both seam lines had various areas where the laminate flooring was puckering (each side of the seam was lifted from the surface and posed a fall risk hazard). The surveyor touched these areas with her shoe. The puckered areas caught the surveyor's foot and could pose a tripping hazard. The brown substance along the seams was thick and sticky (also posing a potential fall risk hazard).The two seams run the length of the dining room and the dining room tables are placed sporadically around the dining room. On 4/16/25 at 1:26 PM, R3 was lying in bed. R3 said had fallen in the dining room a while ago. R3 said he used his walker to go to the dining room and stopped at his table. R3 said another female resident asked for his help and he left his walker parked to get her a clothing protector. R3 said when he turned around to take the clothing protector to her, his foot got stuck on the floor and he tripped. R3 said the floor was really sticky and it made me trip. R3 said the facility put the floor glue down because the floor comes up along that line (the seam in the laminate flooring). R3 said he fell face first and got a bloody nose. R3 said he went to the hospital, but was lucky not to break anything. R3 said he thought they fixed the floor after he fell . R3 said he shouldn't have parked his walker and tried to walk without it, but the floor was what tripped him up. R3 said his nose and under his right eye was pretty bruised up, but it's better now. R3 said he couldn't remember if any staff members were in the dining room, but he saw V10 (Registered Nurse - RN) right after he fell . R3's Facesheet dated 4/16/25 showed diagnoses to include, but not limited to: dementia, anxiety, diabetes, chronic lymphocytic leukemia (CLL), schizophrenia, reduced mobility, and idiopathic peripheral neuropathy. R3's facility assessment dated [DATE] showed he had moderate cognitive impairment; had not limitations to his bilateral upper and lower extremities;could walk 10-150 feet with supervision; and could walk 50 feet with two turns with supervision. R3's Progress Notes dated 3/20/25 showed, At 7 AM a loud crash was heard and resident observed lying on the floor in the dining room, face down. He stated, I tripped. He had bleeding from his nose, reddened area on his right cheek and forehead . He was able to move all extremities but did complain of some pain in the left arm and shoulder . This note showed R3 was transferred to the hospital by ambulance. R3's Progress Note dated 3/20/25 showed he returned to the facility at 11 AM and did not sustain any fractures. R3's Fall Risk Care Plan dated 11/21/24 showed he was at risk for falls due to psychotropic medications or a new medication that could cause dizziness. (This showed R3 was a fall risk prior to his fall). R3's Fall Care Plan initiated 3/21/25 showed he had an actual fall on 3/20/25. This care plan showed an intervention to include, but not limited to: Maintain a safe environment. On 4/16/25 at 12:57 PM, V4 (Maintenance Director) said there are seams that run across the main dining room floor. V4 said occasionally the resident's walker or wheelchair will get caught up on the seam, so I will nail it or glue it down. The surveyor asked what the brown substance was that was along the seam. V4 said it was floor glue. V4 said the floor does pucker (lift along the seam) off and on. V4 stated, I know [R3 and R4] have complained about it and I've done my best to fix it. V4 said all flooring throughout the building is on the list to be replaced. On 4/16/25 at 1:07 PM, V2 (Director of Nursing - DON) said she wasn't in the building when R3 fell . V2 said R3 was in the dining room, he parked his walker to help another resident, and he just fell . V2 said R3 Face planted. V2 said R3 went to the hospital and came back with no fractures. V2 said R3 did have a bruise to the bridge of his nose for a while. V2 said V10 (RN) was the nurse that day. On 4/16/25 at 1:35 PM, V10 (RN) said she was working on 3/20/25. V10 said she did not see R3 fall. V10 stated, I heard a loud crash and found [R3] laying face-down on the dining room floor. He smacked his face right on the floor. V10 said R3 usually sits at the table near the partial wall (one of the seams runs right along area of this table). V10 said she didn't see what happened, but R3 said he tripped. V10 said she was worried he may have fractured his nose, but luckily he didn't break anything. V10 said R3 had some bleeding from his nose and bruises to his nose and right cheek. V10 said there have been issues with the seams of the dining room floor since it was installed. V10 said she's not sure what that brown substance is along the seams, but assumed it must be glue because it doesn't come up when they clean the floors. V10 said R3 is alert and oriented and can make his needs know. V10 said R3 had a steady gait with his walker and was able to ambulate independently. V10 said she was not aware of R3 falling before this incident. On 4/17/25 at 10:11 AM, V1 (Administrator) said he is aware there is an issue with the dining room floor. The surveyor asked V1 if the brown sticky substance or the areas where the seams puckered (both sides of the seam loose from the floor) would be considered a fall hazard. V1 replied, If the flooring is coming up or there is any sort of an obstruction, then it could be a problem. V1 said his job at the facility is to ensure the residents' safety. The facility's Falls and Fall Prevention Policy dated 11/2024 showed, Policy: 1. To ensure residents admitted are assessed for potential fall risk. 2. To ensure a fall prevention program will include measures which will determine the individual need of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as indicated based on assessment . Procedure: . 9. Malfunctioning equipment will be immediately given to maintenance for repair or removal service .

Based on observation, interview, and record review the facility failed to maintain the dining room floor in a safe, functional condition for 9 ambulatory residents (R2, R3, R4, R6, R7, R8, R9, R10, R11) reviewed for a safe, functional environment in the sample of 11. The findings include: On 4/18/25, V1 (Administrator) provided a list of residents that were ambulatory to the dining room. This list included R2, R3, R4, R6, R7, R8, R9, R10 and R11. On 4/16/25 at 12:09 PM, the surveyor toured the dining room area. The room has a small half wall at one end and a sliding, glass door at the opposite end. There were 2 visible seams in the laminate flooring that ran the length of this room. Along the visible seams there were random patches of a brown, sticky substance (floor glue combined with floor debris) and tiny nails that were ran along both sides of the seams in other areas. Both seam lines had various areas where the laminate flooring was puckering (each side of the seam was lifted from the surface and posed a fall risk hazard). The surveyor touched these areas with her shoe. The puckered areas caught the surveyor's foot and could pose a tripping hazard. The brown substance along the seams was thick and sticky (also posing a potential fall risk hazard).The two seams run the length of the dining room and the dining room tables are placed sporadically around the dining room. On 4/16/25 at 12:07 PM, R4 said she usually sits in a table closer to the sliding, glass door. R4 said the floor is messed up in the dining room and she saw a male resident fall about a month ago because of it. R4 stated, The floor is coming up in some places and the leg of her chair gets caught up in it. I've told everyone about it because I don't want anyone to get hurt. R4 said the facility told her that the floor was going to be replaced, but nothing has happened and it's been a month. R4's facility assessment dated [DATE] showed she was cognitively intact. On 4/16/25 at 1:26 PM, R3 said he used his walker to go to the dining room and stopped at his table. R3 said another female resident asked for his help and he left his walker parked to get her a clothing protector. R3 said when he turned around to take the clothing protector to her, his foot got stuck on the floor and he tripped. R3 said the floor was really sticky and it made me trip. R3 said the facility put the floor glue down because the floor comes up along that line (the seam in the laminate flooring). R3's facility assessment dated [DATE] showed he had moderate cognitive impairment; had no limitations to his bilateral upper and lower extremities;could walk 10-150 feet with supervision; and could walk 50 feet with two turns with supervision. On 4/16/25 at 12:57 PM, V4 (Maintenance Director) said the main dining room floor was approximately two years old. V4 said the previous ownership told him to apply the laminate on top of the vinyl flooring that was already down. V4 said he advised that it wasn't the best way to install the floor. V4 said there are seams that run across the main dining room. V4 said occasionally the resident's walker or wheelchair will get caught up on the seam, so I will nail it or glue it down. The surveyor asked what the brown substance was that was along the seam. V4 said it was floor glue. V4 said the floor does pucker (lift along the seam) off and on. V4 stated, I know [R3 and R4] have complained about it and I've done my best to fix it. V4 said all flooring throughout the building is on the list to be replaced. On 4/16/25 at 1:55 PM, V6 (Certified Nursing Aide - CNA) said the flooring in the dining room was 1-2 years old. V6 stated, It was done crappy. The seams don't stay together. That brown stuff on the floor is glue. They keep trying to fix it. I wasn't here, but I heard a resident tripped over one of the seams recently. They did try to fix the floor, but that's what they get when they get cheap stuff. I don't always lift my feet up all the way. I shuffle my feet and I get caught up in it sometimes. On 4/17/25 at 10:11 AM, V1 (Administrator) said the floor in the dining room was on the list for replacement. V1 said it is laminate flooring and there are seams in the floor. V1 said he is aware there is an issue with the dining room floor. The surveyor asked V1 if the brown sticky substance or the areas where the seams puckered (both sides of the seam loose from the floor) would be considered a fall hazard. V1 replied, If the flooring is coming up or there is any sort of an obstruction, then it could be a problem. V1 said his job at the facility is to ensure the residents' safety. The facility's Equipment Maintenance and Repair Policy dated 7/24 showed, All equipment utilized in this facility shall be maintained, operated, and repaired as directed .

Based on observation, interview, and record review the facility failed to identify a wound prior to becoming a deep tissue injury (DTI), failed to ensure pressure ulcer interventions were in place, and failed to ensure weekly wound assessments were done for 2 of 5 residents (R11, R19) reviewed for pressure ulcers in the sample of 13. These failures resulted in R11 being at an increased risk of infection and delayed wound healing. The findings include: 1. R11's face sheet printed on 12/4/24 showed an admitted [DATE] and diagnoses including but not limited to fracture of right lower leg, urinary tract infection, pneumonia, and peripheral vascular disease. R11's facility assessment dated [DATE] showed no cognitive impairment and staff assistance required for transfers and toileting hygiene. The same assessment showed R11 is always incontinent of urine and bowel. R11's pressure ulcer risk assessment dated [DATE] showed a moderate risk for pressure ulcer development. R11's December 2024 physician orders report showed an order start dated 10/6/24 for: Check lower leg, with CAM (controlled ankle movement) boot on for increased edema or complications. Notify MD if changes/occur, every day and night shift. The report showed a second order start dated 11/10/24 for: Right heel: cleanse, paint right side of heel with betadine, wrap with kerlex, apply heel boot, every day and night shift. On 12/3/24 at 9:22 AM, R11 was lying in bed and complained of pain to her right foot, which was wrapped in a white gauze bandage (kerlix) from the ankle to the toes. Her right heel was lying directly on the bed and the left heel had a blue heel boot on it. A sign was posted above the bed showing heel boots to be on at all times. R11 said she has a sore on her right foot but was not able to explain the cause. A black medical boot (CAM boot) was lying on the floor at the foot of the bed. On 12/3/24 at 11:47 AM, V11 and V12 (Certified Nurse Aides) stated R11 has a sore on her right heel. It was caused by the medical boot she wears when she is out of bed. Her heels need to be floated or a heel protector on them to take any pressure off the areas. At 11:50 AM, V14 (Registered Nurse) entered the room and said R11 had surgery on her right leg due to a fall at home. She wears the medical boot daily and it has caused a sore on her foot. V14 stated she was not sure if the boot rubbing has been addressed with the physician or family yet. V14 was unable to provide any specifics related to the stage or characteristics of the wound. R11's progress note dated 11/10/24 at showed: .Writer observed a circular, non-blanchable purple discolored area measuring 3x3 (centimeters). Skin intact, no drainage or odor observed. No (complaint) pain or discomfort. Area cleansed with wound cleanser, betadine applied along with kerlix dressing. Resident tolerated dressing change. MD faxed and made aware. Return orders pending. Will endorse to oncoming shift to follow up. POA make aware and was happy that she was informed. Treatment in place. Will continue with current care plan. R11's November TAR (Treatment Administration Record) showed an order start dated 7/16/24 for weekly skin checks every Tuesday. The TAR was documented every Tuesday with no skin changes for the entire month, including the three Tuesdays after the 11/10/24 progress note showed a wound. R11's electronic and paper medical records were reviewed by this surveyor. No documentation could be located related to any heel wound assessments after the 11/10/24 progress note. R11's care plan was reviewed by this surveyor. There was no focus area or interventions in place related to the wound. On 12/4/24 at 11:51 AM, V4 (Nurse Consultant) stated there are no wound assessments for R11 after the day it was identified on 11/10/24. V4 said there are no wound rounds or weekly assessments available. Nothing is in the progress notes either. On 12/4/24 at 2:35 PM, R11's right heel was observed during the dressing change with V6 (Registered Nurse/RN). A dark purple, half-dollar size pressure ulcer was still located on her right heel. On 12/5/24 at 8:39 AM, V3 (Director of Nursing) stated wounds should be found before reaching an advanced stage. Residents can get more skin break down and have the risk for infection. V3 said a deep, dark purple area would be an unstageable pressure ulcer. That is an advanced stage wound. Any resident with a pressure ulcer should be followed by the wound physician. A wound assessment should be done immediately by the nurse on duty. A full physician wound assessment should be done within a day or two after that and then on a weekly basis. The weekly assessments are important to be sure that the treatment is working. There is no way of knowing if the wound is getting better or worse if there are no assessments. Interventions need to be in place right away. The care plan shows how to direct the wound care being provided. Interventions explain from shift to shift what is needed for good wound healing. R11's Wound and Skin Record dated 12/5/24 at 9:34 AM (only performed after this surveyor requested the wound to be assessed) showed a right heel deep tissue injury, dry with cracks around it, black color on both sides and purple/redness within the wound. The facility Pressure Ulcer Prevention and Guidelines policy reviewed dated 9/2024 states under the procedure section: 3. The skin check assessment tool will be used with new onset and referred to the treatment nurse for follow-up with the Physicians as indicated. The facility Wound Assessment policy review dated 9/2024 states: It is the policy of this facility to do a systemic ongoing wound assessment on all wounds in order to determine the response to nursing care and treatment modalities. The policy states: 2. A complete wound assessment will be done weekly by a licensed nurse for all wounds, ulcers, and impairment in the skin integrity. 3. The weekly wound assessment documentation will be recorded weekly on the weekly pressure sore log and/or other skin condition log. 31615 2. R19's order summary sheet documents his diagnoses to include multiple sclerosis and pressure ulcer of unspecified buttock, stage 4. The current orders include dressing orders for the left buttock and sacrum, and the right buttock. On 12/3/24 at 10:37 AM, R19 said he has wounds to his buttocks. The nurses change the dressings twice a day. On 12/4/24 at 3:02 PM, V6 (RN) performed the dressing change for R19, and he was observed to have a large and deep Stage 4 pressure injury to his left buttock and sacral area. He had an additional wound to his right buttock. The last 3 months of wound assessments were requested from the facility. The last assessment was dated 11/15/24. The previous assessments were dated 10/25/24, 10/4/24 and 9/27/24. The facility Wound Assessment policy review dated 9/2024 states: It is the policy of this facility to do a systemic ongoing wound assessment on all wounds in order to determine the response to nursing care and treatment modalities. The policy states: 2. A complete wound assessment will be done weekly by a licensed nurse for all wounds, ulcers, and impairment in the skin integrity. 3. The weekly wound assessment documentation will be recorded weekly on the weekly pressure sore log and/or other skin condition log.

Based on observation, interview, and record review the facility failed to prevent an unplanned, significant weight loss for 1 of 2 residents (R8) reviewed for nutrition in the sample of 13. This failure resulted in R8 sustaining a 7.98% weight loss over 1 month. The findings include: R8's face sheet printed on 12/4/24 showed diagnoses including but not limited to cerebral infarction, Parkinson's disease, depression, vomiting without nausea, and dysphagia (difficulty swallowing). R8's facility assessment dated [DATE] showed no cognitive impairment and partial to moderate staff assistance for eating. The same assessment showed full staff dependence for transfers. On 12/3/24 at 12:23 PM, R8 was seated at the lunch table with a pureed texture meal in front of her. A magic cup nutritional supplement was next to her plate and R8 was using a sippy-type cup. R8's head was down, and she was not eating. R8 appeared thin and fragile. R8 was missing multiple teeth. Several staff members approached R8 throughout the meal but none offered assistance or cueing. At 12:48 PM, R8 wheeled herself out of the dining room. Her lunch meal was completely untouched. R8's electronic medical record was reviewed and showed on 10/23/24 she weighed 106.5 pounds. On 11/28/24 she weighed 98 pounds. (This is a 7.98% loss in one month). R8's nutrition/dietary note dated 10/18/24 showed resident is under weight for her age and dietary recommendations were given. Those recommendations included pudding 2 times daily, magic cup daily, mighty shake 3 times daily, benecalorie to be mixed with thickened cranberry 2 times daily, and medpass 90 mL (milliliters) mixed with food. The same 10/18/24 nutritional note recommended Remeron (medication) to increase R8's appetite. The note stated resident will continue on weekly weights. R8's November and December 2024 medication administration records and progress notes were reviewed. There was no documentation of any follow up or administration of the dietary recommendations, other than the medpass and pudding. R8's physician order report showed an order start dated 10/24/24 for weekly weights to be done every Wednesday morning. There were no weights done until 11/13/24 (two weeks later). On 12/5/24 at 12:06 PM, V6 (Registered Nurse) stated weights should be done as frequently as ordered. The dietary staff and dietitian reviews them. Any big gains or losses need to be addressed. The dietitian gives recommendations if someone is losing weight. The nurses are responsible for getting the suggestions to the doctor. New orders are put in after he approves the suggestions. It should be done in a couple of days, 1 to 3 max. It is important the recommendations get followed up on quickly for healthy weight gain, wound healing, and good health. V6 stated R8 has definitely lost weight recently. V14 (Registered Nurse) just dug into her chart two days ago and is looking into it. On 12/5/24 at 11:30 AM, V13 (Registered Dietitian) stated she just took over care for R8 three weeks ago. Residents should be seen by a dietician on at least a monthly basis. Weights are obtained from staff and group discussions take place as soon as any concerns are discovered. V13 said the staff should be getting weights recorded sooner. Any refusals to be weighed should be charted. V13 said she defines a significant weight loss based on the general standard of 5% loss over 30 days, 7.5% loss over 90 days, and 10% loss after that. V13 stated R8's weight loss of 7.98% over one month is a significant weight loss. V13 said she would expect staff to be implementing and following up on dietary recommendations within a few days. The physician should have been notified of the recommendations and all the approved recommendations started. V13 said there is the potential for more weight loss, poor skin integrity and overall decline of a resident when the dietary recommendations are not followed. R8's care plan showed a focus area related to weight loss. Interventions included give the resident supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis. Monitor and evaluate any weight loss. Weight monitoring per facility protocol. The facility Unintended Weight Loss policy revision dated 9/2024 states: 1. Resident is weighed monthly after admission and/or weekly, as requested by the physician/dietician .5. Resident's physician will be informed of significant weight loss. 6. Dietician recommendation for weight gain will be referred to the physician.

Based on observation, interview and record review the facility failed to provide a comfortable home like dining experience for two of three residents (R21 and R7) reviewed for clean, comfortable homelike in the sample of 13. The findings include: On 12/4/2024 at 8:20 AM R21 and R7 were observed eating their breakfast in the small dining room near the sliding glass doors leading to the patio. R5 came and opened the patio doors to go outside to fill the bird feeders, leaving the doors open and cold air was blowing into the dining room. R21 was observed pushing himself away from his breakfast and saying,It's too cold to sit here anymore. R21 had over half his breakfast left. R7 was observed glancing over his shoulder several times to look at the open doors. R7 then left the dining room with food still on his plate. Several facility staff were observed walking past the small dining room and the open door and some were heard saying how cold it was. At 8:28 AM, V6 (Registered Nurse/RN) went and got R21 who had wheeled himself around the corner to get away from the cold, and brought him to the medication cart placed in line of the cold draft blowing into the facility. R21 said,It's too cold to sit here and V6 said she just had to give him his medications and then she would move him to another area. On 12/5/24 at 9:25 AM, R7 said it was getting too cold to sit in the dining room with the door open for that long, but he was done eating anyway. R7 said he doesn't know why the door had to be left open for so long. On 12/5/24 at 9:15 AM, R5 said he fills the bird feeders whenever they need to be filled. R5 said he can do it by himself and does it when he wants to. R5 said no staff have ever helped him or asked him to keep the doors closed. The weather on 12/5/24 at 8:30 AM was in the 20's with wind per accu weather. On 12/5/24 at 9:30 AM, V6 said she was so busy with passing medications that she did not notice the residents leaving the dining room. On 12/5/24 at 9:35 AM, V1 (Administrator) said he was not aware R5 was filling the bird feeders outside and he had concerns for his safety doing this. V1 said the staff should have intervened in the situation and closed the door to prevent the cold air from coming in and should have assisted R5 for his safety. The facility policy for resident rights (Residents' Right for People in Long-term Care Facilities) shows you have the right to safety and good care. Your facility must provide services to keep your physical and mental health and sense of satisfaction. Your facility must make reasonable arrangements to meet your needs and choices.

Based on observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner (R8) and failed to ensure a resident was assessed for safe smoking (R18) for 2 of 4 residents reviewed for safety in the sample of 13. The findings include: 1. R8's face sheet printed on 12/4/24 showed diagnoses including but not limited to cerebral infarction, Parkinson's disease, depression, vomiting without nausea, and dysphagia (difficulty swallowing). R8's facility assessment dated [DATE] showed no cognitive impairment and partial to moderate staff assistance for eating. The same assessment showed full staff dependence for transfers. R8's December 2024 order summary report showed an order start dated on 9/30/24 for: Because of potential for injury please make this patient a Mechanical lift only . On 12/4/24 at 9:03 AM, V11 and V16 (Certified Nurse Aides) transferred R8 from her bed to the wheelchair. The aides sat R8 on the edge of the bed and held her underneath her arms. R8 appeared thin, weak, and fragile. R8 was unsteady and struggled to stand. R8's shoe fell off while she was attempting to pivot to the wheelchair. The aides did not apply a gait belt around R8's waist at any time. On 12/5/24 at 8:51 AM, V3 (Director of Nursing) stated the therapy department determines what method is needed to transfer a resident. Any physician order regarding the type of transfer should absolutely be followed. The MDS (facility assessment) also shows how to transfer a resident. The aides ask the nurse or look in the chart to determine which method to use. It is unsafe for the aides to transfer a resident incorrectly. There is a high risk of injury and falls, V3 stated R8 is a high fall risk and could seriously be injured if the mechanical lift is not used. On 12/5/24 at 8:59 AM, V11 and V12 (CNAs) stated they look at the banner in the electronic medical record for resident transfer types. If a resident needs a mechanical lift it will show there. The aides and this surveyor reviewed R8's banner page in the medical record. The banner showed a two person assist and did not state that a mechanical lift should be used. The aides stated the MDS nurse is the one that looks at the transfer orders and inputs it on the banner page. The aides said her banner needs to be updated if she has an order for a mechanical lift. The aides said they were not aware R8 needed a mechanical lift now. The facility's undated transfer policy states: Before the initiation of a transfer, you must know resident's weight bearing status (if appropriate) .medical precautions or contraindication .be knowledgeable of the amount/type of assistance required and any weight bearing precautions. 31615 2. The smoking/vaping safety screen of 12/6/23 shows R18 was admitted to the facility on [DATE]. He uses smoking tobacco, and requires minimal assist with his ability to smoke. The next assessment was completed on 5/16/24, and no further assessments were documented. On 12/3/24, R18 was lying in bed, alert and oriented. He had an unlit cigar in his hand. He said since it is so cold outside, now he only goes out at night time to have a couple of hits. On 12/4/24 at 12:39 PM, V15 (Social Services) said smokers are screened annually and quarterly for safety. She said (R18) should have had a quarterly assessment to determine if he is safe to go outside to smoke. The facility smoking safety policy documents it is to provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. 3. Smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. Residents requiring supervision shall receive this monitoring consistent with their assessment and plan of care.

Based on observation, interview and record review the facility failed to ensure an indwelling catheter drainage bag was maintained in a manner to prevent contamination for 1 of 3 residents (R4) reviewed for catheters in the sample of 13. The findings include: R4's admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including multiple sclerosis, flaccid neuropathic bladder, acute kidney failure, history of UTI's (Urinary Tract Infections). The facility's 10/21/24 annual resident assessment for R4 shows he has an indwelling urinary catheter. The 10/31/24 care plan documents he is at risk for UTI's due to indwelling urinary catheter. On 12/03/24 at 10:02 AM, R4 was observed lying in bed. He had an indwelling catheter bag on the side of his bed, and it was resting on the floor. On 12/03/24 at 11:27 AM, V11 and V12 (Certified Nursing Assistants) said catheter drainage bags should not be on the floor, due to infection issues. The drainage bag should be in a dignity bag. V11 and V12 were advised of R4's catheter drainage bag being on the floor. On 12/04/24 at 10:00 AM, R4's catheter drainage bag was observed still on the floor and the drainage tube was not covered, and touching the floor. On 12/4/24 at 10:13 AM, V3 (Director of Nursing) the catheter drainage bag should not be on the floor, and the drainage tube should be covered and closed. The bag needs to be in a bag. When the bag is on the floor, it could cause infections if that is on the floor.

Based on observation, interview and record review the facility failed to initiate an antibiotic when ordered for 1 of 1 residents (R19) reviewed for pharmacy services in the sample of 13. The findings include: R19's order summary sheet documents he was admitted on [DATE] with multiple diagnoses including multiple sclerosis, and neuromuscular dysfunction of bladder. The orders show he has long term use of a urinary catheter. The after visit summary of the local emergency room shows R19 was seen on 9/20/24 for a fever and abdominal pain. He had blood tests and a urine culture completed. He was given IV (intravenous) antibiotics, and discharged with an order for cefpodoxime 200 mg (milligrams) twice daily for 10 days. The medication was to start on 9/20/24 and end on 9/30/24. The facility order for cefpodoxime was input on 9/21/24 at 1:20 AM. The September MAR (Medication Administration Record) shows the medication was not started until 9/21/24. On 12/05/24 at 10:13 AM, V3 (Director of Nursing) said at that time the facility had a different pharmacy could not say if the medication was available. She said the medication should have been started the same day it was ordered, especially an antibiotic. The doctor should have been notified if there was any issue with obtaining the medication. It is very important to start the antibiotics for UTI's (Urinary Tract Infections). R19 is very susceptible to going septic when he gets sick. The facility's 9/2023 policy for medication administration documents 11. In the event a drug is unavailable, the charge nurse shall be responsible for notifying the pharmacy for delivery. R19's progress notes were reviewed and no pharmacy or physician notification was documented relating to the antibiotic not being available for administration on 9/21/24.

Based on observation, interview and record review the facility failed to administer medications as ordered. There were 25 opportunities with two errors resulting in a 8% error rate. This applies to one of four residents (R23) observed in the medication pass. The findings include: On 12/4/2024 at 8:47 AM, V6 (Registered Nurse/RN) was observed giving R23 his morning medications during the medication pass observation task. The Physician Orders dated 12/2024 shows an order for pantoprazole 40 mg (milligrams) (medication for heartburn) to be given two times a day at 8:00 AM, and 5:00 PM and polyethylene glycol 17 grams ( medication for constipation) at 8:00 AM. These two medications were not given to or offered to R23 during the medication pass on 12/4/24 by V6. On 12/5/24 at 9:00 AM, V4 (Nurse Consultant) and V3 (Director of Nursing) said a resident's medication should be given as ordered by the physician. The facility face sheet shows R23 was admitted to the facility with alcoholic hepatitis, alcoholic cirrhosis and esophageal varices. The facility policy updated on 9/2023 for medication administration shows the medication administration record will be verified against the Physician orders.

Based on observation, interview and record review the facility failed to use the current electronic health records (EHR) medication administration record (MAR) to administer medications to the residents. This applies to 3 of 3 residents (R21, R18 and R23) reviewed for medical records in the sample of 13. The findings include: On 12/3/24 at entrance into the facility at 8:30 AM, V1 (Administrator) said the facility had just gone live with the new EHR at midnight on 12/3/2024. On 12/4/24 between the hours of 8:20 AM to 8:47 AM, V6 (Registered Nurse/RN) was observed passing medications to R21, R18 and R23 and was using the past EHR's MAR. V6 said she had never been trained on how to pass medications and document in the facilities current EHR, so she was using what she knew how to do. V5 (Licensed Practical Nurse), who was in the facility to assist the staff on the use of the new EHR, observed V6 using the old EHR, asked V6 why was she using the old EHR and was told by V6 she did not know how to use the new system. V5 walked away from V6 and allowed her to continue using the old system to complete the AM medication pass. On 12/5/24 at 9:00AM, V4 (Nurse Consultant) and V3 (Director of Nursing) said all staff had been educated on the current EHR on 11/21/24 and the staff were expected to be using the new system for all care and documentation. V3 and V4 said if V6 had questions on how to document medication administration, she should have asked for help rather than using the old system. The old EHR's MAR may not have been up to date with the residents current medication orders. The MAR used for R23 on 12/4/24 at 8:47 AM by V6, did not show the medications pantoprazole (medication for heartburn) and polyethylene glycol (medication used for constipation) and R23 was not given these medications. The facilities current EHR's MAR dated December 2024 showed the medications pantoprazole and polyethylene glycol. The Physician's Order Sheet (POS) for R23 dated December 2024 showed orders for these same two medications should have been given at 8:00 AM medication pass. A medication error occurred for R23. The old EHR's MAR for R21 did not show the following medications that are listed on the new and current EHR's MAR: divalproex and levothyroxine. Both medications are listed as current on R21's POS dated December 2024. The facility policy updated on 9/2023 for medication administration shows the medication administration record (MAR) will be verified against the Physician orders.

Based on observation, interview and record review the facility failed to implement EBP (enhanced barrier precautions) for 3 of 6 residents (R4, R11, R19) reviewed for infection control in the sample of 13. The findings include: 1. R19's December 4, 2024 order summary sheet documents him to have a stage 4 pressure injury, and an indwelling urinary catheter. On 12/2/24 at 9:30 AM, R19's door did not have a sign to indicate he was on EBP, and no PPE (personal protective equipment) including gowns, were readily available. On 12/03/24 at 10:36 AM, R19 was observed to have a urinary drainage bag on the frame of his bed. V11 and V12 (Certified Nursing Assistants/CNAs) were observed entering R19's room without donning gowns. V11 put on gloves. V12 did not have gloves on when she transferred the urinary drainage bag from the bed to the wheelchair during the mechanical lift transfer. V11 and V12 both said they did not know of any EBP, and no residents in the facility had any such isolation. R19's 9/17/24 care plans show Implementation of Enhanced Barrier Precaution due to 3 wounds (pressure injuries) and an indwelling catheter. The interventions show the use EBP during high contact care activities such as transferring, proving hygiene urinary catheter care and wound care. The care plan was revised on 10/2/24. 2. R4's admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including multiple sclerosis, flaccid neuropathic bladder, acute kidney failure, history of UTIs (Urinary Tract Infections). The facility's 10/21/24 annual resident assessment for R4 shows he has an indwelling urinary catheter. The 10/31/24 care plan documents he is at risk for UTIs due to indwelling urinary catheter. On 12/03/24 at 10:02 AM, R4 was observed lying in bed. He had an indwelling catheter bag on the side of his bed. R4's door did not have any signs indicating EBP, and no PPE near his room. R4's care plan shows on 5/9/24 Enhanced Barrier Precautions were to be in place due to R4 having an indwelling urinary catheter. On 12/04/24 at 10:13 AM, V3 (Director of Nursing) said she was not aware residents with catheters had to be on EBP, she thought it was only for residents with open wounds. She said that was why R4 was not on EBP. She did not know R19 was not on EBP (due to wounds and a catheter) and both should have PPE available and signs on their doors. She said the staff should be educated on the procedure. The facility's 3/1/23 policy for EBP shows 1. EBP signs must be posted on the door. 3. Gloves and gowns must be worn for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. It applies to residents with devices such as urinary catheters, and residents with any skin opening requiring dressing. 34891 3. R11's face sheet printed on 12/4/24 showed an admitted [DATE] and diagnoses including but not limited to fracture of right lower leg, urinary tract infection, pneumonia, and peripheral vascular disease. R11's facility assessment dated [DATE] showed no cognitive impairment and staff assistance required for transfers and toileting hygiene. The same assessment showed R11 is always incontinent of urine and bowel. On 12/3/24 at 11:47 AM, V11 and V12 (CNAs) entered R11's room to provide care. There was no signage posted on the door to indicate any type of isolation concerns and no PPE bin (personal protective equipment) nearby. The CNAs performed pericare wearing only gloves. A white gauze dressing was on R11's right foot. The aides stated she has a wound on her heel from a surgical boot. V11 and V12 transferred R11 from the bed to the wheelchair using a mechanical lift. On 12/3/24 at 12:10 PM, the aides and this surveyor exited R11's room. A PPE bin had been placed next to the door and a sign showing she was on enhanced barrier precautions was posted on the door. The sign showed gowns and gloves are needed while providing direct resident care, including transferring, changing briefs, and any wound care. V12 stated the bin and sign just got put there. V12 said if the signs are not posted, we have no way of knowing when to wear PPE.

Based on observation, interview, and record review the facility failed to ensure a resident was free of physical abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. This failure resulted in R1 being punched in the face by R2. The findings include: R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, repeated falls, essential hypertension, generalized anxiety disorder, chronic obstructive pulmonary disease, psychoactive substance abuse, muscle spasm, hypokalemia, unsteadiness on feet, and abnormalities of gait and mobility. R1's facility assessment dated [DATE] showed he has no cognitive deficits and verbal behavioral symptoms directed toward others. R1's care plan initiated 4/22/24 showed, Resident is known to display/has history of paranoid thoughts/behaviors and or open conflict/criticism with others including false accusations. Specific behavior exhibited: verbal aggression towards staff, false accusations, inappropriate gestures and facial expressions, name calling. Related diagnoses/condition: bipolar disorder Noncompliant with facility policies, makes accusations against others to deflect responsibility for breaking rules . Administer psychotropic medication as ordered by physician . Encourage psychotherapy and/or psychiatric consultation as indicated/tolerated by resident . Help resident understand why behavior is inappropriate/disruptive and the impact it has on personal well being and well being of others. Initiate Behavior Monitoring program to attempt to identify patterns, precursors, and causes of behavior and to attempt to understand the meaning of the behavior. On 9/18/24 at 1:20 PM, R1 was in his room sitting in his wheelchair. R1 had a bruise to the right side of his face along his nose line. R1 said, [R2] punched me in the face and made my nose bleed. R1's care plan initiated 5/2/24 showed, The resident is/has potential to be verbally aggressive related to ineffective coping skills, mental/emotional illness, poor impulse control . Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document . R1's care plan initiated 5/21/24 showed, Resident has risk factors that require monitoring and intervention to reduce potential for self injury. Deafness/profound hearing loss, unsteady gait, weakness . psychiatric disorders becomes easily agitated and animated, use of assistive devices/wheelchair/walker . Risk factors include injury, pain as evidenced by resident being witnessed waving his arms, stomping his feet and throwing himself backwards and sideways in his wheelchair when he is angry R1's care plan initiated 4/22/24 showed, The resident may be prone to adjustment disorder issues. As evidenced by: outburst towards staff, refusing to comply by policies, exit seeking . R1's 9/11/24 Behavior Note entered at 8:59 AM showed, Resident out in parking lot, yelling to another resident and motioning him (R2) to go back in the building. [R2] was angry, attempting to hit [R1] with his walker but he ended up slamming his walker into the housekeeping manager who was attempting to get [R2] back into the building. Staff member stated her right arm is tender to touch. R2's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include dementia without behavioral disturbance, Chronic Obstructive Pulmonary Disease, Hypertension, mood disorder, and psychotic disorder. R2's care plan initiated 2/14/24 showed, Per documentation received to date, resident has prior criminal record including but not limited to, multiple accounts of aggravated assault and battery from 1976-1978 . Continue to monitor resident's behavior. Follow plan of care, medications and behavior interventions as needed to maintain resident and milieu safety. R2's care plan initiated 10/24/23 showed, Behavior Management potential for verbal and physical aggression towards others . Ensure the safety of resident and others . Monitor for environmental factors that may contribute to new behaviors(s). R2's Behavior Note entered 9/11/24 at 9:05 Am showed, Resident went in to the parking lot unattended. The housekeeping manager was attempting to convince him to come back in to the building. Another resident, [R1] was yelling and motioning to [R2] to get back in the building. [R2] became angry and attempted to hit [R1] with his walker but ended up slamming the walker into the housekeeping manager. No injuries occurred. [R2] was eventually convinced to come back in the building. The facility's abuse investigation showed, Incident: Alleged Physical Abuse; Time: 3:43 PM; Date: 9/11/24 . It was reported to the administrator that R2 allegedly struck R1 in the face . After investigation and interviews, it was ascertained that R2 did strike R1. R2 who suffers from dementia, was walking with a CNA in front of the facility. R1 was reported to have been aggressively addressing R2 from across the parking lot. R2 started approaching R1. The CNA that was walking with him attempted to redirect R2 to no avail. The CNA attempted to obstruct the patch of R2 and was struck by R2. R2 then struck R1 and the two were quickly separated . On 9/18/24 at 2:20 PM, V7 CNA (Certified Nursing Assistant) said, On 9/11/24 R2 went out the door. I followed him and we walked to the dumpster and back. [R1] was over by the handicap parking and he was yelling F%*k you and flipping [R2] off. I told him to stop. [R1] has been picking on [R2] for a long time and I don't know why. [R2] was a nice guy and he just couldn't take it anymore [R2] turned around and headed to [R1]. [R2] drew his fist back and hit me accidentally and then punched [R1] in the face. Gave [R1] a bloody nose. I felt sorry for [R2] no one was doing anything to stop it. On 9/19/24 at 11:03 AM, V6 CNA (Certified Nursing Assistant) said R1 antagonizes R2 every day. V6 said R1 would scream at R2 and tell him and say he was going to kick his ass, kill him, or tell him to get back here you motherf*&ker. V6 said R2 never instigated R1, it was always R1 and she feels bad for R2 being transferred to another facility because he was not the problem. V6 said V1 was aware of the behaviors R1 was having toward R2. On 9/18/24 at 10:18 AM, V9 CNA said, [R1] is an instigator. A couple of weeks ago he went up to [R2] who was sleeping in the recliner and kicked him in his shin to wake him up and tell him he couldn't go outside. I reported it to the nurse. The facilities policy and procedure titled Abuse Prevention Program with revision date 11/28/2016 showed, Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below . This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect, or abuse of our residents . Physical Abuse includes hitting, slapping, pinching, kicking .

Based on interview and record review the facility failed to notify a resident's Healthcare Power of Attorney (HPOA) regarding medication and weight changes. This applies to 1 of 3 resident (R4) reviewed for notification in the sample of 6. The findings include: R4's Admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia with behaviors, seizures, and depression. R4's 8/6/24 Annual Minimum Data Set (MDS) showed he had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 7 out of 15. R1's Physician Orders showed he was on Lasix (a diuretic/water pill) 40 milligrams (mg) once a day which was ordered on 9/12/24 and started 9/13/24. R1's orders showed the 40 mg Lasix was discontinued on 9/16/24 and a new order for 80 mg Lasix was started with the first dose given on 9/17/24. R1's weights showed on 6/5/24 he weighed 187 pounds, then on 7/2/24 he weighed 175 pounds (a month-to-month weight loss of 6.4 percent), and finally on 8/5/24 he weighed 195 pounds (a weight gain of 11.4 percent). R1's progress notes showed no documented re-weights on or about 7/2/24 and 8/5/24. R1's progress notes showed no documented HPOA notifications on or about 7/2/24 and 8/5/24. R1's 7/29/24 Nutrition Note showed he had lost 6.4 percent body weight from 6/5/24 to 7/2/24. R1's 8/28/24 Nutrition Note showed he gained 11.4 percent body weight from 7/2/24 to 8/5/24. On 9/18/24 at 11:50, V12 R4's HPOA stated she was not notified of R4's weight loss, weight gain, or the Lasix dosage increase. V12 stated she learned about the weight loss from the hospice nurse weeks after the weight loss had happened. V12 said she should have been notified of the weight loss once it was identified. V12 said, Nurse said he (doctor) ordered 80 mg of Lasix and no one from facility called me to let me know. The nurse said I thought you and your Dad were not talking but I told her you are still supposed to call me if there were any changes. On 9/19/24 at 11:20 AM, V11 Registered Nurse stated she received the order from R4's physician and increased R4's Lasix from 40 mg to 80 mg. V11 stated she did not notify R4's HPOA of the Lasix increase and she should have. On 9/19/24 at 12:30 PM, V2 Director of Nursing (DON) stated V12 should have been notified of R4's weight loss and change in Lasix. V2 said V12 should be notified so she is aware of his health condition, and it allows her to make informed decisions about his health care. The facility's Notification for Change in Resident Condition or Status (Revision December 2017) showed, the facility and/or facility staff shall promptly notify appropriate individuals of changes in the resident's medical/mental condition and/or status .a need to alter the resident's medical treatment significantly .5 percent weight gain or loss in 30 days .

Based on observation, interview, and record review the facility failed to assess and notify the physician of a new wound. This applies to 1 of 3 residents (R4) reviewed for wound care in the sample of 6. The findings include: R4's Admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia with behaviors, seizures, and depression. R4's 8/6/24 Annual Minimum Data Set (MDS) showed he had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 7 out of 15. On 9/18/24 at 11:50 AM, V12 R4's Healthcare Power of Attorney (HPOA) stated she visited R4 on Monday, 9/16/24. V12 stated, when she visited R4 on Monday, R4's right leg was wrapped in a gauze dressing. V12 stated she is a nurse, and she removed the gauze dressing. V12 stated under the gauze wrap was an absorbent pad covering a 1.5 round wound to R4's shin. V12 said the wound had a white/yellow slough wound bed and yellow drainage. V12 stated she spoke to V11 Registered Nurse (RN) and V11 said the wound had been there since at least the Friday prior. V12 stated she was not notified of the wound. V12 stated R4's doctor had visited him earlier in the day; however, she did not believe he saw the wound because there were no treatment orders for the wound. V12 stated 9/16/24 was the last time she visited her father. On 9/19/24 at 10:35 AM, R4 had gauze wrap to his right leg from the ankle to below the knee. R4 had a gauze wrap to his left leg that had fallen and collected around his ankle. V3 Registered Nurse (RN) removed the gauze wrap to both legs. Underneath the gauze wrap to his right shin was a petroleum gauze dressing. V3 removed the petroleum dressing which exposed a 1.5-inch round non-draining wound. The wound was open, and the center of the wound had slough (a yellow/white substance comprising dead cells and other body matter) which comprised approximately 50 percent of the wound bed. The wound bed was moist. V3 stated she was the nurse who applied the petroleum dressing on R4's right shin the day prior (9/18/24). V3 said the wound was not open and it was a slit the day prior (despite the wound matching the exact description provided by V12 who last visited R4 on 9/16/24.) On 9/19/24 at 11:20 AM, V11 stated she did work Monday 9/16/24. V11 said the wound had just started developing over the last few days prior to 9/16/24 and it initially presented as a blister. V11 said she did not go in the room with R4's physician on 9/16/24 and she does not know if he saw the wound. V11 said, I don't think there are any treatments in place for his shin, not unless there are new orders since I worked last. V11 said the nurse that identifies the wound should be the one to do the initial assessment, provide an initial treatment, and then notify the physician. On 9/19/24 at 3:30 PM, The first and most recent assessment was requested for R4's right shin wound. The facility provided a skin note from 9/19/24 (3 days after V12 first saw wound). The note showed, .wound on right shin, 3 x 3.5 cm (centimeter) . The note did not describe the wound bed. On 9/19/24 at 12:30 PM, V2 Director of Nursing (DON) stated an assessment is done upon first identifying and then weekly. V2 said an assessment would include measurements and description of the wound bed and drainage. V2 said the purpose of the assessment is to ensure the correct treatments are applied and to track the progress of the wound. V2 said she is also supposed to be notified of new wounds and she was not aware of R4's wound to his shin. V2 said R4's shin wound should have been assessed when it was first identified, even if it was a blister. R4's Care Plan showed, The resident has wounds on the 2nd toe of each foot and on great toe and shin of RLE/foot (Right lower extremity). Possibly r/t (related to) edema, MASD (moisture associated skin damage), or pressure. or potential for pressure ulcer development r/t disease process. The Focus Area was revised on 9/17/24. (Two days before the initial assessment.) R4's Physician Orders on 9/19/24 at 9:50 AM showed no order for petroleum-based dressing or any dressing specific to R4's right shin. (Although one had been applied by V3 on 9/18/24.) The facility's Skin Condition Monitoring policy (Rev January 2018) showed Upon notification of a skin lesion, wound, or other skin abnormality, the Nurse will assess and document the findings in the nurses' notes .Any skin abnormality will have a specific treatment order until area is resolved Documentation of the area must include the following: Characteristic: 1. Size 2. Shape 3. Depth 4. Odor 5. Color 6. Presence of granulation or necrotic tissue .

Based on observation, interview, and record review the facility failed to perform weekly assessments for pressure wounds. This applies to 2 of 3 residents (R5, R6) reviewed for wounds in the sample of 6. The findings include: 1. On 9/19/24 at 12:30 PM, V2 Director of Nursing stated the wound care physician assesses wounds every other Friday. V2 said the opposite week wound assessments are completed by the evening shift nurse. R5's 9/6/24 Wound Physician note showed she had a stage III pressure injury to her right shin that has not resolved. On 9/19/24 at 1:00 PM, the facility was unable to locate R5's 9/13/24 wound assessment. On 9/19/24 at 1:00 PM, R5 had an intact dressing to the right shin. On 9/19/24 at 12:30 PM, V2 stated she was not working the week on 9/13/24. V2 stated the facility does not have any electronic charting reminders/treatment interventions to que the nurse to complete the wound assessment. V2 said there are signs at the nurses' station to remind the nurses to complete the assessments. V2 stated the assessments should have been documented in the residents' electronic charting. V2 stated R5's wound should have been assessed on 9/13/24 and she does not know why the assessment was not completed. V2 said the assessments are important to ensure the correct treatments are in place and for the tracking of wound progression. 2. On 9/19/24 at 12:30 PM, V2 Director of Nursing stated the wound care physician assesses wounds every other Friday. V2 said the opposite week wound assessments are completed by the evening shift nurse. R6's most recent available physician wound note showed he had an open pressure injury to his right heel measuring 0.6 centimeter (cm) by 1.5 cm by 0.1 cm deep. On 9/19/24 at 1:00 PM The facility was unable to produce a wound care physician note for 9/6/24 and they were unable to produce a facility assessment from 9/13/24. On 9/19/24 at 12:30 PM, V2 stated she was not working the week on 9/13/24. V2 stated the facility does not have any electronic charting reminders/treatment interventions to que the nurse to complete the wound assessment. V2 said there are signs at the nurses' station to remind the nurses to complete the assessments. V2 stated the assessments should have been documented in the residents' electronic charting. V2 stated R6's wound should have been assessed by the wound physician on 9/6/24 and by the facility on 9/13/24. V2 stated she does not know why the assessments were not completed. V2 said the assessments are important to ensure the correct treatments are in place and for the tracking of wound progression. The facility's Decubitus Care/Pressure Areas policy (Revision January 2018) showed, .Documentation of the pressure area must occur upon identification and at least once each week on the TAR (Treatment Administration Record) or Wound Documentation From .

Based on observation, interview, and record review the facility failed to prevent residents from smoking in the facility and failed to ensure residents at risk for elopement do not exit the facility for 3 of 3 residents reviewed (R1, R2, R3) reviewed for safety in the sample of 7. The findings include: 1. R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, repeated falls, essential hypertension, generalized anxiety disorder, chronic obstructive pulmonary disease, psychoactive substance abuse, muscle spasm, hypokalemia, unsteadiness on feet, and abnormalities of gait and mobility. R1's facility assessment dated [DATE] showed he has no cognitive deficits and verbal behavioral symptoms directed toward others. On 9/18/24 at 1:20 PM, R1 was in his room sitting in his wheelchair. R1 showed the surveyor he had a pack of cigarettes and an electronic vaping device tucked in the waist band of his pants. R1's care plan initiated 4/22/24 showed, The resident uses smoking tobacco, vaping device . Resident displays inappropriate smoking behaviors and refuses to follow facility smoking policy as evidenced by having smoking materials on his person in his room and witnessed with lit smoking materials on his person in the facility . Instruct resident about the facility policy on smoking: locations, times, safety concerns Notify charge nurse immediately if it is suspected resident has violated facility smoking policy . The resident's smoking supplies are stored in a locked facility smoke box. R1's 7/8/24 Smoking/Vaping Safety Screen showed, . Demonstrates safety measures for handling cigarette/vaping device . Demonstrates safe storage of materials when not in use. Resident exhibits a clear understanding of the smoking/vaping policy as evidenced by accurately answering questions related to designated smoking/vaping areas, storage and use of smoking materials/vaping device, consequences of non-compliance, and responsibilities of the resident to prevent other residents from obtaining smoking/vaping materials . Resident agrees to abide by the smoking/vaping policy, understands that a change in condition may necessitate additional screening, impact the status of participating in the smoking/vaping procedures and result in discontinuance or modification of smoking/vaping procedures. Resident agrees to smoke/vape only in attendance of staff, approved family member or volunteer The Interdisciplinary Team determines the above named resident may smoke/vape under the following conditions: Resident must sign self out, have staff let him out, and dispose of cigarette butts appropriately if he is to smoke outside of facility smoking times. R1's Health Status Note dated 9/1/24 at 4:32 PM showed, Resident has been argumentative and confrontational with other residents today. This upsets the female residents to the point that they go back into their rooms. He does not heed, in any way, the posted smoking times and continuously goes in and out the front door, causing it to alarm which, in turn, interrupts the nurse and CNA's (Certified Nursing Assistants). On 9/18/24 at 10:18 AM, V9 CNA (Certified Nursing Assistant) said, [V1] told us [R1] is like a child and we have to overlook what he does. Residents are smoking dab pens (marijuana) inside the facility. [R1] is smoking it all the time. We are told they can do what they want but I don't think they are supposed to be smoking marijuana here. On 9/18/24 at 2:20 PM, V7 CNA (Certified Nursing Assistant) said residents are smoking marijuana right outside the front door. V7 said V1 (Administrator) told them the residents are adults and they can do what they want. V7 said, I guess we are just supposed to leave them alone but you can clearly smell it is marijuana. On 9/19/24 at 11:03 AM, V6 CNA (Certified Nursing Assistant) said residents are smoking marijuana everyday either inside or outside the facility. V6 said R1 smokes cigarettes and marijuana vapes both inside and outside the building. V6 said she knows it is marijuana because of the distinct smell. V6 said it is obvious that it is marijuana. V6 said it has been reported to V1 (Administrator) and he tells us it is not weed we are smelling. On 9/18/24 at 11:30 AM, V3 RN (Registered Nurse) said, [R1] and [R7] have marijuana pens. I know they are marijuana pens because they smell like marijuana. I think [R1] is the main one who is smoking it in the building though. My understanding is we can't do much about it other than confiscate it. The administrator said if we can safely confiscate them we should do that. On 9/19/24 at 1:00 PM, V2 DON (Director of Nursing) said, [R1] likes to get marijuana vapes and share them with other residents. All we can do is confiscate them if we see him with them. [R1] has community pass so he will go to the gas station and get them. [R1] is not allowed to smoke or vape in his room but he has no regard for the rules. On 9/19/24 at 10:27 AM, V1 (Administrator) said residents have been found to have marijuana vapes. V1 said he does not allow smoking either cigarettes or vapes within 50 feet of the building. V1 said R1 does not adhere to the 50 foot rule. V1 said the facility does not allow vaping inside the building of either marijuana pens or regular vapes and if they are found to have them they are confiscated and locked in a drawer. If they have a POA (Power of Attorney) we give it to them when they leave. They have all been educated. V1 said everyone understands it is not allowed and obviously no smoking in the building. V1 said what they do on their own time is their business. V1 said if the residents sign themselves out and go to the park and smoke marijuana it is their right as citizens to do that. V1 said he concerns himself with the rules of the facility. V1 said everyone is allowed to keep their smoking materials with them and in their room. V1 said they had gone back and forth on that decision to allow them to keep their smoking materials but they were educated if they are caught to be smoking inside that they could be restricted. V1 said if they are caught vaping in the facility they are educated. V1 said residents are assessed as to whether or not they are smokers but not whether or not they are safe smokers. V1 said if there were an allegation brought to him regarding a resident smoking in their room or possessing marijuana within the facility he would ask the resident about it. V1 said there would have to be significant proof before they would search a resident's room. The facility's policy with revision date of 10/27/22 showed, Safe Smoking and Vaping Policy, Policy: The facility works to provide appropriate care for residents keeping safety and comfort in mind. Residents may have the desire to smoke/vape and accommodations will be provided as the facility deems appropriate. The electronic cigarette is a non-flammable electronic device with similar functions to those of a common cigarette and can be used as a substitute for the cigarette. Those choosing to vape must follow all expectations of the Safe Smoking and Vaping Policy. Procedure: . A. Smoking is allowed in the resident smoking area only . E. No negative behaviors related to smoking . Breaking of these smoking rules results in: A. 1st offense - loss of ability to carry smoking materials for at least 30 days. 2nd Offense - loss of ability to carry smoking materials for at least 30 days; 3rd Offense - loss of ability to carry smoking materials for at least 30 days; After the 3rd offense, must be re-evaluated for the smoking program 5. Discovery of any prohibited drug as described in the Prohibited Drug Policy found in the facility or used within the facility will lead to immediate discharge from the facility. The facility's policy issue date of 10/10/22 showed, Prohibited Drug/Alcohol Policy; Policy: [the facility] has a responsibility for all resident's safety. Drugs and other substances not prescribed by a resident's treating physician can cause dangerous and life threatening conditions. [The facility prohibits the presence or use of illegal or non prescribed drugs in the facility or anywhere on the premises . As used herein the term Prohibited Drugs shall mean any prescription medication not prescribed to the user and/or controlled substances, including without limitation: marijuana . [The facility] recognizes marijuana is classified as a schedule 1 drug under the federal Controlled Substances Act. This means that there is no currently accepted medical use of marijuana under federal law . Violation of this policy may result in involuntary discharge and a report of criminal action to the authorities. 2. R2's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include dementia without behavioral disturbance, Chronic Obstructive Pulmonary Disease, Hypertension, mood disorder, and psychotic disorder. R2's facility assessment dated [DATE] showed he has severe cognitive impairment and has wandering behaviors. R2's 7/5/24 Wandering-Elopement Evaluation showed he is a High Risk to Wander/Exit Seek. R2's care plan initiated 11/30/23 showed, Resident exhibits/has exhibited in past a tendency to seek to leave facility or wander near exits Frequent visual monitoring and redirection from exits . Intervene as needed to ensure residents/others safety . R2's Health Status Note entered 9/16/24 at 11:56 PM showed, This nurse observed resident irritated and very aggressive verbalizing he was getting out of this place to a CNA (Certified Nursing Assistant). Resident seemed to be redirected with a sandwich and began heading back in the direction of his room. Alarm sounded and it was made apparent resident was attempting to elope. Resident began walking towards street. Resident was finally able to be redirected and brought back in to facility . R2's Behavior Note entered on 9/15/24 at 9:24 AM showed, Resident again outside alone, half way down the parking lot. He is argumentative and difficult to redirect back in to the building. R2's Behavior Note entered 9/15/24 at 8:56 AM showed, Continues to leave the facility unattended at least 3x so far this morning. He becomes angry when we try to redirect and goes right back out the door again. Difficult to have someone constantly sitting with him or walking with him outside. R2's Behavior Note entered 9/11/24 at 9:05 Am showed, Resident went in to the parking lot unattended. The housekeeping manager was attempting to convince him to come back in to the building. Another resident, [R1] was yelling and motioning to [R2] to get back in the building. [R2] became angry and attempted to hit [R1] with his walker but ended up slamming the walker into the housekeeping manager. No injuries occurred. [R2] was eventually convinced to come back in the building. R2's Health Status Note entered 9/9/24 at 2:00 PM showed, Resident continues to walk out the front door without assistance greater than 12 times today. He becomes angry and argumentative when attempts to redirect him are made . R2's Health Status Note entered 9/6/24 at 5:52 PM showed, Resident continues to leave the building without assistance, without supervision. We have addressed this with him multiple times but he continues this behavior. At times he can become angry and combative with staff. On 9/18/24 at 11:30 AM, V3 RN (Registered Nurse) said, [R2] had exit seeking behaviors. Over the weekend I ran out and tracked him down in the parking lot over 13 times. It was terrible. You could get him back in and he would turn around and go right back out. It was Monday night when he got down to the stop sign . On 9/18/24 at 10:18 AM, V9 CNA said, [R2] was exit seeking. Yesterday we got in report that he had taken off and was down at the stop sign. We don't have the staff to make sure he does not get out . On 9/18/24 at 2:20 PM, V7 CNA said, [R2] left on third shift the day before he was discharged from here. They found him down by the stop sign. It was an agency nurse I believe that was here. We only have one nurse and one CNA on night shift so if they are taking care of someone who requires 2 staff for assist there isn't anyone else watching. On 9/19/24 at 1:00 PM, V2 DON (Director of Nursing) said, [R2] would mostly try and walk out of the front door He didn't like that he had to be supervised. I wasn't aware of him making it to the stop sign. [R1] had gotten in trouble for letting [R2] out of the building. [R1] would be outside and he would push the button to turn the alarm off when [R2] went out. To prevent elopement we have the door alarm. When it goes off we run to see who it is and redirect them back into the building . The facility's policy and procedure with revision date of 10/06 showed, Elopement Prevention Policy; Policy: It is the policy of [the facility] to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. Procedure: . The Interdisciplinary Team will initiate a plan of care for any resident determined high risk for elopement. Facility specific measures as well as resident specific measures will be included in each high risk resident's plan of care to minimize risk factors. Communication of these interventions will be made to direct care staff through exposure to the resident's plan of care . Interventions of personal door alarm devices and monitoring will be initiated as deemed necessary by the IDT and documented in the individual resident's plan of care . Any high risk residents will be promptly and courteously escorted back to the appropriate nursing unit, activity room, dining area or resident room when noted to be near an exit door . 3. R3's face sheet showed he was admitted to the facility 10/12/23 with diagnoses to include Type 2 Diabetes, dementia with agitation, atherosclerotic heart disease, Bipolar Disorder, Hypertension, Schizoaffective Disorder, and Insomnia due to other mental disorder. R3's facility assessment dated [DATE] showed he has moderate cognitive impairment. R3's Behavior Note dated 8/5/24 at 2:07 AM showed, Resident has been anxious this evening but went to bed without difficulty. At approximately 1:00 AM he was found wandering down the hallway, attempting to push on the Southwest door stating, I've got to get to my trailer. I initially felt he was dreaming and he was reoriented to time and place. he seemed to accept that and went back to bed. He was given Ativan 0.5 per his PRN (as needed) orders. At approximately 1:30 AM we heard the door alarm sound and found he had eloped out the southeast door. We ran outside and found him a good way down the sidewalk . He became somewhat angry stating I want out of here, I'm not staying here. We finally got him back in the building and seated him in the dining room. CNA got him a sandwich, chips, and pop. I went to the nursing office to start this report. CNA stepped inside the door of the office to tell me something and a door alarm went off. This time it was the North east door. We ran outside and resident was a good ways down the sidewalk once again. He was not agreeable to coming inside but we finally persuade him to stay just for tonight . On 9/18/24 at 11:30 AM, V3 RN said, [R3] left the facility. It was myself and a CNA. The alarm went off on the Southeast door and was out the door. We ran outside and found him right away a little ways down the sidewalk. He was hard to redirect. Then 20 minutes later he did it again . No one wears wanderguards or anything, we just respond when we hear the door alarm going off.

Based on observation, interview, and record review the facility failed to ensure resident's were free from physical abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. The findings include: The facility's Incident Report dated 7/24/24 shows R1 claims that he was on his side of the room and that R2 pulled back the curtain and following a brief argument that R2 struck him in the face. R2 claims that he pulled back the curtain and following a brief argument, R1 struck him twice in the face before he struck R1 once. There were no eyewitnesses. On 8/5/24 at 9:43 AM, R2 was in his room sitting at the bedside eating breakfast. R2 said he used to have a room mate but he got moved. R2 said R1 was watching dirty movies and making noise and he asked him to stop. R2 said it embarrassed him and he could hear what was going on. R2 said R1 and him argued and he opened up R1's privacy curtain. R2 said R1 put up a fist like he was going to hit and he told him don't touch my face. R2 said R1 then hit him on one side of the jaw and went on about how he was a cop in New York. R2 said he told R1 are you happy?, You hit my face, don't hit my face! and then R1 punched him in the other side of the jaw. R2 said he then punched R1 one time in the nose and R1 started screaming. On 8/5/24 at 11:45 AM, R1 was in his room watching TV with the volume loud. R1 had a small yellow/purple resolving bruise on the left side of his nose and under his right eye. R1 said his old room mate punched him in the nose. R1 said he was in his room with the curtain closed having privacy and R2 opened up the curtain and punched him in the nose. R1 said there was no argument and R1 did not punch R2 at all. R1 said he had one drop of blood coming from his nose but no other injuries. R1 said the next day he saw the bruising to his nose and decided to press charges against R2. On 8/5/24 at 10:37 AM, V1 Administrator said R1 and R2 were room mates. V1 said R1 was on his side of the room masturbating to porn and R2 could hear him and asked him to stop. V2 said R2 claims R1 hit him twice in the face and R2 hit R1 once. V1 said the stories matched perfectly up until who hit who. V1 said there were no witnesses and both were separated by staff. V1 said R1 had a bloody nose, but there were no other injuries. V1 said the police were called and both declined going to the hospital. V1 said the next day R1 called the police back and wanted to press charges against R2. V1 said the police gave R2 a citation and he has to go to court. R1's Progress Notes dated 7/24/24 shows resident was in a physical fight with another resident around 3:00 PM today. Resident was noted to have a minor nosebleed. The facility's Abuse Prevention Program Policy dated 11/28/16 shows This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on observation, interview, and record review the facility failed to provide an altered diet for a resident with dysphagia for 1 of 3 residents (R6) reviewed for therapeutic diets in the sample of 22. This failure resulted in R6 experiencing a choking episode requiring the Heimlich Maneuver and abdominal thrusts to dislodge. The Immediate Jeopardy began on 4/26/24 when an order was received to downgrade R6's diet from regular consistency to a mechanical soft consistency and R6 continued to be served a regular diet. V18 (Registered Nurse) was notified of the Immediate Jeopardy on 6/28/24 at 11:10 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/28/24 at 3:47 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R6's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include sepsis, Type 2 Diabetes, Acquired Absence of right leg below knee, hyperlipidemia, arteriosclerotic heart disease of native coronary artery, ischemic cardiomyopathy, cognitive communication deficit, abnormal posture, oropharyngeal phase dysphagia, and vascular dementia. R6's most recent quarterly dietary assessment was completed on 10/2/23 (approx. 8 months prior). R6's care plan initiated 11/6/23 showed, The resident has nutritional problem or potential nutritional problem related to Type 2 Diabetes . Provide, serve diet as ordered . Another care plan initiated for R6 on 11/6/23 showed, The resident has a need for oral/dental health maintenance . Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted . R6's facility assessment dated [DATE] showed he has severe cognitive deficits and no swallowing deficits. R6's Physician Order Sheet showed an order dated 4/26/24, Diet Downgrade to Mechanical Soft/TL (thin liquid) per ST (Speech Therapy). R6's Speech Therapy Discharge notes showed he participated in Speech Therapy from 4/15/24 through 5/10/24. The same Speech Therapy discharge note showed recommendation for oral intake to be Mechanical Soft/Chopped Textures . The facility's Diet Type Report dated 5/8/24 showed R6 was a regular diet and it was crossed off and mechanical was written next to it. R6's 6/16/24 Nursing Note entered at 5:50 PM showed, Resident eating in dining room with several residents and a staff member (V10) (Certified Nursing Assistant/CNA). Resident took a bite of bread and meat, an Italian beef sandwich. Resident began to have signs and symptoms of choking. (V10) reports she did the Heimlich, as resident sitting in his chair. Staff member called for additional help, I approached, resident not responding, color poor, we laid him on the floor, [V10] did abdominal thrusts, turned him on his side, still choking, did another set of abdominal thrusts, turned him on his side, object/food expelled resident breathing, alert . R6's Acute Care Hospital Emergency Department documents dated 6/16/24 showed, Todays Visit Reason for Visit: Choking . R6's Physician Order Sheet showed an order dated 6/19/24, Meals: Cut food into bite size pieces, offer drink every 2-3 bites with meals to prevent choking. On 6/25/24 at 1:07 PM, V14 RN (Registered Nurse) said, . It was supper time. Everyone was in the dining room. [R6] sits in the back corner. I was across the hall in the TV room assisting a resident into a chair. I saw the aide, [V11] running. I saw action in the dining room so I went in and saw [V10] and she said [R6] was choking. [R6] could not speak or breathe. He does not stand so we put him on the floor and did abdominal thrusts. A chunk of food came out, it was a bread ball with beef. It looked like he did not chew it . His diet was regular at the time. It is mechanical soft now. He had a regular tray . On 6/25/24 at 1:45 PM, V12 (Dietary Manager) said the nurse is supposed to send diet changes to the kitchen in paper form. V12 said they do not make changes until the order comes from the nurse and that is when the dietary card would be changed. V12 said she does not have a way to track when the dietary card was actually changed because she does not have R6's old cards. On 6/25/24 at 2:34 PM, V11 (CNA) said, [V10] was feeding [R6] and I was feeding another resident. [V10] started doing the Heimlich and I went to get the nurse. Me and [V10] picked him up and put him on the floor. The nurse just stood there while we were doing the Heimlich. [R6] was completely blue before the food came up a little. When the food came up the nurse put her finger in his mouth and pulled it out. He went to the hospital . his diet was regular at that time but they changed it after that to mechanical soft. On 6/26/24 at 9:40 AM, V10 (CNA) said, I was the one that was feeding him. He was eating regular food. He started choking. I went behind his wheelchair and had another aide go get the nurse. My arms wouldn't go around him. We pulled him to the floor. The kitchen asked if we needed 911. I did stomach thrusts . He was not breathing, his lips turned purple His whole face was purple . His diet got changed now to pureed . On 6/27/24 at 12:34 PM, R6 was in the dining room. R6 was served tomato soup, pasta salad, and a grilled ham and cheese sandwich (not mechanically altered) and cut into halves. V23 (CNA) was sitting near R6 while he was eating. R6 took a large bite of his ham and cheese sandwich and began coughing. V23 said to R6, That was a pretty big bite, better slow down. On 6/27/24 at 1:36 PM, V12 (Dietary Manager) said, [R6] was not seen by the dietitian after his choking episode. [R6] was a regular diet but there was a change around the beginning of May. On 7/2/24 at 1:10 PM, V2 (Director of Nursing) said, Diet changes are entered as an order in the computer by the nurse. They print out a copy and give it to the kitchen. If they don't give it to [V12] and they just put it in the kitchen sometimes things disappear. It is important to ensure the correct diet is entered and changed right away to avoid choking. I don't know where the breakdown happened. I don't know if the dietary card did not get changed or they just didn't read it. The surveyor attempted to call V30 (Registered Dietitian) multiple times with no response. The facility's policy and procedure with review date of April 2006 showed, Therapeutic & Mechanically Altered Diets; It is the policy of [the facility] that therapeutic and mechanically altered diets are ordered by the physician and planned by the dietitian. A therapeutic diet is ordered to manage problematic health conditions . A mechanically altered diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake . A physician's order is written for all diets including therapeutic and mechanically altered diets . The dietitian approves, signs and dates all menus . The facility prepares and serves all therapeutic and mechanically altered diets as planned . The facility's policy and procedure with revision date of April 2015 showed, Diet Orders; Policy: It is the policy of [the facility] to establish procedures for writing and communicating diet orders . The Food Service Manager, upon receiving the diet order, shall check the order against the medical record, making sure that the written order exists and that it agrees with the diet order. Any discrepancies in the Diet Order Form and diet order in the chart are discussed with the Director of Nurses or the nurse in charge . The Diet Order Form is to be kept on file in the Dietary Department for reference. The facility's policy and procedure with revision date of April 2016 showed, Regional Dietitian . Provide dietitian consultation to the facility to help meet the needs of the residents . 1. Collects, analyzes and summarizes relevant data from the resident and/or medical record, including anthopometic and laboratory information, appetite, diet orders, nutrition history, medications, and medical concerns . Evaluates the diet prescription relative to diagnosis and recommends changes as appropriate . Assist in development of menus . The facility's policy and procedure with revision date of October 2013 showed, Quarterly Assessments; It is the policy of [the facility] that all residents will be evaluated at least quarterly to ensure periodic monitoring of the nutritional status of the resident and prevent deterioration of nutritional status . 1. The Food Service Manager or designee re-evaluates and documents each resident's nutritional problems or needs at least quarterly. The Food Service Manager or designee writes the progress note on the Dietary Notes form or the Quarterly Assessment form . 2. Quarterly notes by the Food Service Manager or designee shall include at least the following: A. Current diet order . E. Appropriateness of diet order . The Immediate Jeopardy that began on 4/26/24 was removed on 6/28/24 when the facility took the following actions to remove the immediacy. 1. On 6/28/24 the following was initiated: A. In house audit of all diet orders to ensure accurate reconciled with dietary cards completed 6/28/24. B. IDT will review Speech Therapy recommendations daily in morning meeting. C. Regional Director in-serviced Dietary Supervisor on quarterly and annual dietary assessments. D. Staff in-serviced on appropriate diets by Regional Director and Administrator on 6/28/24. 2. Compliance will be monitored through the QA process. A. Speech orders will be reviewed daily during morning meeting by the IDT. DON/Designee will ensure all new diet orders are communicated to dietary. B. DON/Designee will in-service on diet orders once a month for the next 3 months.

Based on observation, interview, and record review the facility failed to implement interventions for a resident experiencing significant weight loss for 1 of 4 residents (R8) reviewed for weight loss in the sample of 17. This failure resulted in R8 experiencing a 19.47% weight loss from 11/23/23 to 1/24/24 (2 months and 1day.) The findings include: R8's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include abnormal posture, cerebral infarction, dysphagia, Gastro-Esophageal Reflux Disease, major depressive disorder, Type 2 Diabetes, and weakness. R8's facility assessment dated [DATE] showed she has no cognitive impairment and requires substantial to maximum assistance with eating. R8's weight was recorded in her medical record as follows: 11/23/23 she weighed 113 lbs, on 12/4/23 she weighed 89 lbs, and as of 1/24/24 she weighs 91 lbs (19.47% weight loss over 2 months). R8's January 2024 Physician Order sheet showed nutritional supplements including 2.0 Calorie Supplement, Magic Cup, and Mighty Shake all starting 1/13/24 (over 1 month after the significant weight loss was identified). R8's care plan initiated 7/20/23 showed, Potential risk for altered nutritional status and/or weight loss. Related Diagnosis: dysphagia, Additional Risk Factors: noncompliance . Resident will gain 1# (pound) per month for next 90 days. Assist/feed mealtimes as needed to complete meal. Educate family, visitors and staff not to provide food from outside the facility without checking with charge nurse before giving to resident. Encourage self-feeding. Feed resident to complete as much of meal as possible . R8's care plan initiated 1/5/24 showed, The resident has unplanned/unexpected weight loss related to poor intake . The resident will consume 75-100% two of three meals/day . Alert dietitian if consumption is poor for more than 48 hours . Give the resident supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis. If weight decline persists, contact physician and dietitian as soon as practical . Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. Monitor and record food intake at each meal. Offer substitutes as requested or indicated. The residents prefers: ___________ (no preferences mentioned) . On 1/24/24 at 12:20 PM, R8 was sitting in the dining room in her wheelchair at the table. A tray of pureed meatloaf was given to R8 and placed out of reach. At 12:25 PM, there was a CNA sitting across the round table from R8 and she was assisting two other residents with their lunch. At 12:38 PM (18 minutes after R8's lunch was placed on the table), V11 CNA (Certified Nursing Assistant) sat down next to R8. V11 placed R8's spoon into the meatloaf and moved it in front of R8. R8 did not attempt to eat the meatloaf. V11 then put the spoon into R8's dessert and moved that in front of R8. R8 did not eat the dessert. At 12:50 PM, R8 left the dining room without eating any of her lunch. Staff did not offer assistance at any time during the meal. There was no Magic Cup or ice cream provided. On 1/24/24 at 2:20 PM, R8 said, They give me pureed food and it is gross. My feeding tube came out before and I don't know how it happened, but I had an infection . Most of my weight loss happened before the feeding tube came out. I do sometimes eat the pureed food, but I hate their meatloaf and I don't like chili. I can't ask for anything else, they won't get it for me. I've asked before. I like Spaghetti-O's and ice cream, but they don't give me that very often. On 1/25/24 at 11:04 AM, V10 CNA (Certified Nursing Assistant) said, [R8's] appetite is not good, and she refuses a lot of her meals. We try to encourage her, but she tends to refuse a lot. She just says she isn't hungry, or she doesn't like the meal. If she does not like the main meal or the substitute, we can offer her a peanut butter and jelly or a deli sandwich. We also have snack bins that have chips, pudding, jello, and crackers. I would say it is very rare that she does request a sandwich. I know she likes pop, chips, mac and cheese, canned ravioli, and spaghetti. She really likes those. I haven't seen her get any supplements. I haven't seen a magic cup or anything. I don't recall ever seeing ice cream on her tray either. On 1/24/24 at 12:45 PM, V14 (Dietary Manager) said R8 always refuses the pureed diet. V14 said family bring in canned Spaghetti-Os and raviolis and she will eat that, applesauce or pudding. She will not eat pureed food, always refuses it. On 1/25/24 at 1:25 PM, V14 (Dietary Manager) said the Registered Dietitian (RD) comes in once a month to review residents. V14 said, The RD comes into the kitchen and looks at everybody. She talks about the menu to see if there is any problems. I am learning how to monitor weight loss, but it's been a little hard because I started in November, and we were down a couple people in the kitchen. Dietary assessments should be done by me but I'm still learning so the floor nurse is doing the assessments while I am being trained. I am trying to talk to the residents about their preferences but haven't had much of a chance to do that due to staffing shortage. I am starting to do one on one interviews with the residents and ask how things are going, allergies, likes and dislikes. If a resident does not like something we are serving, we also have a substitute. If they don't like the substitute, they can get a deli sandwich or a peanut butter and jelly sandwich. We have a weight meeting once a week that I sit in on and they talk about gains and losses, and we work out a game plan. I have a notebook that I have written down some things in from the weight meeting, but I don't have anything that I put in their chart. For R8, I know we are giving her ice cream at every meal if she takes it. We are doing chocolate pudding; she likes tomato soup, so we try and give her tomato soup. Anything she wants we are giving her just because we are trying to get her to gain weight. We have not given her any ravioli or Spaghetti-O's because her husband brings some of that in, but it is in my notes to see if that is something they want to start doing. On 1/25/24 at 2:12 PM, V2 (Regional Clinical Director) said, the nurses are doing the dietary assessments right now until the Dietary Manager is trained. They are assessing weight, diet, their diagnoses, hydration needs, chewing ability, swallowing, any issues like that. R8 can have whatever she wants, and I know one of the nurse's has brought a can of ravioli in at times because she does eat that. If they told her she can't have a substitute, I know who that would have been in the kitchen. The facility's policy and procedure revised 9/2008 showed, Resident Weight Monitoring . If there is an actual significant weight change, the resident, family/guardian, physician and dietitian are notified. The date of notification for the physician and family/guardian is documented on the Report of Monthly Weight form . The food service manager and/or dietitian reviews the resident's nutritional status and makes recommendation for interventions in the nutrition progress note.

Based on observation, interview, and record review the facility failed to implement interventions to prevent the worsening of pressure ulcers, failed to perform weekly assessments and measurements of a pressure wound, and failed to perform scheduled dressing changes for a pressure ulcer for 1 of 3 residents (R1) reviewed for pressure ulcers. These failures resulted in the deterioration and increase in size of R1's pressure ulcer from a stage 3 to unstageable. The findings include: R1's admission assessment showed he was admitted to the facility on [DATE]. R1's face sheet showed he has diagnoses of age-related physical debility, mixed hyperlipidemia, Parkinson's Disease, Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia, Hypertension, and muscle weakness. R1's 12/20/23 facility assessment to determine risk for skin breakdown showed R1 to be a high risk. This assessment showed the interventions in place for R1 at that time was a pressure relieving device in his chair and a turning and repositioning program. R1's care plan initiated 8/7/23 showed, Resident has wound that appears to be related predominately to pressure. Major contributing factors include Parkinson's immobility, unstageable pressure wound noted to coccyx. Please see treatment records for current measurements . Administer treatments as ordered and monitor for effectiveness. See current orders in eChart Orders/eTAR (electronic Treatment Administration Record) . Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD (physician) . Monitor/document/report PRN (as needed) changes in current wound and/or skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infections such as redness, swelling, drainage, foul smell, decline in function and reduced mobility, wound size, stage. Report adverse findings to practitioner . On 1/16/24 at 12:18 PM, V11 (R1's Daughter) said she feels that her father is not getting the treatment he needs at the facility for his pressure sore. V11 said R1 was recently sent to the emergency room , and she saw his pressure sore on his coccyx. V11 said R1's pressure sore was completely black and was extremely deteriorated from the last time she had seen his wound. V11 said, I was so appalled by it because he was in the hospital back in December and his wound was looking pretty good. V11 said she was told the wound care doctor comes to the facility every two weeks, but she has never received any updates regarding her father's wound. V11 said in December R1's wound was pink around the edges, had no black on it, and the center was a little mucous looking. R1's 12/20/23 Admission/Readmission Nursing Evaluation showed, . Sacrum, Pressure, Stage N/A (Not Applicable) . Resident has some small openings on his sacrum. This assessment showed no measurements or description of R1's wound. R1's November 2023 eTAR (electronic Treatment Administration Record) showed an order started 10/1/23 for Site: Coccyx, cleanse with NSS (normal saline solution), pat dry, apply Medihoney and Calcium Alginate, cover with foam silicone border, every day and PRN (as needed). This eTAR showed R1's dressing change was not documented as completed on 11/2/23, 11/6/23, 11/9/23, 11/10/23, 11/14/23, 11/15/23, 11/16/23, 11/17/23, 11/21/23, 11/22/23, 11/23/23, 11/26/23, 11/29/23, and 11/30/23 (14 of 30 scheduled dressing changes were not completed). R1's December 2023 eTAR (electronic Treatment Administration Record) showed an order for Site: Coccyx, cleanse with NSS (normal saline solution), pat dry, apply Medihoney and Calcium Alginate, cover with foam silicone border, every day and PRN (as needed) started 10/01/2023. This treatment was not documented as completed 12/1/23, 12/7/23, 12/8/23, 12/9/23, 12/10/23, 12/13/23, and 12/14/23. This order was placed on hold on 12/15/23 when R1 went to the acute care hospital for evaluation and treatment. The same eTAR showed a new order started 12/21/23 for Cadexomer Iodine 0.9%, Apply to sacrum topically one time a day for pressure ulcer. (On 1/18/23, V1 [Regional Clinical Director] indicated the order for Cadexomer Iodine originated from R1's acute care hospital stay 'After Visit Summary'. R1's 'After Visit Summary' dated 12/20/23 showed an order for 'Cadexomer Iodine 0.9% Gel, 1 Application topically daily.' This order did not have directions for the location of the application. R1's medical record showed no evidence of a clarification order or notification to R1's wound care doctor regarding the change to his prescribed treatment.) R1's same December 2023 eTAR showed an order for checking R1's skin every Monday, Wednesday, and Friday based on his high risk for skin breakdown starting 12/22/23. These assessments were not documented as completed on 12/22/23, 12/25/23, 12/27/23, 12/29/23, and 12/31/23 (5 of 5 scheduled skin assessments were not completed). R1's weekly wound assessments were reviewed and were noted to be missing for the week of October 23, 2023, November 13, 2023, November 20, 2023, November 27, 2023, December 11, 2023, December 25, 2023, and January 1, 2024. (6 of 12 weekly wound assessments were not completed.) R1's weekly wound assessment provided by the facility dated 12/19/23 showed R1's wound measured 2.5 cm x 2 x 0.1 cm. R1 was not in the facility on 12/19/23. On 1/17/24 at 1:45 PM, V1 (Regional Clinical Consultant) emailed this surveyor stating the measurements from the 12/19/23 wound assessment were taken from the last completed wound assessment on 12/5/23. R1's wound had not been assessed by the facility staff from 12/5/23 through 1/10/24. The facility's wound log dated 1/10/24 showed R1's coccyx wound was unstageable and measured 5.8 cm x 3.5 cm x 0.1 cm. R1's January 2024 eTAR showed an order started 1/3/24 for Cadexomer Iodine 0.9% External Gel to be applied daily to R1's sacrum topically for pressure ulcer. Cleanse with normal saline solution or wound cleanser and apply iodoform and cover with dressing. The facility was unable to determine where this order came from. R1's January 2024 eTAR showed a new order for treatment for R1's pressure wound on his coccyx starting 1/10/24 to Apply to coccyx topically every day shift for wound care for 7 days. Cleanse with normal saline, pat dry. Skin prep peri wound. Apply Dakins 0.25% soaked gauze and cover with foam dressing every day and PRN for 7 days. This order was active from 1/10/24 through 1/12/24. This treatment was not documented as completed 1/10/24. R1's 1/11/24 Health Status Note entered at 8:46 AM showed, Resident unable to swallow morning medications or food. Resident unable to maintain posture in wheelchair, leaning to the left. When attempting to communicate with resident, he was unable to speak, only inaudible mumble . Contacted MD and POA (Power of Attorney). Resident sent to ED (Emergency Department) for evaluation per MD recommendation. R1's 1/11/24 Order Administration Note showed R1's wound care to his coccyx was not performed 1/11/24 due to R1 being at the emergency department. R1's 1/11/24 Health Status Note entered at 5:00 PM showed, Resident returned via ambulance Resident placed in his bed. R1's 1/12/24 Health Status Note entered at 12:22 PM showed, Clarification orders for wet to dry to coccyx received see orders. R1's current physician order showed, 1/12/24 Cleanse wound with NS (normal saline), wet to dry gauze cover with ABD pad and secure with tape q (every) day. Every evening shift for wound care. R1's January 2024 eTAR showed R1's wound care to his wound on his coccyx was not documented as completed 1/14/24. On 1/16/24 at 10:08 AM, R1 was lying in his bed with oxygen in place. R1's eyes were opened but he would not respond. V5 CNA (Certified Nursing Assistant) and V6 CNA were in R1's room to reposition R1. V5 and V6 turned R1 to his left side to show this surveyor R1's pressure wound on his coccyx. There was no dressing on R1's wound. R1's wound had red edges periwound and was 100 % black necrotic tissue within the wound. On 1/16/24 at 10:08 AM, V5 and V6 were interviewed together. V5 said R1's wound does not usually have a dressing on it because it is left open to air. V5 said she knows it is left open to air because she worked yesterday (1/15/24) and there was no dressing on it all day yesterday either. On 1/16/24 at 10:34 AM, V9 LPN (Licensed Practical Nurse) was rounding with V10 (Wound Care Physician). V9 said R1's current treatment is for a wet to dry dressing to his pressure ulcer on his coccyx because that is what the orders were from the hospital when he returned. On 1/16/24 at 10:37 AM, V10 (Wound Care Physician) said he had not seen R1's wound for about 5-6 weeks and it is definitely worse than it was. V10 scored R1's coccyx wound with his scalpel and said, There is very little bleeding which means this necrotic tissue is pretty thick. On 1/16/24 at 2:12 PM, V8 CNA said if they notice a dressing has come off of a resident they usually try and get the nurse to come down and redo the dressing. V8 said she worked the evening shift on 1/14/24 and when she put R1 to bed he did not have a dressing in place. V8 said she removed R1's incontinence brief when she realized the dressing was not in place and she assisted R1 to bed to let his wound air out. V8 said, We CNAs think it is best to leave the dressing off and remove the brief to leave it open to air out. The facility's nursing schedule was reviewed for 1/14/24 and confirmed V8 was working the night she reported the wound was without a dressing and left open to air out through the night. On 1/16/23 at 11:50 AM, V4 LPN (Licensed Practical Nurse) said the facility does not have a dedicated wound care nurse. V4 said the nurses do not do the wound measurements unless the wound has changed significantly. On 1/19/24 at 8:07 AM, V1 (Regional Clinical Director) said nurses are required to do skin checks. V1 said the skin checks are documented on the TAR (Treatment Administration Record). V1 said if the resident has a wound the nurses would document the assessment under a Skin Only assessment in the electronic record. V1 said if a resident is being followed by the wound care physician and they go to an acute care hospital, the wound physician should be notified when the resident returns and if the hospital made any changes to the resident's orders for wound care. V1 said dressing changes should be completed as ordered by the physician for healing. V1 said the dressing changes are ordered for a reason and need to be completed. V1 said dressing changes should be documented in the TAR when completed. On 1/18/24 at 1:54 PM, V10 (Wound Care Doctor) said he does not go to the facility weekly and expects the facility nursing staff to complete wound assessments weekly and update him with changes to the wounds. V10 said the facility has been having a lot of changes to the Administrative and Nursing Staff over the last several months which has caused some difficulties with care being completed. V10 said he was unaware that R1 had gone to the hospital and that the hospital had made changes to R1's wound care orders. V10 said he needs to be notified if the hospital makes changes to his wound care orders so he can ensure a proper treatment is in place. V10 said the order change from the hospital to Cadexomer Iodine would have been changed if he was notified because applying iodine to an open would be cytotoxic. V10 said the Cadexomer Iodine order did not make sense as treatment for R1's wound. V10 said not maintaining consistent wound care orders can negatively affect the wound. In addition, V10 said it would not be appropriate to have the wound open to air because the wound would not be protected and there would be nothing to absorb any drainage. V10 said leaving the wound open to air would impede healing. V10 said it would be critically important for the nurses to assess and update him on the condition of wounds. V10 said if he is not updated in a timely manner it could be detrimental to the patient. The facility's policy and procedure revised 1/18 showed, Skin Condition Monitoring, Policy: It is the policy of this facility to provide monitoring, treatment, and documentation of any resident with skin abnormalities . Procedure: . 3. Any skin abnormality will have a specific treatment order until area is resolved . Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation must include the following: a. Characteristic 1. Size, 2. Shape, 3. Depth, 4. Odor, 5. Color, 6. Presence of granulation tissue or necrotic tissue. b. Treatment and response to treatment. Observe and measure pressure ulcers at regular intervals The facility's policy and procedure revised 1/18 showed, Decubitus Care/Pressure Areas, Policy: It is the policy of the facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer . The pressure area will be assessed and documented on the Treatment Administration Record or the Wound Documentation Record Document size, stage, site, depth, drainage, color, odor, and treatment . Documentation of the pressure area must occur upon identification and at least once each week on the TAR or Wound Documentation Form . Reevaluate the treatment for response at least every two to four weeks. Most pressure areas will respond to treatment in this amount of time. If no improvement is seen in this time frame, contact the physician for a new treatment order . When a pressure ulcer is identified additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers.

Based on observation, interview, and record review the facility failed to ensure a catheter was maintained per physician orders, failed to ensure orders were in place for a resident with a catheter, and failed to provide catheter care for 2 of 3 residents (R1 and R4) reviewed for indwelling catheters. This failure resulted in R1 being diagnosed with a urinary tract infection on 1/16/24. The findings include: 1. R1's admission assessment showed he was admitted to the facility on [DATE]. R1's face sheet showed he has diagnoses of age-related physical debility, mixed hyperlipidemia, Parkinson's Disease, Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia, Hypertension, and muscle weakness. R1's care plan initiated 8/1/23 showed, The resident has a foley catheter: Neurogenic bladder, terminal condition . Catheter care every shift . On 1/16/24 at 12:18 PM, V11 (R1's Daughter) said she feels her father is not getting the care he needs for his catheter. V11 said her dad's catheter is supposed to be changed every two weeks and he became septic from a urinary tract infection in September 2023. V1 said during her dad's last hospital stay the nurse at the hospital was very concerned about the condition of his catheter. R1's January 2024 eMAR (electronic Medication Administration Record) showed a new order 1/16/24 for Cipro (antibiotic) 250 mg . two times a day for UTI (Urinary Tract Infection) for 10 days. R1's January 2024 eTAR (electronic Treatment Administration Record) showed no orders for catheter care, changing the catheter bag, flushing the catheter, or changing the catheter until 1/16/24 (the day the surveyor was in the facility). R1's December 2023 eTAR showed an order to Urinary Catheter- Drainage Bag - Change weekly which started 10/1/23 and was discontinued on 12/19/23 when R1 went to the hospital. This same eTAR showed the urinary drainage bag due to be changed 12/3/23, 12/10/23, and 12/17/23. There was no documentation that the urinary catheter drainage bag was changed at all in the month of December 2023. R1's December 2023 eTAR showed an order for Urinary Catheter Care every shift for catheter use started . This eTAR shows that catheter care was documented as being completed 24 out of the 43 scheduled (19 missed between 12/1/23 and 12/15/23 when R1 went to the acute care hospital for evaluation and treatment.) R1's December 2023 eTAR showed no catheter orders were restarted upon R1's return to the facility on [DATE]. No catheter care was documented from 12/20/23 through 1/16/24 (the day the surveyor was in the facility). On 1/19/24 at 8:07 AM, V1 (Regional Clinical Director) said there should be catheter orders in place for residents who have indwelling catheters. V1 said these are important to make sure that the resident's catheter is being taken care of properly and to monitor for infections. V1 said catheter care, catheter changes, catheter flushes, and catheter drainage bag changes should be documented as completed on the resident's eTAR. 2. R4's face sheet showed he was admitted to the facility on [DATE] with diagnoses to inlcude anxiety disorder, dementia, hypertension, left bundle-branch block, non-st elevation myocardial infarction, abnormalities of gait and mobility, macular degeneration, aphasia, dysphagia, low back pain, protein calorie malnutrition. R1's 11/9/23 Skilled Charting showed he has a catheter in place. On 1/16/24 at 12:48 PM, R4 said he has a catheter and uses a leg bag. R4 said he is not sure why he has a catheter but that he went to the hospital from home and then came to the facility with a catheter. R4 said he tries to take care of his catheter himself. R4 said he was supposed to have an appointment with a physician about the catheter and would like to have it removed. R4 said the facility staff tell him it would be more painful to remove the catheter than to just leave it in. R4 said he does not recall having the catheter changed at all since he has been in the facility. R4 said the facility staff do not clean his catheter. R4 said if he does not shower for a week or so it starts to get really itchy around his penis where the catheter goes in but that if he takes a shower then it stops itching so much. R4 said the longer he goes without a shower the itchier he gets around his catheter. R4's January 2024 Physician Order Sheet showed no orders for a foley catheter, no orders for catheter care, no orders to change the catheter bag, and no orders for flushing or changing the catheter. R4's Physician Order Sheet showed no evidence that R4 had a catheter in place. V1 (Regional Clinical Director) said if a resident has a catheter there should be orders in place to care for the catheter. The facility's policy and procedure revised 3/15/23 showed, Catheter Care, Purpose: Catheter care is provided daily and as needed to all residents who have an indwelling catheter to reduce the incidence of infection.

Based on interview and record review the facility neglected to ensure a resident (R1) was assessed and provided pain management in a timely manner after being dropped from a mechanical lift on 11/21/23 at 5:30 AM which resulted in a right hip fracture. The facility neglected to notify the physician in a timely manner and provide ongoing nursing assessments, pain assessments, and pain management from the time of the incident on 11/21/23 at 5:30 AM through 11/22/23 at 1:25 AM (approximately 20 hours) when R1 was transported to the emergency department for evaluation and treatment of a right hip fracture. These failures resulted R1 being placed on bedrest without necessary care and effective pain management services being provided. R1 required medical evaluation and treatment at the hospital on 11/22/23 due to a right hip fracture sustained in a fall during a mechanical lift transfer at the facility. This applies to one of three residents (R1) reviewed for neglect in the sample of five. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/21/23 at 5:30 AM when the facility staff dropped R1 in a mechanical lift resulting in a fracture to her right hip and not providing nursing assessments, pain assessments or pain management from the time of her injury until she left the faciity on [DATE] at 1:25 AM when she was transported to the hospital for evaluation and treatment. The facility was notified of the Immediate Jeopardy on 12/7/23 at 11:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/8/23; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The A.I.M. (Assessment, Intercommunicate, & Management) Event Record Late Entry for R1 for the incident on 11/21/23 at 5:30 AM showed there were two CNA's present, the mechanical lift tipped, and the resident fell . R1 was being transferred from the shower to bed. New onset of pain; complaints of pain at the time of the event. The Practitioner, resident responsible party and facility management were not notified at the time of the incident. It happened around shift change so the nurse endorsed to the oncoming nurse to follow up. There weren't any other nursing assessments or pain assessments completed for R1 on 11/21/23. The Health Status Notes for R1 on 11/21/23 showed, 2:50 PM - orders received for a portable x-ray. The Health Status Notes for R1 on 11/22/23 showed, 1:15 AM - Called 911 to get R1 transported to the emergency room ; 1:25 AM emergency medical technicians x 3 to transport patient to the hospital. The facility's Final Report dated 11/28/23 to Illinois Department of Public Health for R1's Incident on 11/21/23 showed, R1 sustained a ground level witnessed fall. Resident was immediately assessed by the nurse and sent to the hospital for further evaluation. R1 was diagnosed with a greater trochanteric fracture; surgical repair was noted to be not operative at this time per medical doctor. R1 returned to the facility with new interventions and pain management in place. Further consult was obtained; surgical repair was completed on 11/25/23. R1 is currently at the hospital and plans to return to the facility upon discharge. This is our final report. Signed by V1 - Regional Clinical Director. On 12/1/23 at 9:15 AM V2 DON (Director of Nursing) stated she is the current acting DON. V3 LPN (Licensed Practical Nurse) stated she is the Resident Care Coordinator. V2 stated R1 was recently injured during an unsafe mechanical lift transfer. V2 stated they ultimately found out the floor was wet, and the mechanical lift fell over with R1 in the lift. V2 stated they found out about 20 hours later that R1 had a greater trochanter fracture (right hip fracture). V2 stated she found out on 11/21/23 at 2:30 PM by V5 CNA (Certified Nursing Assistant) and V6 CNA that R1 complained of back pain and was not feeling well. V2 stated she asked V5 and V6 if V9 (Licensed Practical Nurse) was told and they stated, yes and that R1 had been hurt during a fall that morning. V9 stated she knew R1 had a fall. V2 stated she texted V16 (Physician) at 2:47 PM and told him R1 had a fall and asked him for x-ray orders. V2 stated she showed V9 the text from the physician for the x-ray orders so she could put them in for R1. V2 stated V9 ordered the x-rays to be done stat. V2 stated she left the facility at 4:30 PM - 5:00 PM for the day thinking the x-ray orders would get done stat. V2 stated she did not hear anything until the next day that an injury occurred for R1. V2 and V3 stated V10 LPN (Licensed Practical Nurse/night nurse) did not do any assessment after the incident; V10 did not document anything. V2 stated V10 was on shift on 11/21/23 until 6:00 AM. V2 stated she expected a head-to-toe assessment to be completed and documented after the incident. V2 stated V10 told her R1 complained of pain, she gave R1 Tylenol, and she reported what happened to V9 LPN (the oncoming day nurse). V2 stated, when she asked V9, they told her that when she talked to R1 she wasn't having any pain. V9 never documented an assessment or pain assessment for R1. V2 and V3 stated nurses are to document assessments and if they are not documented then they are not done. V3 stated if they could have done anything differently, they would have provided pain control for R1; that was her biggest concern for R1. V3 stated the scheduled Tylenol that R1 had was not enough. V2 stated R1 suffered in pain on 11/21/23 and 11/22/23 until R1 received pain medication on the evening of 11/22/23. V2 stated R1 was in pain for 24 hours. V2 and V3 stated V10 came in 4-5 days later and entered a late entry for R1 for the incident that occurred on 11/21/23 at 5:30 AM. On 12/1/23 at 10:29 AM, V9 LPN stated she came in at 6:00 AM and she did not know what time the incident with R1 occurred. V9 stated she got report from V10 LPN and was not told about R1's fall. V9 stated she did rounds at 6:30 AM and noticed R1 was sleeping. V12 CNA from nights was still here and told her that R1 fell . V9 stated she asked what was done and was told V10 LPN helped them get R1 up but did not do anything. V9 stated she reported it to V3 (Resident Care Coordinator), and she believes V3 notified V16 (Physician). V9 stated R1 had pain in both of her hips and in her lower back. V9 stated she doesn't remember if she documented an assessment. V9 stated they kept R1 in bed and told staff not to move her. V9 stated when a resident falls the CNA is to notify the nurse. The nurse does an assessment which includes vital signs, head to toe assessment, and range of motion. They would get the resident up with a mechanical lift. They would notify the doctor and family right away. The DON and Administrator would be notified. Risk management documentation is done, and a note populates from the risk management documentation into the electronic medical record charting so everyone can see it. For pain control R1 received her already scheduled Tylenol; she did not receive anything else for pain. It was only when R1 moved that she complained of pain otherwise she was okay. This was a change for her; she is normally up in her wheelchair for meals and some activities. V9 stated she worked from 6:00 AM to 6:00 PM and then reported off to V17 LPN and told her that R1 had a stat x-ray ordered. V9 stated she told V17 what happened to R1 and that R1 was on bedrest until the x-ray results come back. V9 stated a stat x-ray is to be done within 4-6 hours from being ordered. V9 stated she didn't see R1 writhing in pain, or her leg turned out like normal with a hip fracture, so she just did what the doctor said. On 12/1/23 at 11:48 AM, V1 RN (Registered Nurse/Regional Clinical Director) stated R1's medical record (paper and electronic) had very little documentation in it regarding the incident, so it is impossible to know what happened and piece it together. V1 stated she was not sure exactly how the mechanical lift flipped or what the cause was. V1 stated she found out later that an assessment was not done after R1's incident. V1 stated V3 LPN/Resident Care Coordinator told her that there wasn't any injury, but they were going to send R1 to the hospital for pain. V1 stated V10 LPN should have documented right away and not 4-5 days later because she wouldn't remember what happened later. V1 stated the A.I.M. (Assessment, Intercommunicate, & Management) Event Record should be filled out in the electronic medical record at the time of the incident/accident. V1 stated there should have been ongoing monitoring and documentation that ongoing monitoring of the resident is being done. V1 stated V10 did not notify R1's family and physician and she should have. V1 stated yes when asked if she felt neglect occurred for R1 after the incident on 11/21/23. V1 stated the nurse should have sent R1 to the hospital and didn't. V1 stated a lot more could have been done for R1. The stat x-ray should have been done in 4 hours. If staff couldn't get the x-ray done within 4 hours, then R1 should have been sent to the hospital. V1 stated if she had been the nurse, she would have sent R1 to the hospital after the fall as a standard precaution. R1 should have been sent to the hospital and had her pain treated. Everyone knew there was a fall, that she had pain and her scheduled Tylenol would not be effective for pain management. That shouldn't have happened. On 12/1/23 at 1:03 PM, V10 LPN stated, on 11/21/23 at 5:30 AM V12 CNA came and got her because R1 was on the floor. V10 stated she went to R1's room, the floor was wet and R1 was in the mechanical lift sling on the floor crying and in pain. R1 was asking for her mom. V10 stated V12 told her the mechanical lift tipped over. R1 couldn't tell her where her pain was located; just said that she had pain. V10 stated she gave R1 Tylenol and reported off to V10 LPN to do a follow up with R1 and V10 stated she would. V10 stated she told V9 what had happened. V10 stated she checked on R1 before she left and R1 was in pain. They dropped the ball on this and let R1 sit there for greater than 12 hours in pain and no stat x-ray done. There was no follow up. V10 stated after a fall or change in condition an assessment is done and documented. V10 stated she did not document at the time of the incident and came back in to document it. V10 stated she thought V9 would follow up and do an assessment for R1. V10 stated she did check R1's vital signs, did a body check but did not check range of motion. On 12/1/23 at 2:00 PM, V12 CNA stated that her and V14 transferred R1 from the shower chair to the bed using a mechanical lift on 11/21/23 at 5:30 AM and the lift flipped. V12 stated R1 was not lifted above the shower chair, she pulled the shower chair out but R1's butt got stuck on the shower chair, the lift flipped onto the right side. V12 stated she got V10 LPN and the nurse came in and just looked at R1. She bent over and just looked at R1. The nurse did not palpate or check R1 for injuries. No vitals were done or range of motion. V10 assisted the CNAs to get R1 into bed. V12 stated in her opinion R1 should have been sent out; R1 had new pain. V12 stated she told V10 about the fall and told the oncoming CNA's what happened. V12 stated the day CNAs told her that night when she came back for her next shift that R1 had been in pain all day and they had told V9 about it. R1 sat like that too long. R1 was sent out the next day (11/22/23) on our shift at around 1:00 AM after they got the x-ray results. Every time we rolled R1 she complained of pain. Just laying in bed R1 looked fine, when moving she had pain. On 12/5/23 at 11:00 AM, V13 CNA stated she worked with R1 on day shift after her fall. V13 stated they requested that we keep her in bed. V13 stated she didn't know anything happened until V9 came in and was talking about it, that it wasn't reported and to keep R1 in bed and not move her until she knew more about the pain. At first, we didn't reposition R1 or provide care. As the shift went on, we were trying to figure out a way to move and roll R1 without pain. We couldn't leave R1 like that. Maybe around 12:00 PM - 12:30 PM there was 3 CNA's and a nurse, and we had two people on each side. We tried to provide support to R1's hip with the most pain. R1 was in pain so we tried to do this as quickly as possible. R1 was complaining of pain, scrunching her face and making noises when we were moving her. R1 slept a lot during the day. R1 was more vocal about pain with any movement. On 12/5/23 at 11:43 AM V6 NA(Nursing Assistant) stated she worked on 11/21/23 from 6:00 AM to 2:00 PM and received report from V12 CNA who told her that the mechanical lift flipped and R1 fell . V6 stated V12 said R1 had pain and said she told V10 LPN the night nurse. R1 complained of pain that day but did not say what it was from. R1 stated her leg hurts, and her feet were tingling. R1 stated that on and off throughout the shift. R1 was in bed, and they told us to leave her in bed. V6 stated she asked V9 if there was anything they could do because R1 was in a lot of pain and V9 stated no and that R1 was fine, there was nothing we can do. V6 stated she couldn't just let R1 lay there in pain so around 12:00 PM - 1:00 PM she went to V2 DON and told her R1 was in pain. V2 was aware R1 was dropped in the mechanical lift but she was not aware of the severity of it. V6 stated she told V2 that R1 had pain and V2 had V6 call V9 LPN into the office. V2 told V9 to get an x-ray and give some Tylenol. On 12/5/23 at 2:35 PM, V1 RN (Registered Nurse/Regional Clinical Director) stated the facility does not have a policy for nursing assessments after a fall/incident. V1 stated the nurses should assess after an incident, check range of motion, and a pain assessment should be done. This should be documented right away. V1 stated the nurses can put a health status note or do a follow up using the A.I.M record. V1 stated assessments should be done for 72 hours and should be done at least each shift. V1 stated that was not being done for R1. V1 stated this was just nursing 101 to do this. V1 stated R1 only received her scheduled Tylenol and did not have an order for as needed Tylenol. V1 stated if a nurse gave as needed Tylenol for R1, it's not documented in the electronic medical record. On 12/6/23 at 9:03 AM V16 (Physician) stated, it looks like on 11/21/23 at 2:47 PM I was notified of an incident with R1. I was notified the mechanical lift tipped in the shower and R1 had back and leg pain. I was told x-rays were ordered and I said that was fine. There was not a request for pain medication. With a fall of any kind, they should call right away, relay what happened and if the resident hits their head or not. If a resident is on blood thinners and hits their head, then they are sent to the emergency room 100% of the time. If not, and it depends on what has happened, we may opt for x-rays to be done. What happened was not good. The message I received did not have any urgency to it. After a fall, a nursing assessment should be done, and range of motion should be part of the assessment. The facility usually has a fall follow up protocol they follow. I would expect the facility to notify me if the available pain control they have is not effective. If the x-ray is not done in 4 hours and there is no sign of it being done, and the resident has pain then they should just send the resident to the hospital. When there is a fall, they should make sure the resident is safe, an assessment should be done, and I should be notified of the change in condition. It sounds like that wasn't done. I can't help if they don't notify me. On 12/6/23 at 9:35 AM, V1 RN (Registered Nurse/Regional Clinical Director) stated she found the AIM for Wellness Communication Form (A-Assess, I-Intercommunication, M-Manage) policy that she thinks the facility uses as the policy for assessments after a fall/injury/change in condition. On 12/7/23 at 12:28 PM, V21 (R1's son/power of attorney) stated he still did not know exactly what happened and the facility won't tell him. V21 stated he was told the mechanical lift tipped and R1 fell . The facility told him the floor was slippery and the wheel got caught. V21 stated this is the second time they broke her bones in a transfer. The last time they only had one person lifting her and should have had two people. V21 stated this happened about 1.5 years ago and R1's leg was broken during that transfer at the facility. V21 stated he did not know it happened at 5:30 AM because he wasn't notified about it until 3:30 PM. V21 stated he is upset that R21 did not have any pain medication and was probably in pain until she was seen at the second hospital. V21 stated the orthopedic doctor that did her surgery said it was an extremely painful break. V21 stated he is upset and worried about R1 at the facility. V21 stated R1 has dementia but knows who he is when they face time. V21 stated R1 is terrified she will be dropped. V21 stated he was not given a timeline on when this incident happened. V21 stated he told the facility he was not happy that he was not getting notified when things happen, or when R1 went to the hospital and when she returned. V21 stated, It is incompetence at all levels. I continue to worry that she is in constant pain, and they can't get R1 back to where she was before they dropped her. On 12/7/23 at 1:02 PM, V5 CNA stated she worked day shift on 11/21/23 and was one of the CNA's that took care of R1. V5 stated V6 NA came to her and stated they have a problem and told her R1 had fallen in the mechanical lift, no one reported it, and R1 was complaining of pain and stating, help me. V5 stated she told V9 LPN at 10:00 AM - 11:00 AM that R1 was complaining of pain, and V9 said, I will figure it out and walked away. V5 stated she never saw V9 check on R1. V5 stated V9 kept ignoring her and she got pissed. V5 stated she went to R1 and R1 was not the same; she was not okay. V5 stated at 1:30 PM - 2:00 PM she went to V2 DON and V2 had no clue what had happened or what was going on. V5 stated her and V6 told V2 they had heard R1 had fallen, she was screaming in pain and begging for help. V2 told them to get V9 who came to the office and V2 told her to give R1 pain medication and get a stat x-ray ordered. The Diagnoses Report dated 12/5/23 for R1 showed diagnoses including cerebral infarction, hypertension, hypothyroidism, hyperlipidemia, major depressive disorder, dementia, age related osteoporosis, and obesity. The November 2023 MAR (Medication Administration Record) for R1 showed she had an order for Acetaminophen 325 mg, give two tablets orally three times daily for pain at 8:00 AM, 12:00 PM, and 5:00 PM. R1 has had this order since 8/1/23. R1 received her scheduled doses of the medication on 11/21/23 and 11/22/23; no pain scale with administration was documented on the MAR. The Care Plan dated 7/19/23 for R1 showed, Alteration in comfort/pain related to right foot drop. Administer analgesic as ordered and assess effectiveness. Monitor every shift for breakthrough pain. Evaluate residents' level of pain every shift and as needed. Ask How would you rate your pain right now? Monitor for indicators of pain. Interview for pain symptoms, causes and relief patterns. Use pain scale prior to administering pain medication and to evaluate effectiveness of pain medication. Utilize pain scale to assess intensity of pain (faces or 1-10 scale). Encourage the same type of scale each assessment to compare consistent values. The facility's Abuse Prevention Program (11/28/16) showed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident Protection Investigation Paths: Possible Neglect. Cause: Based on the allegation, determine what goods or services were not provided to the resident. Result: Determine what physical harm, mental anguish, mental illness, emotional distress or deterioration in the resident's physical or mental condition resulted in the failure to provide goods and services. Intent: Determine if the goods or services were not provided because of a pattern of deliberate negligence, carelessness, or indifference. The facility's AIM for Wellness Communication Form (A-Assess, I-Intercommunication, M-Manage) policy (10/23/18) showed, Policy: To communicate effectively between nurses and primary care providers the facility has developed standardized criteria. This form will be used on residents who have had a change in condition or for shift-to-shift communication among nursing staff. Responsibility: Licensed nursing staff. Procedure: 1. Upon receiving a report in change of condition, review the resident's chart (diagnosis, medications, recent progress note from physician and nurses' notes). 2. Obtain an AIM for Wellness Form .and talk with staff and/or family that is available about the current situation with the resident. 3. Refer to Care Paths or Acute Change in Status File Cards if indicated. 4. Complete every section of the AIM for Wellness Form prior to calling the medical doctor. 5. Have the chart available when making the call to the medical doctor. 6. Complete the AIM for Wellness Form and Progress Note. The Progress Note should be used to document the physical assessment, physician and POA (power of attorney) notification, treatment ordered and given, etc. 7. Place the AIM for Wellness Form and Progress Note in the Nurses Notes section of the medical record. 8. Use the AIM for Wellness Form to assist in shift report. The facility's Pain Prevention & Treatment Policy (12/7/17) showed it is the facility policy to assess for, reduce the incidence of and severity of pain in an effort to minimize further health problems, maximize ADL functioning and enhance quality of life. Assessment of pain will be completed with changes in the resident's condition, self-reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. The Pain Management Flow Sheet will be initiated for those residents with but not limited to routine pain medication, daily pain, diagnosis that may anticipate pain (i.e., arthritis, wounds, fractures, etc.). The facility's Notification for Change in Resident Condition or Status policy (12/7/17) showed the facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON, Physician, Guardian, HCPOA - Healthcare Power of Attorney, etc.) of changes in the resident's medical/mental condition and/or status. 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a. Any symptom, sign or apparent discomfort is: 1. Sudden onset; 2. A marked change (i.e., more severe) in relation to usual signs or symptoms; 3. Unrelieved by measures already prescribed. b. An accident or incident involving the resident; h. A need to transfer the resident to a hospital/treatment center. 2. The nurse supervisor/charge nurse will notify the DON, physician, and unless otherwise instructed by the resident the resident's next of kin or representative when the resident has any of the afore mentioned situations or: a. The resident is involved in any accident or incident that results in an injury including injuries of unknown source; b. There is a significant change in the resident's physical, mental, or psychological status. 3. Except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The Immediate Jeopardy that began on November 21, 2023, was removed on 12/8/23 when the facility took the following actions to remove the immediacy: Facility actions to remove immediacy include: 1. On 12/07/23 the following was initiated: A. All staff in-serviced by the regional nurse on the abuse prevention policy and procedure prior to working their next scheduled shift. B. Nursing staff in-serviced by the regional nurse on change in condition and notification of change. C. Nursing staff in-serviced by the regional nurse Aims for Wellness (assessment and monitoring). D. Nursing staff in-serviced by the regional nurse on pain assessment and pain management. E. R1 resides at Sandwich Rehabilitation and Healthcare pain assessment and pain management in place per MD orders. F. Medical Director was notified of Immediate Jeopardy for F600. 2. All residents have the potential to be affected by the alleged deficient practice, but due to A-E the deficient practice will not recur. 3. Compliance will be monitored through the QA (quality assurance) Process. A. Staff will be in-serviced on abuse by regional nurse/designee once a month for the next 3 months and then reviewed quarterly during QA. B. Admin/Designee to in-service new employees on abuse prevention policy and procedure during orientation, as needed and annually per policy. C. Nursing staff will be in-serviced on change in condition, notification of change, aims for wellness (assessment and monitoring), pain assessment and pain management once a month for 3 months and reviewed during quarterly QA.

I. Based on interview and record review the facility failed to ensure a resident (R1) was safely transferred with a mechanical lift device. This failure resulted in R1 sustaining a hip fracture on 11/21/23 at 5:30 AM during a mechanical lift transfer after the lift device tipped over with R1 in the sling on the device. R1 required medical evaluation and treatment at the hospital on 11/22/23 due to a right hip fracture that was sustained when the mechanical lift tipped over. This applies to one of three residents (R1) reviewed for safety in the sample of five. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/21/23 at 5:30 AM when facility staff dropped R1 in a mechanical lift resulting in a fracture to her right hip. The facility was notified of the Immediate Jeopardy on 12/7/23 at 11:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/08/23; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The A.I.M. (Assessment, Intercommunicate, & Management) Event Record Late Entry for R1 for the incident on 11/21/23 at 5:30 AM showed there were two CNA's present, the mechanical lift tipped, and the resident fell . R1 was being transferred from the shower to bed. New onset of pain; complaints of pain at the time of the event. Practitioner, resident responsible party and facility management were not notified at the time of the incident. It happened around shift change so the nurse endorsed to the oncoming nurse to follow up. The facility's Final Report dated 11/28/23 to Illinois Department of Public Health for R1's Incident on 11/21/23 showed, R1 sustained a ground level witnessed fall. Resident was immediately assessed by the nurse and sent to the hospital for further evaluation. R1 was diagnosed with a greater trochanteric fracture; surgical repair was noted to be not operative at this time per medical doctor. R1 returned to the facility with new interventions and pain management in place. Further consult was obtained; surgical repair was completed on 11/25/23. R1 is currently at the hospital and plans to return to the facility upon discharge. This is our final report. Signed by V1 - Regional Clinical Director. On 12/1/23 at 9:15 AM V2 DON (Director of Nursing) stated she is the current acting DON. V3 LPN (Licensed Practical Nurse) stated she is the Resident Care Coordinator. V2 stated R1 was recently injured during an unsafe mechanical lift transfer. V2 stated they ultimately found out the floor was wet, and the mechanical lift fell over with R1 in the lift. V2 stated they found out about 20 hours later that R1 had a greater trochanter fracture (right hip fracture). V2 stated she found out on 11/21/23 at 2:30 PM from V5 CNA (Certified Nursing Assistant) and V6 CNA that R1 complained of back pain and was not feeling well. V2 stated she asked V5 and V6 if V9 (Licensed Practical Nurse) was told and they stated, yes and that R1 had been hurt during a fall that morning. V9 stated she knew R1 had a fall. V2 stated she texted V16 (Physician) at 2:47 PM and told him R1 had a fall and asked him for x-ray orders. V2 stated she didn't hear anything until the next day that an injury occurred. V12 CNA and V14 CNA were the CNA's that transferred R1 with the mechanical lift and they said it happened 11/21/23 at 5:30 AM. V10 LPN was the night nurse on duty, and she said that R1 was transferred by one CNA and not two CNA's. V3 stated she opened a risk management documentation and put in what she knew about the situation, and they are supposed to have two people for mechanical lift transfers because it is the facility's policy. V2 and V3 stated V10 LPN (night nurse) and V9 LPN (day nurse) did not document anything about what happened for the incident involving R1 or any assessments. V2 and V3 stated they were upset that they did not find out what happened to R1 right away and then all the different stories they were getting about what happened. V2 and V3 stated 4-5 days after the incident happened V10 LPN documented in R1's chart. V2 and V3 stated they did not take the legs off R1's wheelchair and that was part of the reason the mechanical lift tipped when they were maneuvering the lift around the legs and the floor being wet. V12 and V14 went to get V10 (LPN) after the fall. V12 stated V10 was asleep at the nurse's desk and would not know if 1 CNA did the transfer. V2 and V3 stated the CNAs should have removed the foot pedals and the mechanical lift they used gets stuck under the wheelchair due to the foot pedals. It affects the center of gravity and the mechanical lift tipped. It was an unsafe transfer and unsafe environment. On 12/1/23 at 11:48 AM, V1 RN (Registered Nurse/Regional Clinical Director) stated R1's medical record (paper and electronic) had very little documentation in it regarding the incident, so it is impossible to know what happened and piece it together. V1 stated she was not sure exactly how the mechanical lift flipped or what the cause was. On 12/1/23 at 1:03 PM, V10 LPN stated, on 11/21/23 at 5:30 AM V12 CNA came and got her because R1 was on the floor. V10 stated she went to R1's room, the floor was wet, and R1 was in the mechanical lift sling on the floor crying and in pain. V10 stated V12 told her the mechanical lift tipped over. V10 stated she told V12 that there was supposed to be 2 people for transfers with the mechanical lift. V12 stated to V10 that they always operate the mechanical lift by themselves and not with two people. V10 stated she was asked by V3 LPN/Resident Care Coordinator not to document that there was only 1 CNA for the transfer and to put that there were two CNA's. On 12/1/23 at 1:31 PM, V11 CNA stated she did not work the night when the lift tipped over on R1; V12 and V13 were working. V11 stated she was told by other staff that V12 and V13 were putting R1 to bed and the mechanical lift tipped over. V11 stated they are supposed to use 2 people when they do a transfer with a mechanical lift but there are a lot of girls that will do it by themselves. V11 stated she gets a lot of repercussions from other staff because she won't transfer a resident with a mechanical lift by herself and she gets told you can do it yourself; we do it ourselves. V11 stated there is a mechanical lift with long legs on it and they have had to close the legs on the lift which then shifts it's balance. If they close the legs on the mechanical lift with the resident in it, then it swings, and the weight is not distributed evenly so it is not safe. On 12/1/23 at 2:00 PM, V12 CNA stated that her and V14 transferred R1 from the shower chair to the bed using a mechanical lift on 11/21/23 at 5:30 AM and the lift flipped. V12 stated R1 was not lifted above the shower chair, she pulled the shower chair out but R1's butt got stuck on the shower chair, the lift flipped onto the right side. V12 stated the lift could have gotten caught under the chair and that they were not able to open the base (legs) of the mechanical lift all the way and that makes the lift unstable. V12 stated when you adjust the lift one way, the residents weight goes the opposite way, and the lift goes the other way and can flip. On 12/6/23 at 9:35 AM, V1 RN (Regional Clinical Director) stated she did not have any competencies for the CNA's including competencies for mechanical lifts. V1 stated competencies should be done at hire and annually. On 12/6/23 at 10:41 AM, V14 CNA stated there were two of them for the transfer that night for R1. V14 stated the other girl (V12) called for help transferring R1 from the shower chair to the bed. V14 stated they used the tall white mechanical lift that gets tricky if it gets swinging it goes unbalanced. V14 stated the mechanical lift sling under R1 was wet and that got water on the floor. They were trying to get R1 to bed as soon as possible. V14 stated the mechanical lift began to swing in an unruly manner and it tipped over. V14 stated V12 was operating the lift. V14 stated she was standing there watching to see if the sling was still hooked. V14 stated it happened so fast, the sling started to swing, and the lift was tilting, and it was too hard to pull it back. V14 stated she was looking at the top of the lift and R1's butt could have gotten caught on the chair with the combination of the chair and floor being wet that could have caused the fall. V14 stated during a mechanical lift transfer one person operates the lift while the other person holds onto the sling and guides it. V14 stated if the sling gets caught when the lift is going up it can throw the lift off balance. V14 stated she wasn't doing anything with the sling lift under R1 because she wasn't out of the chair yet. V14 stated she thought maybe using a bigger shower chair for R1, so she wouldn't get stuck in the chair, would help with the transfers. V14 stated she has been doing mechanical lift transfers for [AGE] years and does not receive training yearly for competency on using a mechanical lift. On 12/7/23 at 12:28 PM, V21 (R1's son/power of attorney) stated he still did not know exactly what happened and the facility won't tell him. V21 stated he was told the mechanical lift tipped and R1 fell . The facility told him the floor was slippery and the wheel got caught. V21 stated this is the second time they broke her bones in a transfer. The last time they only had one person lifting her and should have had two people. V21 stated this happened about 1.5 years ago and R1's leg was broken during that transfer at the facility. V21 stated R1 is terrified she will be dropped. The facility's Safe Resident Handling and Movement policy (no date) showed, the facility wants to ensure that it's residents are cared for safely, while maintaining a safe work environment for employees. This infrastructure includes resident handling and movement equipment, employee training, and a Culture of Safety approach to safety in the work environment. Goals: Reduce injury potential for both resident and caregiver. Assure staff competency in the safe use of transfer and mobility related equipment. Procedures: It is the duty of employees to take reasonable care of their own health and safety, as well as that of their co-workers and their residents during handling activities by following this policy. Use mechanical lift devices and other approved resident handling aids in accordance with instructions and training. Staff will complete and document safe resident handling and movement equipment training initially, annually, and as required to correct improper use/understanding of safe resident handling and movement. Nursing Management: Ensure high-risk resident handling tasks are assessed periodically and staff are completing the tasks safely, using mechanical lifting devices and other approved resident handling aids and appropriate techniques. As of 12/6/23 V12 CNA did not have any competencies/training by the facility for mechanical lifts. V14's last competency on the mechanical lift was dated 7/25/2007. The Diagnoses Report dated 12/5/23 for R1 showed diagnoses including cerebral infarction, hypertension, hypothyroidism, hyperlipidemia, major depressive disorder, dementia, age related osteoporosis, and obesity. The Minimum Data Set, dated dated dated [DATE] for R1 showed total dependence for mobility and transfers. The Immediate Jeopardy that began on November 21, 2023, and was removed on 12/08/23 when the facility took the following actions to remove the immediacy: Facility actions to remove immediacy include: 1. On 12/07/23 the following was initiated: A. R1 resides at Sandwich Rehabilitation and Healthcare, pain assessment in place and pain management in place per MD orders. B. All nursing staff in-serviced by regional nurse on safe transfers prior to their next scheduled shift. C. All nursing staff in-serviced by regional team with return demonstration on mechanical lift safe transfers prior to the start of their next shift. D. All nursing staff in-serviced by regional nurse on fall prevention policy and procedure. E. Medical Director notified of Immediate Jeopardy for F689. 2. All residents requiring use of mechanical lift transfers have the potential to be affected by the deficient practice, due to A-D the alleged deficient practice will not recur. 3. Compliance will be monitored through the QA process: A. Staff will be in-serviced on safe transfers and safe mechanical lift use once a month for 3 months and reviewed during quarterly QA. B. DON/Designee will review random transfers 3 times a week for 2 weeks and then once a week for 4 weeks. C. DON/Designee will review competencies of Certified, licensed and registered staff annually and as needed. II. Based on observation, interview and record review the facility failed to ensure safe transfers using mechanical lift devices were provided for two of three residents (R4 & R5) reviewed for safety in the sample of five. 31615 1. R4's admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease. The special instructions on his electronic record banner shows he is to be transferred with the mechanical lift with the assist of 2-3 persons. On 12/1/23 at 11:15 AM, V6 and V4 CNA's said R4 was going to be transferred from his bed into the wheelchair using the mechanical lift. V4 moved the mechanical lift over the bed and attached the loops of the sling to the hooks of the mechanical lift. V4 did not lock the wheels of the lift as she was raising R4 out of the bed. V6 was holding R4's feet and guiding him over his wheelchair as V4 was behind the mechanical lift. No staff were supporting R4's body as he was in the air moving towards his chair. Once R4 was over his wheelchair, without locking the wheels of the wheelchair or the mechanical lift, V4 lowered R4 down into the wheelchair as V6 guided only his legs. V4 then pulled on the sling behind R4 to move him up in his wheelchair. 2. R5's admission record shows he was admitted to the facility on [DATE] with a primary diagnosis of multiple sclerosis. The 7/24/23 care plan documents R5 is dependent on staff for his ADL's (Activities of Daily Living) and requires the use of a mechanical device for transfers using 2 staff members. On 12/1/23 at 11:20 AM, R5 was lying in his bed, dressed, and a lift sling under his back. V4 moved the mechanical lift over the bed and attached the loops of the sling to the hooks of the mechanical lift. The wheels of the mechanical lift were not locked. R5's wheelchair was placed at the end of the bed, without the wheels locked in place. V4 raised R5 using the lift, and V5 was holding only R5's foot and guiding him towards the wheelchair. Once over the wheelchair, V4 did not lock the wheels of the mechanical lift, or widen the base of the lift, and as R5 was being lowered into the wheelchair, the mechanical lift was moving back towards V4, and the leg of the lift was under the front wheels of the wheelchair. The wheelchair was not stable, and the front wheels of the wheelchair were observed to be sitting on the leg of the lift, about 2 inches off of the floor. V4 was lowering R5 into the chair, and V5 continued to hold onto his foot until he was in the wheelchair. During the transfer no staff were observed behind R5 to guide or support him as he was transferred into the wheelchair. On 12/1/23 at 11:33 AM, V4 said she never locks the wheels of the mechanical lift or the wheelchair for transfers. She said staff should be behind the resident up in the sling to support them as they are moved. This would be a safer way to transfer the resident. On 12/5/23 at 11:17 AM, V13 CNA said the mechanical lift used on R4 and R5 has straight legs, and it is hard to try and figure out how to get under the wheelchair. The legs do not open wide enough to get around the wheelchair as it is supposed to, so the legs have to go under the chair with one leg behind the back wheel and the other leg in front of the larger back wheel. On 12/1/23 at 1:20 PM, V2 said the mechanical lift requires 2 staff, and sometimes 3 staff to safely transfer a resident. The resident should have the appropriate sling size and it should be in good repair. She said one staff member should be operating the lift while the second staff is standing next to the resident and guiding them during the transfer. The legs of the lift should be spread out under the resident to stabilize the weight in the lift. The wheels of the lift should be locked before raising the resident up to ensure the wheels do not slip and the lift does not tip over. V2 said if the resident is moving from the bed into a wheelchair, the wheels of the chair should be locked so it does not move as the resident is being guided down. She said the base of the lift should go around the back and front wheels, and the legs of the wheelchair should not be off of the floor during a transfer.

Based on observation, interview, and record review the facility failed to have a full time Administrator at the facility which contributed to deficient practices in the facility. This failure resulted in residents not receiving necessary care and services including nursing assessments, pain assessments, and pain documentation. The facility failed to follow their own policies and procedures and failed to ensure staff were trained upon hire and annually on the use of facility equipment. This has the potential to affect all 31 residents in the facility. The findings include: The Facility Data Sheet dated 12/1/23 showed the facility had a census of 31 residents. On 12/1/23 upon entry to the facility they did not have an Administrator and the Corporate Administrator overseeing the building was not onsite. On 12/1/23 at 9:15 AM, V2 DON (Interim Director of Nursing) stated the facility has not had an Administrator for 2-3 weeks. V2 stated V22 (Corporate Administrator) was over the building. V2 stated the DON was moved to another facility 1 week ago. V2 stated she is acting DON but is also the MDS/Care Plan Coordinator. V3 LPN (Licensed Practical Nurse) stated she is the Resident Care Coordinator. V2 stated recently R1 was injured during an unsafe transfer. V2 stated the mechanical lift tipped over during a transfer and R1 fell . V2 stated they found out 20 hours later that R1 had a hip fracture. V2 stated she was never informed of the accident for R1 that occurred on 11/21/23 at 5:30 AM until 11/21/23 at 2:30 PM when it was brought to her attention by some CNA's (Certified Nursing Assistants). V2 and V3 stated V10 LPN (Licensed Practical Nurse/night nurse) did not do any assessment after the incident; V10 did not document anything. V2 stated V10 was on shift on 11/21/23 until 6:00 AM. V2 stated she expected a head-to-toe assessment to be completed and documented after the incident. V2 stated V10 told her R1 complained of pain, she gave R1 Tylenol, and she reported what happened to V9 LPN (the oncoming day nurse). V2 stated when she asked V9 the nurse told her that when she talked to R1 she wasn't having any pain. V9 never documented an assessment or pain assessment for R1. V2 and V3 stated nurses are to document assessments and if they are not documented then they are not done. V3 stated if they could have done anything differently, they would have provided pain control for R1; that was her biggest concern for R1. V3 stated the scheduled Tylenol that R1 had was not enough. V2 stated R1 suffered in pain on 11/21/23 and 11/22/23 until R1 received pain medication on the evening of 11/22/23. V2 stated R1 was in pain for 24 hours. V2 and V3 stated V10 came in 4-5 days later and entered a late entry for R1 for the incident that occurred on 11/21/23 at 5:30 AM. On 12/1/23 at 11:48 AM, V1 (Corporate Regional Nurse) was advised by IDPH (Illinois Department of Public Health) of the seriousness of the concerns. IDPH was onsite at the facility on 12/5/23, 12/7/23 and 12/8/23 and V22 (Corporate Administrator) was not onsite. On 12/7/23 at 11:23 AM, an IJ - Immediate Jeopardy was declared at the facility for deficient practices in the facility. The IJ was declared with V2 (acting DON). V1 (Corporate Regional Nurse) and V22 (Corporate Administrator) were not at the facility. On 12/7/23 at 12:15 PM, V2 said the last Administrator left around 11/18/23 to another facility, and at times will assist with some Administrative duties. She said V1 is not in the facility even weekly, maybe 3-5 times a month. The Corporate Administrator is physically not in the facility but may do some parts of the job. On 12/7/23 at 3:30 PM, V1 was at the facility and stated the facility doesn't have an Administrator and the Corporate Administrator was not onsite. V1 stated she knew the facility was supposed to have a full time Administrator in the building. V1 stated she did not know how often the Corporate Administrator comes to the facility. The facility's Job Description Administrator (no date) showed, job summary - The Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting and physical management of the facility, residents & equipment in a way that the purpose of the facility shall be maintained in accordance with all established practices, policies, laws, and applicable state regulations. The Administrator will manage and conduct business of the facility in a manner that protects the facility license and certification at all times. The major goal of the Administrator is to provide an atmosphere in which residents may achieve their highest physical, mental and social wellbeing. A review of R1's medical records showed she did not receive necessary care and services including nursing assessments, pain assessments and pain documentation from 11/21/23 at 5:30 AM through 11/22/23 at 1:25 AM (approximately 20 hours) when R1 was transported to the emergency department for evaluation and treatment of a right hip fracture. The A.I.M. (Assessment, Intercommunicate, & Management) Event Record Late Entry for R1 for the incident on 11/21/23 at 5:30 AM showed there were two CNA's present, the mechanical lift tipped, and the resident fell . R1 was being transferred from the shower to bed, and had a new onset of pain. The physician, the resident's responsible party and facility management were not notified at the time of the incident. It happened around shift change so the nurse endorsed to the oncoming nurse to follow up. There weren't any other nursing assessments or pain assessments completed for R1 on 11/21/23. On 12/1/23 at 11:48 AM, V1 RN (Registered Nurse/Regional Clinical Director) stated R1's medical record (paper and electronic) had very little documentation in it regarding the incident, so it is impossible to know what happened and piece it together. V1 stated she was not sure exactly how the mechanical lift flipped or what the cause was. V1 stated she found out later that an assessment was not done after R1's incident. V1 stated V10 LPN should have documented right away and not 4-5 days later because she wouldn't remember what happened later. V1 stated the A.I.M. (Assessment, Intercommunicate, & Management) Event Record should be filled out in the electronic medical record at the time of the incident/accident. V1 stated there should have been ongoing monitoring and documentation that ongoing monitoring of the resident is being done. V1 stated V10 did not notify R1's family and physician and she should have. V1 stated yes when asked if she felt neglect occurred for R1 after the incident on 11/21/23. V1 stated the nurse should have sent R1 to the hospital and didn't. V1 stated a lot more could have been done for R1. R1 should have been sent to the hospital and had her pain treated. Everyone knew there was a fall, that she had pain and her scheduled Tylenol would not be effective for pain management. That shouldn't have happened. On 12/6/23 at 9:03 AM V16 (Physician) stated, it looks like on 11/21/23 at 2:47 PM I was notified of an incident with R1. What happened was not good. The message I received did not have any urgency to it. After a fall a nursing assessment should be done and range of motion should be part of the assessment. The facility usually has a fall follow up protocol they follow. I would expect the facility to notify me if the available pain control they have is not effective. If the x-ray is not done in 4 hours and there is no sign of it being done, and the resident has pain then they should just send the resident to the hospital. When there is a fall, they should make sure the resident is safe, an assessment should be done, and I should be notified of the change in condition. It sounds like that wasn't done. I can't help if they don't notify me. The facility failed to follow the following policies: A. The facility's Abuse Prevention Program (11/28/16) showed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident Protection Investigation Paths: Possible Neglect. Cause: Based on the allegation, determine what goods or services were not provided to the resident. Result: Determine what physical harm, mental anguish, mental illness, emotional distress or deterioration in the resident's physical or mental condition resulted in the failure to provide goods and services. Intent: Determine if the goods or services were not provided because of a pattern of deliberate negligence, carelessness, or indifference. B. The facility's AIM for Wellness Communication Form (A-Assess, I-Intercommunication, M-Manage) policy (10/23/18) showed, Policy: To communicate effectively between nurses and primary care providers the facility has developed standardized criteria. This form will be used on residents who have had a change in condition or for shift-to-shift communication among nursing staff. Responsibility: Licensed nursing staff. Procedure: 1. Upon receiving a report in change of condition, review the resident's chart (diagnosis, medications, recent progress note from physician and nurses' notes). 2. Obtain an AIM for Wellness Form .and talk with staff and/or family that is available about the current situation with the resident. 3. Refer to Care Paths or Acute Change in Status File Cards if indicated. 4. Complete every section of the AIM for Wellness Form prior to calling the medical doctor. 5. Have the chart available when making the call to the medical doctor. 6. Complete the AIM for Wellness Form and Progress Note. The Progress Note should be used to document the physical assessment, physician and POA (power of attorney) notification, treatment ordered and given, etc. 7. Place the AIM for Wellness Form and Progress Note in the Nurses Notes section of the medical record. 8. Use the AIM for Wellness Form to assist in shift report. C. The facility's Pain Prevention & Treatment Policy (12/7/17) showed it is the facility policy to assess for, reduce the incidence of and severity of pain in an effort to minimize further health problems, maximize ADL functioning and enhance quality of life. Assessment of pain will be completed with changes in the resident's condition, self-reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. The Pain Management Flow Sheet will be initiated for those residents with but not limited to routine pain medication, daily pain, diagnosis that may anticipate pain (i.e., arthritis, wounds, fractures, etc.). D. The facility's Notification for Change in Resident Condition or Status policy (12/7/17) showed The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON, Physician, Guardian, HCPOA - Healthcare Power of Attorney, etc.) of changes in the resident's medical/mental condition and/or status. 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a. Any symptom, sign or apparent discomfort is: 1. Sudden onset; 2. A marked change (i.e., more severe) in relation to usual signs or symptoms; 3. Unrelieved by measures already prescribed. b. An accident or incident involving the resident; h. A need to transfer the resident to a hospital/treatment center. 2.The nurse supervisor/charge nurse will notify the DON, physician, and unless otherwise instructed by the resident the resident's next of kin or representative when the resident has any of the afore mentioned situations or: a. The resident is involved in any accident or incident that results in an injury including injuries of unknown source; b. There is a significant change in the resident's physical, mental, or psychological status. 3. Except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. E. The facility's Safe Resident Handling and Movement policy (no date) showed, the facility wants to ensure that it's residents are cared for safely, while maintaining a safe work environment for employees. This infrastructure includes resident handling and movement equipment, employee training, and a Culture of Safety approach to safety in the work environment. Goals: Reduce injury potential for both resident and caregiver. Assure staff competency in the safe use of transfer and mobility related equipment. Procedures: It is the duty of employees to take reasonable care of their own health and safety, as well as that of their co-workers and their residents during handling activities by following this policy. Use mechanical lift devices and other approved resident handling aids in accordance with instructions and training. Staff will complete and document safe resident handling and movement equipment training initially, annually, and as required to correct improper use/understanding of safe resident handling and movement. Nursing Management: Ensure high-risk resident handling tasks are assessed periodically and staff are completing the tasks safely, using mechanical lifting devices and other approved resident handling aids and appropriate techniques. The facility failed to ensure staff were trained on mechanical lifts devices upon hire and at yearly competencies. During the survey from 12/1/23 through 12/8/23 the facility could not state when the last time they had any competencies done with staff and could not find any paperwork in at least the last 5 years. On 12/6/23 at 9:35 AM, V1 RN (Regional Clinical Director) stated she did not have any competencies for the CNA's including competencies for mechanical lifts. V1 stated competencies should be done at hire and annually. On 12/7/23 at 12:15 PM, V2 said she does not have records for competencies and training, she would have to request them from corporate. A copy of the facility assessment was requested, and V2 said she did not know what a facility assessment was. On 12/7/23 at 1:00 PM, V5 CNA said she had been employed for one year in the facility, and during that time she has not had to perform any demonstrations for evaluation. She said there have not been any annual evaluations. On 12/7/23 at 1:02 PM, V20 CNA said she had been working at the facility since July. When she was hired no one reviewed the mechanical lift training with her, and she had no supervisors observe her performing transfers. V20 said for trainings she is given materials to read, usually by whoever the DON is at the time. On 12/7/23 at 1:10 PM, V18 CNA said she started 4 months ago and recalls in-services on fire, falls, and safety. Upon hire she was given material and talked about mechanical lift transfers, but the DON had not observed her perform any transfers. She said there has not been any skills checks since she has been at the facility. On 12/7/23 at 1:13 PM, V8 CNA said she had been working in the facility for 5 years. She said the last training she had regarding the mechanical lift was in school. She has had no annual skills test with observations and return demonstrations.

Based on observation, interview, and record review the facility failed to provide a deaf resident with a mode of meaningful communication for 1 of 6 residents (R1) reviewed for quality of life in the sample of 6. This failure resulted in R1 being unable to communicate with his friends in the deaf community, as well as his Care Services Coordinator. R1 was unable to receive counseling services for several months and showed signs of depression and isolation. The findings include: On 10/5/23 at 9:30 AM, R1 was lying in bed, with his head covered. R1's blinds were closed and the room was dark. R1 remained in his dark room until the noon meal. At 12:30 PM, the surveyor, V8 (R1's POA), and V9 (Ombudsman) entered R1's room. R1 was pulling at a thick mattress that was resting against his bed. R1's TV was connected to a small box, with wires extending to the ceiling. The wires extended to the ceiling and across the room, into the wall. R1's electronic device, under the TV, would flash lights. V8 said, It looks like the video calling system is ringing, but he can't answer it. It's V19 (R1's Care Service Coordinator) calling. V8 signed to R1 and asked if he knew how to answer the phone. R1 sighed loudly and signed back to V8, YES. I know how to answer it, but the video is not working. It hasn't been working since 6/25/23. I keep telling them it doesn't work. They don't do anything about it. V8 stated, He has no way to communicate with anyone outside of the building without this video calling system. I've called and asked numerous times. I ask every time I'm here and I get I don't know?, You need a hotspot, or it needs to be hard wired. The problem is no one communicates with us. He (R1) is supposed to have video calls with [V19 - Care Services Coordinator/Counselor] weekly. He can use the video communication device to sign with [V19] or anyone else. It provides a meaningful way for him to communicate. R1 is culturally deaf. He has been deaf all his life and he was ingrained in the deaf community, prior to coming to this facility. He is getting depressed. I can see a decline in his mental functioning, ability to sign, and his mood. He seems depressed to me and I understand why. The only time he gets to use his primary language, American Sign Language (ASL), is when I visit. I try to make it weekly, but he doesn't have any way to communicate in ASL otherwise. This video system would provide that, much needed interaction, for him. It's just sad to see. He had a great connection with [V19], but he hasn't been able to communicate with her in months. She is deaf and a Social Worker, so she understands him in a ways that others can't. I've asked multiple times why the facility doesn't have any interpreter options for him and they don't have an answer for that either. The lack of communication here is beyond frustrating! V3 (Director of Nursing - DON) entered R1's room. R1 pointed at the wires and signed, Why is this still not working? V3 replied, I don't know. I haven't been involved in this issue. The higher ups have been handling it. V8 (R1's POA) stated, This is for his mental health. It should be important. R1 signed that it had not been working since 6/25/23. At 1:01 PM, a Care Plan Meeting was held with R1, V8 (R1's POA), V9 (Ombudsman), V2 (Administrator in training), V3 (DON), and V18 (Social Services Director). V19 was patched in on a conference call with an interpreter. V19 introduced herself and said that she had been in contact with R1 for over [AGE] years. V19 said she enjoyed her interactions with R1. V19 said R1's ability to use his video communication device is imperative to his mental and physical health care needs. V19 said she had not been able to communicate with R1 for months and had made multiple attempts to reach him. V19 said she provided services to R1 on a weekly basis, until his video communication device stopped working. V19 said she had notified the facility that she could not get in contact with R1 and relayed the importance of being able to communicate with R1. V19 said the video communication device was imperative for R1's mental health and social networking. V8 sat across the room from R1 to interpret R1's sign language and provide interpretation to R1. R1 said he was happy to have a care plan and discuss his concerns. R1 said he'd only had one other care plan. V8 said R1 had been in the facility over a year and this meeting was only his second one. R1 said the communication at the facility was awful. R1 said some of the CNAs do use the whiteboards to communicate simple things with him and a few are trying to learn sign language. R1 said he had not been able to use his video communication device since 6/25/23. R1 said he used to talk with V19 (Care Services Coordinator/Counselor) weekly, but had not been able to communicate with her in months. R1 looked down at the floor and his eyes teared up. R1 said he keeps telling the staff that the video communication is not working, but nothing ever gets done. R1 said the communication sucks at the facility. V8 said she had spoken with V1 (Acting Administrator), V3 (DON), V17 (Previous Activities Director) and V20 (Maintenance Director) and still it doesn't work and R1 can't communicate with the outside world. V8 (R1's POA) explained that the video communication device provided R1 with weekly counseling, care service coordination, and access to his friends in the deaf community. V3 (DON) stated, I wish I knew how much this did for R1 sooner. V8 replied, I've been telling everyone. V8 continued to discuss R1's care and the recent falls. V3 (DON) and V8 (R1's POA) discussed R1's increased weakness. V8 said R1 is basically wheelchair dependent now and the facility is using a mechanical lift to transfer him. V19 replied, Oh my, that's a HUGE change for him. I didn't know that. V3 stated, [V2 (Administrator in training)] and myself were not kept in the loop on this. [V1 - Acting Administrator] and [V20 - Maintenance Director] were involved. Clearly the communication is not working. V3 (DON) said IT (Information Technology) would be notified and someone would need to make the trip from Peoria to figure out what the problem is. R1's Face Sheet dated 10/5/23 showed diagnoses to include, but no limited to: diabetes, epilepsy, heart failure, schizoaffective disorder, chronic respiratory failure, dysphagia, anemia, hypothyroidism, unspecified hearing loss, hypertension, and morbid obesity. R1's facility assessment dated [DATE] showed he had moderate cognitive impairment and was deaf, non-speaking. R1's Progress Notes were reviewed. There was no documentation of the facility's attempts to get the video communication device working, nor was there any mention of V19 calling the facility. R1's Care Plan initiated 7/24/23 showed, Ineffective Individual Coping with new situation. Resident wrote that he is struggling with lack of independence . R1's Communication Care Plan initiated 7/24/23 showed, Impaired Communication - Expressive: Resident is deaf and mute. Currently relies on pen and paper to communicate. Some staff understand some sign language, very limited . Interventions: .Communication devices/techniques: Flash cards, communication board, dry erase board, pad/pencil. Use questions that require yes/no answers or one or two word response. Validate response through repeating answers. R1's Care Plan revised 10/4/23 showed, Potential for altered activity pursuit pattern/social isolation as r/t (related to) impaired communication. Resident specific information, resident is deaf/mute. Uses whiteboard to communicate . R1's Care Plan did not contain any documentation of the video communication device for his communication needs. On 10/5/23 at 2:25 PM, V8 stated, He can't contact anyone. He's getting depressed. He's lonely. He gets mad at me because nothing happens after the meetings. There is poor follow-through and communication here. There are a few CNAs that are trying to learn ASL and make the effort to use the white board. But he isn't having any meaningful, deep conversations. He should be allowed to discuss concerns that he doesn't want his sister (me) to know. He doesn't have that luxury because they rely on me for his communication needs. He went from a deaf community that he was very involved with to this facility and he has no meaningful way to communicate. I'd like him to have an interpreter for care plans and important conversations, so I can just be his sister. The facility has never provided an interpreter for R1. When he goes to the hospital there is an interpreter. They tell me they can't do it. On 10/5/23 at 2:55 PM, V3 (DON) said she wished V8 would have explained the importance of R1's video communication device. V3 said it's important for R1 to have counseling and communicate with the deaf community. On 10/6/23 at 11:03 AM, V16 (corporate MDS) said her interactions with R1 were usually brief. V16 said they would communicate using the white board. V16 said 2-3 weeks ago R1 was complaining about this TV not working. V16 said she referred him to the higher ups. V16 said she asked about his TV and heard different things, like: Report it to Maintenance; He needs to get his own hotspot; or something else. V16 stated, I really don't understand. It hasn't been working for a while. I reported it to V1 [Acting Administrator]. I told [V20 - Maintenance Director]. We spoke about it in morning meetings. V16 said R1 was the first hearing impaired resident she had seen at the facility. V16 said, I questioned the appropriateness of his admission here. Writing on the white board does nothing for R1 socially. On 10/6/23 at 11:47 AM, V15 (CNA) said she was familiar with R1. V15 said she mostly used the white board to determine R1's immediate needs. V15 said she is trying to learn some sign language. V15 said it is difficult to have any deep conversations with a white board. V15 said R1 stays in his room most of the day and sleeps. V15 said he will come out for meals and sometimes he will read the paper in the morning. V15 said R1 came out of his room more, when he first came to the facility. V15 said R1 had a video phone that hooked up to his TV and she saw him using it all the time, but it hadn't been working for several months. On 10/6/23 at 12:33 PM, V20 (Maintenance Director) said R1's video communication device is out of my scope and ability. I forwarded the issue to corporate and haven't heard anything back. V20 said R1's video communication device had not been working for months. V20 said R1's device stopped working when the facility rewired for the EMR (Electronic Medical Record) installation. V20 said, It shouldn't be that way. I looked at it and all the wires appear to be connected correctly. [V17 - Previous Activity Director] was trying to figure it out as well. On 10/6/23 at 12:38 PM, V17 (Previous Activity Director) said he started working at the facility when R1 was admitted in 2022. V17 said R1 was more lively, when he came to the facility. V17 said he was able to get in the car from the wheelchair and his sister was able to take him out for meals or social events. V17 said after R1's therapy ended, he would come out for some movies, but started spending more time in his room. V17 said R1 used his video communication device frequently to communicate with his social network before it stopped working. V17 said no one in the building knew ASL, but V8 (R1's POA) had provided a book and he was trying to learn. V17 stated, I'm sure [R1] felt very isolated, not being able to socialize with anyone. V17 said R1's video issues started when the building was re-wired, toward the end of June 2023. V17 said V8 (R1's POA) spoke with him regularly and reported that the device still wasn't working and no one was communicating with her. V17 said V8 was very frustrated because R1 had no way to contact anyone. V17 said he notified V1 (Acting Administrator) about V8's concerns. V17 stated, They (R1 and V8) never really got a real resolution. He spent more time in his room. He only came out for meals. At first he would pay attention to the time and come out for the meals, then he just quite coming out. The CNAs would have to go get him. V17 said he used the white board to communicate with R1, but it was hard to complete a Mood Assessment. And I understand that not having social interactions would be very isolating. I'd spend more time in my room too. [V8] said her being utilized as [R1's] interpreter all the time was a dis-service to him and it was supposed to be the responsibility of the facility to ensure he could communicate effectively. On 10/6/23 at 12:59 PM, V1 (Acting Administrator) said she was notified of issues with R1's video communication device on 9/5/23. V1 said V8 (R1's POA) was upset because it wasn't working. V1 stated, I told her that nothing stated we needed to supply wifi and that she would need to pay for wifi service. She [V8] became very upset with me, so I sent [V20 - Maintenance Director] in to check on it. He sent me pictures of the setup. He said he checked the wires to see if they were cut or not attached properly and could not find an issue. I called IT. The surveyor informed V1 that R1 reported the service had been down since 6/25/23. V1 said she was not aware and she took action as soon as she was aware. V1 said V8 (R1's POA) told her it was how R1 communicated with a counselor or something. V1 stated, Its a video that allows him to sign and someone to sign back to him. The DON said she had other means of communication, but did not tell me what she was using. V1 said she had made no effort to obtain an ASL interpreter for R1. The 9/18/23 Resident Council Meeting Minutes showed, Staff communication needs to improve. Staff constantly using, I don't know. Should at least attempt to find out for residents. The facility did not have a Communication Policy. The facility provided Restorative Nursing Communication Program. This program included Interventions/Approaches . Encourage socialization with other residents who are able to interpret this resident communication attempts . R1 was not on the Restorative Communication Program.

Based on observation, interview, and record review the facility failed to provide medically necessary social services to a deaf resident with a history of schizoaffective disorder for 1 of 6 residents (R1) reviewed for medically necessary social services in the sample of 6. This failure resulted in R1 becoming depressed, lonely, and isolated. The findings include: On 10/5/23 at 9:30 AM, R1 was lying in bed, with his head covered. R1's blinds were closed, and the room was dark. R1 remained in his dark room until the noon meal. At 12:30 PM, the surveyor, V8 (R1's POA), and V9 (Ombudsman) entered R1's room. R1 was pulling at a thick mattress that was resting against his bed. R1's TV was connected to a small box, with wires extending to the ceiling. The wires extended to the ceiling and across the room, into the wall. R1's electronic device, under the TV, would flash lights. V8 said, It looks like the video calling system is ringing, but he can't answer it. It's V19 (R1's Care Service Coordinator) calling. V8 signed to R1 and asked if he knew how to answer the phone. R1 sighed loudly and signed back to V8, YES. I know how to answer it, but the video is not working. It hasn't been working since 6/25/23. I keep telling them it doesn't work. They don't do anything about it. V8 stated, He has no way to communicate with anyone outside of the building (without this video calling system). I've called and asked numerous times. I ask every time I'm here and I get I don't know? You need a hotspot, or it needs to be hard wired. The problem is no one communicates with us. He (R1) is supposed to have video calls with [V19 - Care Services Coordinator/Counselor] weekly. He can use the video communication device to sign with [V19] or anyone else. It provides a meaningful way for him to communicate. R1 is culturally deaf. He has been deaf all his life and he was ingrained in the deaf community, prior to coming to this facility. He is getting depressed. I can see a decline in his mental functioning, ability to sign, and his mood. He seems depressed to me, and I understand why. The only time he gets to use his primary language, American Sign Language (ASL), is when I visit. I try to make it weekly, but he doesn't have any way to communicate in ASL otherwise. This video system would provide that, much needed interaction, for him. It's just sad to see. He had a great connection with [V19], but he hasn't been able to communicate with her in months. She is deaf and a Social Worker, so she understands him in a way that others can't. V3 (Director of Nursing - DON) entered R1's room. R1 pointed at the wires and signed, Why is this still not working? V3 replied, I don't know. I haven't been involved in this issue. The higher ups have been handling it. V8 (R1's POA) stated, This is for his mental health. It should be important. R1 signed that it had not been working since 6/25/23. At 1:01 PM, a Care Plan Meeting was held with R1, V8 (R1's POA), V9 (Ombudsman), V2 (Administrator in training), V3 (DON), and V18 (Social Services Director). V19 was patched in on a conference call with an interpreter. V19 introduced herself and said that she had been in contact with R1 for over [AGE] years. V19 said R1's ability to use his video communication device is imperative to his mental and physical health care needs. V19 said she had not been able to communicate with R1 for months and had made multiple attempts to reach him. V19 said she provided services to R1 on a weekly basis, until his video communication device stopped working. V19 said she had notified the facility that she could not get in contact with R1 and relayed the importance of being able to communicate with R1. V19 said the video communication device was imperative for R1's mental health and social networking. V8 sat across the room from R1 to interpret R1's sign language and provide interpretation to R1. R1 said he was happy to have a care plan and discuss his concerns. R1 said he'd only had one other care plan. V8 said R1 had been in the facility over a year and this meeting was only his second one. R1 said the communication at the facility was awful. R1 said he had not been able to use his video communication device since 6/25/23. R1 said he used to talk with V19 (Care Services Coordinator/Counselor) weekly but had not been able to communicate with her in months. R1 looked down at the floor and his eyes teared up. R1 said he keeps telling the staff that the video communication is not working, but nothing ever gets done. R1 said the communication sucks at the facility. V8 said she had spoken with V1 (Acting Administrator), V3 (DON), V17 (Previous Activities Director) and V20 (Maintenance Director) and still it doesn't work and R1 can't communicate with the outside world. V8 (R1's POA) explained that the video communication device provided R1 with weekly counseling, care service coordination, and access to his friends in the deaf community. V3 (DON) stated, I wish I knew how much this did for R1 sooner. V8 replied, I've been telling everyone. V8 continued to discuss R1's care and the recent falls. V3 (DON) and V8 (R1's POA) discussed R1's increased weakness. V8 said R1 is basically wheelchair dependent now and the facility is using a mechanical lift to transfer him. V19 replied, Oh my, that's a HUGE change for him. I didn't know that. This is why the communication with me is so important. The physical changes also effect his mental wellbeing. At 3:45 PM, R1 was sleeping in his dark room. On 10/6/23 at 9:50 AM and 10:40 AM, R1 was sleeping in his dark room, his head covered with the blankets. R1's Face Sheet dated 10/5/23 showed diagnoses to include, but no limited to: diabetes, epilepsy, heart failure, schizoaffective disorder, chronic respiratory failure, dysphagia, anemia, hypothyroidism, unspecified hearing loss, hypertension, and morbid obesity. R1's facility assessment dated [DATE] showed he had moderate cognitive impairment; was deaf, non-speaking; had diagnoses of Bipolar Disorder and Schizophrenia; and received antipsychotic medications 7 days a week. R1's Care Plan initiated 7/24/23 showed, Ineffective Individual Coping with new situation. Resident wrote that he is struggling with lack of independence . R1's Care Plan revised 10/4/23 showed, Potential for altered activity pursuit pattern/social isolation as r/t (related to) impaired communication. Resident specific information, resident is deaf/mute. Uses whiteboard to communicate . R1's Care Plan initiated 7/24/23 showed, Resident requires use of Psychotropic Medications to manage mood and/or behavior issues. Candidate for Gradual Dose Reduction. Needs monitored for Drug Related Complications . Perform Behavior Management Program and behavior tracking. Monitor behaviors and document on behavior flowsheet . Refer to psychiatrist or neuropsychologist for effective and safe behavior and med management . R1's Care Plan did not contain any documentation of the video communication device for his communication or mental health needs. R1's EMR did not contain any visits with Behavioral Health Services while he was at the facility. On 10/5/23 at 2:25 PM, V8 stated, He can't contact anyone. He's getting depressed. He's lonely. He gets mad at me because nothing happens after the meetings. There is poor follow-through and communication here. There are a few CNAs that are trying to learn ASL and make the effort to use the white board. But he isn't having any meaningful, deep conversations. He should be allowed to discuss concerns that he doesn't want his sister (me) to know. He doesn't have that luxury because they rely on me for his communication needs. He went from a deaf community that he was very involved with to this facility, and he has no meaningful way to communicate. On 10/6/23 at 10:40 AM, V3 (DON) said R1 had not been provided Behavioral Health Services by the facility. V3 said R1 should have been followed by Behavioral Health Services due to his diagnoses of Bipolar Disorder and Schizophrenia. V3 said it is important to properly manage his medications and to ensure that his mental health is not declining. V3 said the facility did not have a policy regarding Behavioral Health Services.

Based on observation, interview and record review the facility failed to coordinate a resident's care to ensure a resident received therapy, failed to ensure a resident received a wheelchair, and failed to coordinate discharge planning for a resident wishing to transfer to another facility in a timely manner. These failures resulted in R1 feeling depressed and hopeless with his current situation. This applies to one of one resident (R1) reviewed for care and services in the sample of 11. The findings include: The facility face sheet for R1 shows diagnosis of paraplegia and major depressive disorder and was admitted to the facility on [DATE] at the age of 29. The facility assessment dated [DATE] shows R1 to be totally dependent on staff for all activities of daily living. The same assessment describes his mood as little interest in doing things, feeling down, depressed or hopeless, trouble falling asleep, no energy and low appetite nearly every day. The Physician progress note dated 5/27/2023 shows R1 to be a paraplegic from a recent gunshot wound, right shoulder injury related to gunshot wound and a sacral pressure ulcer. The note goes on to show R1 is not at all happy about being in the nursing home, being so far away from home and a very difficult situation for this very young individual and will require close monitoring. On 6/16/2023 at 9:10 AM, R1 was observed laying in his bed in his room. The curtains were drawn, and the room was dark. No wheelchair was observed in the room. R1 said he is not sure why he ended up in a nursing home 4 hours away from his family and wants to leave this facility. R1 said he can't leave against medical advice because he has no one to care for him and no wheelchair to get around in. R1 said he feels like no one in the facility is trying to help him get closer to his family. R1 said he has not received any therapy since being at the nursing home. R1 said he calls 911 for himself frequently hoping he won't have to come back to the facility. R1 said he does not feel like the facility is caring for his pressure ulcer the right way and just wants to get out of this facility and be closer to his family. On 6/16/2023 at 10:30 AM, V13 Therapy Director said R1's therapy has been delayed due to his insurance and waiting on approval to start care. V13 said a referral for a specialized wheelchair has just been sent out. On 6/16/2023 at 10:45 AM, V1 Business office manager said R1 is a charity case and the corporate staff had to review the paperwork to approve therapy and a wheelchair for R1. On 6/27/2023 at 9:16 AM, V1 said she submitted the paperwork to corporate the week after R1 was admitted and she never heard back if it was approved until just recently. On 6/16/2023 at 2:20 PM, V1 said she sent an e-mail to the corporate hospital liaison for R1's request to be moved to another facility. V1 said she sent the request when she was officially notified of R1's request to leave the facility. (The e-mail is dated 6/14/23, 19 days after admission) On 6/20/2023 at 11:40 AM, V3 Activity Director said he has been doing some of the social service work since the facility does not have a social service director. V3 said R1 made it very clear when he came to the facility that it was too far away from his family and wanted to be placed somewhere else. V3 said R1 was promised therapy before he came to the facility and the therapy has been delayed due to him being a charity case and no one following up on the paperwork to make the therapy happen. V3 said many things at the facility are not being followed up on due to the lack of directors. On 6/27/2023 at 9:35 AM, V2 Director of Nursing said the facility has not had any administration staff in the facility for a long time, and things are not being followed up on as they should be. V2 said the IDT (interdisciplinary team) team discusses a residents care in their daily meetings and the resident needs are determined and followed-up on. V2 admits there has been a delay in R1's care due to lack of follow-up by IDT team. The facility mood assessment dated [DATE] shows R1 to have moderate to severe depression. A nursing progress note dated 6/1/2023 shows communication between facility staff and R1's mother regarding the disappointment regarding the lack of therapy being provided to R1. The facility told R1's mother the paperwork had been submitted and the facility was waiting on the approval. A nursing note dated 6/1/2023 shows at 12:05 AM, R1 was asking staff about leaving the facility against medical advice. R1's clinical record shows no referral for any Psychiatric services for his history of depression and ongoing depressed mood. R1's facility care plan for ineffective coping related to new diagnosis of paraplegia shows to provide education on psychiatry and for his sad/depressed mood to encourage psychiatry services. The facility undated job description for the Social Service Director shows: will assist in planning, developing, organizing, implementing and directing social service programs in accordance with current existing federal, state and local standards as well as our established policies and procedures in order to assure that the medically related emotional and social needs of the resident are met and maintained on an individual basis.

Based on observation, interview, and record review the facility failed to ensure residents were transferred in a safe manner for 4 of 5 residents (R22, R17, R27 and R23) reviewed for transfers in the sample of 12. These failures resulted in R22 sustaining two broken bones in R22's ankle. The findings include: 1. R22's computerized face sheet showed [DIAGNOSES REDACTED]. R22's facility assessment dated [DATE] showed severe cognitive impairment. The facility assessment showed R22 was totally dependent on staff for transfers on and off the toilet. R22's Fall Risk assessment dated [DATE] showed at high risk for falls. R22's progress note dated 11/13/19 at 8:50 AM, showed R22 was found on the floor of her bathroom with her right leg in external rotation (turned outward). On 11/19/19 at 2:32 PM, R22 was lying in bed with her right ankle wrapped in a cast, which was resting on top of a pillow. R22 stated she fell while being transferred off the toilet and onto her wheelchair. R22 said she was being transferred by only one CNA (Certified Nurse Aide). R22 said the aide helped her into a standing position while she reached for the wall grab bar. R22 said the CNA was a newer employee and had never transferred her before. R22 said the CNA did not put a gait belt around her waist and R22 slipped while moving off the toilet. R22 stated she was sent to the hospital because of a broken ankle. On 11/20/19 at 1:58 PM, V8 (CNA) stated she was helping R22 go to the bathroom. V8 said she transferred R22 onto the toilet without the use of any mechanical device or assistance by other staff members. V8 said R22 did reach for the wall grab bar while V8 provided pericare, put on a clean brief, and pulled up her pants. V8 said she directed R22 to move her right foot over and pivot into the wheelchair. V8 said R22's feet got tangled up and her legs became weak. V8 said she lowered R22 to the ground by holding her under her arms and by the back of her pants. V8 said R22 did not have a gait belt on. V8 said she had forgotten to use it when transferring R22 on and off the toilet. V8 said R22 is weak on one side and the gait belt helped to stabilize her during transfers. V8 said R22 was either a sit to stand lift or two person assist for transfers. V8 said the lift was broken that day and she could not find anyone to help her, therefore she transferred R22 by herself. V8 said she yelled out for help after R22 fell to the floor. On 11/20/19 at 2:09 PM, V6 (CNA) said she responded to R22's fall. V6 said when she entered the bathroom, R22 was on the floor and her leg was bent in a fake and unnatural position. V6 said nurses were immediately notified. V6 said she had transferred R22 in the past and she was a sit to stand or two person assist for transfers. On 11/20/19 at 2:59 PM, V10 (Licensed Practical Nurse) said she responded to the aides report of R22's fall. V10 said R22 was immediately sent out to the emergency room . V10 said she did not see any mechanical lift in the room or a gait belt around R22. V10 said, I think she (R22) is a one assist, stand pivot transfer. V10 said R22's care plan would reflect how she transferred on and off the toilet. On 11/21/19 at 1:44 PM, V2 (Director of Nurses) said gaits belts are used to aid in walking and transferring residents. V2 said anyone who is a fall risk needs them. Gait belts are used to hold onto residents in a safe manner. On 11/20/19 at 3:05 PM, V1 (Administrator) stated he did a fall investigation after the incident. V1 said V8 (CNA) was the only staff member involved in the transfer and a mechanical lift device was not used. V1 also stated R22 should have been transferred as stated on her care plan. V1 said R22 suffered a broken tibia and fibula (ankle bones) due to the fall. On 11/20/19 at 3:14 PM, V3 (MDS/Care Plan Coordinator) said R22's care plan was updated following the fall and shows she should be a sit to stand as of 11/13/19. V3 said the intervention was determined following her fall investigation as stated in the Quality Assurance Analysis binder. V3 said R22 was a one assist with a gait belt prior to her fall. V3 said R22 had standing issues and one sided weakness. V3 said gait belts are absolutely necessary for control if a resident begins to fall. On 11/21/19 at 12:30 PM, V2 (Director of Nurses) stated resident care plans drive a resident's plan of care. V2 said staff should be looking at the care plan to determine how a resident should be transferred. R22's care plan was reviewed with V2 present. V2 stated R22's care plan did not show how she should have been transferred prior to the fall and the aides had no idea how she should have been transferred. V2 said she could not say if R22 should have been transferred with a sit to stand lift, a one person, or two person assist. V2 said there is nothing shown on the care plan. V2 said. That is a huge potential for falls and injuries which is exactly what happened to (R22). V2 said R22 was transferred wrong and fell , breaking her ankle because of it. V2 said R22 cannot bear weight now due to the broken ankle and requires a total mechanical lift. Again, R22's care plan was reviewed with V2 which showed a new intervention dated 11/13/19 (the day of the fall). The intervention showed: Use sit to stand for transfers. V2 stated, No, the care plan is still incorrect. There is no way (R22) can be a sit to stand. That is a wrong intervention. Staff definitely should not be following the updated fall care plan. On 11/21/19 at 10:25 AM, R22's room door signage still indicated a one person assist for transfers. R22's local emergency room discharge summary dated 11/13/19 showed: reason for visit-leg deformity, fall. Diagnosis-broken leg. Distal right tibia and fibula with tenderness and rotation outward. Findings: The right calf has been placed in a plaster cast. 2. R17's computerized face sheet showed [DIAGNOSES REDACTED]. R17's facility assessment dated [DATE] showed severe cognitive impairment. The facility assessment showed R17 requires extensive assistance from staff for all transfers. On 11/19/19 at 11:23 AM, V8 and V9 (Certified Nurse Aides) sat R17 up in bed and began to transfer her out of her bed and into the wheelchair. V9 applied a gait belt around R17's waist. V8 stood on one side and V9 stood on the other side of R17. Each aide grabbed the gait belt around R17' back with one arm and looped their arms under R17's arm pits. V8 and V9 then lifted R17 out of the bed and place her into the wheelchair. R17's feet were completely 6 to 8 inches off of the floor throughout the transfer. On 11/21/19 at 12:23 PM, V2 (Director of Nurses) stated if a resident is unable to bear weight, a mechanical lift should be used. V2 said, No, it is never appropriate to lift a resident out of bed! V2 said it is unsafe for residents to be lifted. Residents could be dropped, joints could be dislocated and/or nerve damage could occur. V2 said, Absolutely not! Lifting a resident is not safe! V2 said residents should be transferred in the manner reflected in their care plans. R17's care plan was reviewed with V2 present. V2 said (R17's) care plan does not show how she should be transferred. 3. R27's computerized face sheet showed diagnosesto include history of [MEDICAL CONDITION], dementia, lack of coordination, and history of falls. R27's facility assessment dated [DATE] showed severe cognitive impairment. The facility assessment showed R27 requires total staff assistance from staff for all transfers. On 11/19/19 at 12:04 PM, R27 was lying in a low bed which was only inches off the floor. V8 and V9 (CNAs) sat R27 on the edge of the bed and applied a gait belt around his waist. R27 was resistive to the transfer and V8 exited the room to get additional help. At 12:22 PM, V7 (CNA) entered the room to assist. V9 and V7 each grabbed the gait belt and looped their arms under R27's armpits. The aides pulled R27 up and off the low bed to place him in his wheelchair. R27 did not stand on his feet and his toes dragged across the floor during the transfer. 4. The facility face sheet for R23 shows [DIAGNOSES REDACTED]. The facility assessment dated [DATE] shows her to have moderate cognitive impairment and requires extensive assist of one for transfers. On 11/19/2019 at 11:16 AM, V7 and V8 CNA's (Certified Nursing Assistants) were getting R23 up for lunch from her bed. R23 was in a low bed that can not have the height adjusted. V7 and V8 loosely applied the gait belt to R23's waist and the gait belt was gaping in the back. V7 and V8 reached under R23's arms and lifted her to a standing position. The weight of R23 was resting on V7 and V8's arms. R23's knees were bent and not fully holding her weight. V7 said it is difficult to get R23 out of the bed since it is so low. On 11/21/2019 at 8:24 AM, V5 CNA said R23 is difficult to get up from the low bed. V5 said it takes two CNA's reaching under her arms to get her up to a standing position. On 11/21/2019 at 1:38 PM, V9 CNA said a gait belt should be applied to the residents waist tight enough so only two fingers can be inserted between the gait belt and the resident. On 11/21/2019 at 8:32 AM, V4 RN (Registered Nurse) said a resident should be lifted using a gait belt not under the residents arms. On 11/21/2019 at 10:00 AM, V3 RN Restorative said in order for a resident to be a 1-2 person assist pivot transfer the resident must be weight bearing, have strength and stability. V3 said a resident in a low bed that can't be raised should be a mechanical lift transfer for the safety of the resident. V3 said a resident should never be lifted under the arms because it can injure the resident. The facility policy for Transfer Belts/Gait Belts with a revision date of 4/10/2006 shows To promote safety in transferring and ambulating residents, a gait belt is utilized when deemed appropriate by nursing or therapy staff. All certified nursing assistants and licensed personnel engaged in the lifting and transferring of residents will use gait belts. Mechanical lifts will be used when the use of the gait belt does not provide an adequate margin of safety. Gait belts are mandatory. A gait belt is used if indicated on the care plan and/or kardex. Monitor the resident during transfers for: B. Decline in the amount of effort given by the resident C. Inability to participate in the transfer.

Based on interview and record review the facility failed to treat a urinary tract infection. This applies to 1 of 3 residents (R2) reviewed for urinary tract infections in the sample of 3. This failure resulted in R2 having to be sent to the local emergency room to be treated for [REDACTED]. The findings include: R2's (MONTH) (YEAR) Physician order [REDACTED]. R2's cumulative [DIAGNOSES REDACTED]. R2's (MONTH) 14, (YEAR) POS shows an order for [REDACTED]. The facility infection control log was reviewed for the last three months and showed R2 experienced UTIs on (MONTH) 5, (MONTH) 20, and (MONTH) 14, (YEAR). R2's progress notes dated (MONTH) 12, (YEAR) stated: c/o (complaint) of burning at catheter. Note to MD (medical doctor) to notify of this. C/O lower body pain. New order received per (MD) for UA/C&S (urinalysis/culture and sensitivity - a laboratory test of urine to determine presence of infection and organism involved). R2's progress notes dated (MONTH) 15, (YEAR) stated: UA reordered. VS-100.3 (vital sign temperature of 100.3 degrees Fahrenheit). R2's progress note dated (MONTH) 17, (YEAR) stated: patient urine for UA/C&S collected, ready for pickup. R2's progress note dated (MONTH) 19, (YEAR) stated: patient didn't sleep well, C/O discomfort and burning .in pain .foley (catheter) intact with dark urine. T99.7 (temperature 99.7 degrees Fahrenheit). R2's progress notes dated (MONTH) 20, (YEAR) stated: New T.O. (telephone order) Keflex 500 mg p.o. x 10 days. Urine cloudy .large amount foul smelling milky drainage. Catheter flush attempted-Unable. D/C'ed (discontinued) with clumps noted at end of catheter .new catheter inserted .yellow then purulent (drainage indicative of infection) and bloody with small clots then purulent yellow. R2's progress notes dated (MONTH) 21, (YEAR) stated: R2 continued with a high temperature of 100.2 degrees F and catheter with white sediment and blood clots. Small amounts of sediment and light brown tinged urine off and on. R2's (MONTH) 22, (YEAR) progress note shows R2 was admitted to the local hospital emergency room with a [DIAGNOSES REDACTED]. R2's medical chart showed a telephone doctor order dated (MONTH) 12, (YEAR) for a UA/C&S test. R2's medical chart showed a second telephone order dated (MONTH) 20, (YEAR) (8 days later) for Keflex (antibiotic) 500 mg TID x 10 days. R2's laboratory results show a specimen collect date of (MONTH) 17, 2108 (5 days after the initial order was placed). R2's (MONTH) 18, (YEAR) preliminary laboratory report showed positive for urinary tract infection and R2's (MONTH) 20, (YEAR) final laboratory report showed the organism responsible for the infection. R2's (MONTH) (YEAR) Medication Administration Sheet shows the Keflex was finally begun on (MONTH) 21, (YEAR), (9 days after symptoms began). On (MONTH) 15, (YEAR) at 11:25 AM, V2 (Director of Nurses) stated in (MONTH) (YEAR), R2 had a long lag between the time her UTI symptoms began and the time an antibiotic was finally administered. V2 said R2 was showing signs and symptoms of a urinary tract infection during the lag time. V2 said R2 continued to have intermittent fevers, cloudy urine, and pain while the facility was waiting for laboratory results. V2 stated waiting nine days to begin treating a UTI is too long. , V2 (Director of Nurses) stated, Our lab service is horrible, horrible! V2 stated R2's urine test request was sent to the outside lab company on (MONTH) 12, (YEAR). V2 stated they should have picked up the urine sample within 24 hours but they never did. V2 said facility staff called the lab company on (MONTH) 13th and questioned when they would arrive to pick up the urine sample. V2 and the lab company promised they would be there on either the 13th or 14th. V2 said she came in to work on (MONTH) 15th and the urine sample was still in the facility. V2 said she phoned the lab company and threw a fit over the urine still not picked up. V2 said she was promised it would be picked up on (MONTH) 16th. V2 said on the 16th it had not been picked up and she again phoned the lab company and spoke with the lab supervisor. V2 said the lab supervisor finally came to the facility and picked up a freshly obtained urine sample on the 17th. V2 said the lab dropped the ball and it never should have taken that long for lab services. V2 said a preliminary report should be back within 48 to 72 hours and a final report available within the same time frame. On (MONTH) 15, (YEAR) at 12:40 PM, V1 (Administrator) stated residents should be assessed and treated for [REDACTED]. V1 said there should not be any delays. V1 stated UTIs left untreated have the potential to progress [MEDICAL CONDITION], kidney damage, and organ failure. V1 stated waiting an extended length of time increases the risk for an infection to spread throughout the body. V1 (Administrator) stated lab samples should be picked up as soon as possible and there should not be any delays in sending them out or getting the results. V1 said labs should be picked up within four to six hours after being ordered The facility's undated Management of Catheter-Associated Urinary Tract Infections (CAUTI) guidelines show: Assess for signs or symptoms of CAUTI (such as) fever greater than 100.4 degree F (or an increase of 1.5 degree F above baseline), new costovertrebral (lower back) tenderness, rigors, new onset [MEDICAL CONDITION], acute hematuria (blood in urine), lower abdominal pain. The guidelines show if CAUTI symptoms are present: obtain a urine sample prior to implementing antibiotic treatment for [REDACTED]. If urinalysis shows criteria is met for treatment with antibiotic, treatment with an antibiotic should be considered. The facility did not have any policy related to the timeliness of obtaining a UA/C&S.

Based on interview and record review the facility failed to ensure a resident was free from verbal abuse by E13 on July 14, 2016. This failure resulted in R1 feeling frustrated and humiliated by E13. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: R1's Minimum Data Set, dated dated dated [DATE] shows a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact), no hallucinations, and no delusions. On July 21, 2016 at 10:15 AM, R1 stated, around 7:00 the morning of July 14, 2016, he was walking past the nurse's station and R1 said aloud, What an a**-hole. R1 said he did not direct it to any individual in particular. R1 said he did not realize E13 (Licensed Practical Nurse) was behind the nurse's station area. R1 said E13 replied, No, you're the a**-hole. R1 stated a loud yelling match of words began between himself and E13. R1 said he did go nuts and could not remember verbatim what words were exchanged. R1 said, (E13) had a dream I was a scary monster and then she began treating me like one. R1 said, (E13) should have walked away from me when I began to lose my temper. She (E13) did not deescalate the situation at all. R1 said he began walking away from the nurse's station when E13 followed him and said, You're a c**t. R1 said he felt extremely frustrated and humiliated during the encounter with E13. On July 21, 2016 at 11:30 AM, E5 (Licensed Practical Nurse) stated she witnessed the incident between R1 and E13 on the morning of July 14, 2016. E5 stated they had words. E5 said E13 called R1 a psycho, psych-stalker, or something like that. E5 said E13 used a loud voice and continued to yell back and forth with R1. E5 stated she heard bickering continue down the hall but could not make out what exactly was said. On July 21, 2016 at 12: 40 PM, E2 (Director of Nurses) stated she received a phone call from E13 on the morning of July 14, 2016. E2 said E13 explained to her there was an incident that morning between E13 and R1. E13 stated R1 was out of line and admitted calling R1 a crazy, psycho-stalker. E2 said that was not appropriate language for facility staff to use with any resident. On July 21, 2016 at 12:50 PM, E3 (Registered Nurse) stated she witnessed the incident between R1 and E13 on the morning of July 14, 2016. E3 stated R1 and E13 began a verbal altercation at the nurse's station, but could not hear exactly what was said until the altercation continued down the hallway. E3 said, I clearly heard (E13) say to (R1) 'youre acting like a psycho-stalker.' E3 said she had to physically intervene between the two in order to ensure resident safety. E3 said the exchange was pretty loud, heated and E13's tone was very disrespectful. E3 said E13 did not try to disengage with the resident and continued to argue with him. On July 21, 2016 at 1:25 PM, E12 (Certified Nurse Aide) stated she witnessed the incident between R1 and E13 on the morning of July 14, 2016. E12 said she heard E13 tell R1, Stay away from me you hairy monster. E12 stated she heard E13 yell, This is why I don't give him his meds. E12 said R1 yelled,You're a f**ing c**t. E12 said E13 yelled back to R1 but she was unable to understand the exact reply. E12 said it was a loud tone and most likely profanity. On July 21, 2016 at 1:20 PM, E1 (Administrator) stated E13's behavior was definitely humiliating and willful toward R1. E1 said, (E13's) behavior was not appropriate facility staff conduct. E13 was arguing back and forth. (R1) told me she (E13) used profanity, something like 'no, you're a dirty c**t and psycho-stalker'. E1 said R1 was upset after the incident. E1 stated E13 immediately resigned after the July 14, 2016 incident. E13's personal file showed a hand written resignation letter signed by E13 on July 14, 2016. The facility's Abuse Prevention Policy revision dated 11/11/11 states, This facility affirms the right of our residents to be free from abuse .This facility therefore prohibits mistreatment, neglect or abuse of its residents . The policy also states, Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend or disability .

Based on observation, interview, and record review, the facility failed to follow dietary recommendations to provide fortified foods for a resident who had a 25 pound unplanned weight loss over eight months. This failure contributed to a significant weight loss of 8.29% in three months, along with a documented decreased food intake. This applies to 1 of 5 residents (R10) reviewed for weight loss in the sample of 11. The findings include: R10's October 13, 2015 MDS (Minimum Data Set) showed her [DIAGNOSES REDACTED]. R10 was assessed to have moderate cognitive impairment. On January 19, 2016 at 1:05 PM, R10 was seated in the corner of the Main Dining Room holding a spoon. R10 had only eaten her meat. R10's 2015 Monthly Weight Record showed R10 showed R10 lost 25 pounds (155 pounds to 130 pounds) between March and November 2015. R10's January 4, 2016 Dietary Quarterly Assessment showed a significant weight loss of 6.31% in one month, and an 8.29% loss in three months. R10's February 5, 2015 Nutrition Assessment shows her [MEDICATION NAME] value as 3.2 g/dl (low). R10's Dietary Quarterly Assessment showed a decline in food intake from 75-100% in June 2015 to 50% in January 2016. MDS of October 13, 2015 showed R10 is not on planned weight loss program. R10's Registered Dietitian note from July 7, 2015 showed a recommendation for adding fortified cereal at breakfast after R10 lost seven pounds in one month, and 13 pounds in the previous three months. R10's Registered Dietitian note dated November 24, 2015 showed to add fortified foods again, after R10 lost nine more pounds. A Dietary Services Communication dated November 24, 2015, showed R10's physician approved the recommendation for adding fortified foods on December 23, 2015, almost one month later. No physician order for [REDACTED]. On January 21, 2016 at 3:25 PM, E8 (Dietary Manager) stated fortified foods have never been offered at the facility. On January 22, 2016 at 10:30 AM, E3 (Care Plan Coordinator) stated there was no care plan for R10's weight losses. R10's January 13, 2015 Nutrition care plan has not been updated and showed No concerns with appetite at this time. The facility's October 2014 Resident Weight Monitoring policy showed, 8. The Food Service Manager and interdisciplinary team review the residents' weights and nutritional status, and make recommendations for intervention . 10. Nursing contacts the physician to convey recommendations from the interdisciplinary team and/or dietician and obtains any new orders. 11. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed.

Based on observation, interview and record review, the facility failed to prevent an unstageable pressure ulcer, failed to assess and document resident ' s wounds, failed to develop a specific care plan to address skin breakdown and failed to ensure wound treatments were implemented. These failures contributed to R11 developing an unstagable pressure ulcer to the left buttock. This applies to 3 of 7 residents (R11, R3, R10) reviewed for pressure ulcer in the sample of 12. The findings include: 1. R11 ' s Physician order [REDACTED]. The Minimum Data Assessment Set (MDS) of 09/29/14 shows R11 as incontinent of bowel and bladder, and requires extensive assistance with bathing, hygiene and transfers. R11 ' s Braden Scale of 06/30/14 shows a score of 17 (moderate risk for developing pressure ulcer). R11 ' s care plan of 06/30/14 does not document specific risk factors for possible skin breakdown. The Nursing note dated 11/05/14 at 5:00 PM shows a new order to off load wound to left buttock and monitor daily; and wound care nurse if needed. The Treatment Flow Sheet/Treatment Administration Record of 11/14 shows the weekly skin checks were done on 11/03/14, 11/10/14, 11/17/14 and 11/24/14. The skin assessment note on 11/03/14 documents clear skin. The skin assessment notes on 11/10/14 and 11/17/14 shows open areas on right shin and calf. The skin assessment note on 11/24/14 shows clear skin. No documentation regarding R11's wound on the left buttock was shown. No wound assessments of the left buttocks (description, measurements) were found for R11. The Nursing note for R11 on 11/13/14 states "[MEDICATION NAME] dressing to left buttock. Wound measurement of 2.5 cm". ( No other wound description is documented. ) The physician progress notes [REDACTED]. The facility wound tracking sheet for R11 was not initiated until 11/24/14. The left buttock wound measured 1.8x 1.0 cm with the wound status documented as deteriorating. There is no care plan identifying the presence and treatment interventions of R11's left buttock pressure ulcer. On 12/04/14 at 11:05 AM, E3 and E4 (Certified Nursing Assistants-CNAs) provided incontinent care to R11 and a foam dressing was observed on R11's left buttock area. On 12/04/14 at 10:55 AM, E2 (Director of Nursing-DON) said that when the Certified Nursing Assistants (CNAs) find anything unusual on the resident's skin, they are to report it to the nurse right away. " The nurse should document the findings right away-the wound length, width, and depth, if any, the condition of the wound bed and the drainage. The nurse should inform the doctor right away and document all orders. " On 12/04/14 at 11:05 AM, E3 and E4 (CNAs) stated "We perform skin checks with the resident's shower schedules and record them. If we find anything-redness, skin tear, wound, drainage, anything abnormal, we let the nurse know and show it to her." The pressure reducing cushion/mattress was not initiated until 11/20/14. The Nursing note dated 11/20/14 at 3:45 PM states " May have pressure reducing cushion/mattress per MD order." The facility's pressure sore prevention policy dated 05/07 says..."documentation of the pressure area must occur upon identification and at least once each week...the assessment must include characteristic,treatment and response to treatment...initiate problem on care plan." 2. The undated Resident Fact Sheet shows R3 has the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS) of 10/31/14 shows R3 was at risk for developing pressure ulcers and had one or more unhealed pressure ulcers at stage 1 or higher. The Minimum Data Set (MDS) of 6/12/12 shows R3 has a history of a healed left hip pressure ulcer, and has an indwelling urinary catheter. R3 has moderate cognitive impairement. R3 requires extensive assistance from 2 staff members for bed mobility. On 12/2/14 at 1:25 PM E3 and E9 (Certified Nursing Assistants-CNAs) were performing perineal care for R3. A dry, scabbed wound was noted on R3's left hip that was approximately 0.3 x 0.4 cm. The nurses notes dated 10/15/14 labeled 'late entry from 10/13/14' show that a CNA reported to the nurse that R3 had a "fragile area to his left hip". The nurse note states, "R3's left hip has an abrasion and redness noted at raised area about the size of an egg. The doctor was called." The Physician Wound Care notes dated 10/17/14 show R3 had a stage 3 pressure ulcer measuring 0.9 cm x 0.6 cm with no drainage noted. The notes state the wound bed was 26-50% adherent, yellow slough. On 12/4/14 at 10:00 AM, E5 (Licensed Practical Nurse-LPN) stated "The Doctor ordered the x-ray on 10/13/14 because we thought the area appeared jutted out ... the area had some breakdown, it was blanchable but the area was darkened. E5 stated the interventions in place were to turn R3 every 2 hours " but he would keep turning himself back to face the wall ...We were propping pillows under him to try to get him to stay off of the left side, but he would keep ending up on the left side." On 12/4/14 at 9:00 AM, E7 (Registered Nurse-RN) stated "When we put R3 into bed he is mobile and he can turn himself. E7 stated, "R3 always wanted to face the wall (when in bed). " E7 stated skin checks are done weekly by the CNA giving the resident a shower ...and if they see anything of concern, they let the nurse know." E7 stated after R3 developed the new pressure ulcer on his left hip, they turned R3's bed around to where R3 would not be on his left hip when he was facing the wall. On 12/4/14 at 11:00 AM, E5 (LPN) stated, "Skin checks are done weekly by the nurse and it is usually on the resident's shower day. The information is documented in the treatment book ...the treatment records from October should say what interventions were in place before he (R3) developed a pressure ulcer ...the interventions after he (R3) developed a pressure ulcer were more frequent checks to keep him off of his left side, his bed was turned around, and he is out of bed more often." The Pressure Ulcer Care plan dated 6/30/14 for R3 states, "Assist resident to turn and reposition every 2 hours and as needed or per reposition schedule." The care plan has not been updated to address the history of a left hip wound or specific intervention to prevent reoccurrence. On 12/3/14 at 8:15 AM E2 (Director of Nursing-DON) stated that R3 had a pressure ulcer on his left hip when he was admitted to the facility on [DATE]. E1 stated the left hip pressure ulcer that R3 had on admission has healed and the current pressure ulcer located on R3's left hip was facility acquired. On 12/3/14 and 12/4/14, requests were made to E2 (DON) for R3s October and November treatment records, all applicable (prior to R3's wound development). E2 was asked to provide prevention and treatment interventions implemented for R3's pressure ulcer. No requested documentation was provided prior to survey exit. R3's risk factors for developing pressure were not identified and documented. No documentation was found indicating the R3 was non compliant with turning or positoning, or that he favored his left side. The facility did not document a complete wound assessment of R3's pressure ulcer prior to R3 being seen by the wound doctor on 10/17/14. 3. The Physician order [REDACTED]. The facility nursing re-admission assessment (return from hospital) dated 10/28/14 shows R10 had "redness on buttocks ". No additional assessment or information regarding the redness on the buttocks was documented. The pressure ulcer risk score on 10/28/14 was assessed as 12 (high risk). The Care plan dated 6/9/14 (most recent) for R10 shows she is at risk to develop pressure related to incontinence, confusion, impaired balance and impaired bed mobility. The interventions include applying house stock incontinent barrier cream to peri area with every incontinent episode and as needed, to complete a daily skin check with documentation, providing a pressure relieving device in the wheelchair. The care plan was not updated to address the wound on R10's red buttocks. The treatment record dated 11/1/14 shows R10 received weekly skin checks (not daily). On 11/3/14 it is noted R10 has "Coccyx reddened". The weekly skin checks on 11/10/14 and 11/17/14 also state R10 ' s coccyx is reddened. There is no additional skin assessment regarding the reddened coccyx between 10/28/14 - 11/17/14. There is no skin treatment order documented. The nurses ' notes dated 11/22/14 at 2230 hrs (10:30 PM), states R10 has a " Purple area to coccyx 2.0 cm x 1.0 cm with pinpoint open area. Cleansed with normal saline and covered with dry dressing. " The treatment record on 11/24/14 shows, " Coccyx 4.0 x 2.0, Stage II " . No additional wound assessment is documented. The physician order [REDACTED]. The physician order [REDACTED]. " Review of the November 2014 treatment record shows the first treatment to the coccyx area was not completed until 11/25/14. On 12/3/14 at 2:15 PM, R10 was observed in bed lying on her back. On 12/3/14 at 4:00 PM, E11 and E12 (CNA) assisted R10 to get up into the reclining geriatric wheelchair. R10 was turned to provide incontinence care and no dressing was noted over the coccyx wound. R10 had been incontinent of stool. E11 confirmed the treatment dressing was not in the soiled brief. When incontinence care was completed, barrier cream was not applied. R10 was transferred to the wheelchair. There was no pressure reducing cushion placed under R10. On 12/3/14 at 3:30 PM, E5 (LPN) stated, " I usually do R10 ' s wound treatment each day between 10:30 - 11:00 AM. " The facility policy Decubitus Care/Pressure Areas of 5/2007 states, " The pressure area will be assessed and documented on the treatment administration record. Complete all areas, document size, stage, site, depth, drainage, color, odor and treatment (upon obtaining from physician). " The policy states to " Initiate the (wound) problem on the (resident) care plan. " The Pressure Sore Prevention Guidelines dated 11/2012 states, " Care plan entry; Skin risk and appropriate interventions are to be placed on the care plan. If despite interventions, a pressure ulcer develops, the care plan must reflect updated interventions or healing of ulcers and additional interventions for further prevention of pressure ulcers. "

Based on interview and record review the facility failed to notify the physician that R1 was on anticoagulation medication; failed to notify the physician when pain and a bruise developed on R1's right hip secondary to fall; and failed to notify the Physician when R1 had a signficant change in condition: vomiting, decline in mental status, and pupil changes. These failures resulted in R1 sustaining an [MEDICATION NAME] Hemorrhage, and expiring on 3/18/14. On 6/27 at 4:30PM E1 (administrator) was informed of the Immediate Jeopardy. While the immediacy was removed on 6/27/14 at 10:15 PM, the facility remains out of compliance at Severity Level 2 due to the need to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 1 of 5 residents (R1) reviewed for physician notification of change in condition in the sample of 20. The findings include: R1 ' s Profile Face Sheet shows [DIAGNOSES REDACTED]. The physician's order [REDACTED]. On 6/27/14 at 2:55 PM E9 (Registered Nurse-RN) said that on 3/8/14 at 12:20 AM, R1 fell and hit his head on the bed side table. E9 called Z2 (R1 ' s physician) but she did not tell Z2 that R1 was on [MEDICATION NAME]. R1 ' s 3/8/14 11:30 AM nurses notes shows R1 had purple bruising to his right hip and complained of pain, " especially in the lower back and waistline. " R1 ' s physician was not notified until 3/9/14 at 4:30 PM when a fax transmittal form was sent to Z2 ' s office. On 6/27/14 at 2:38 PM, E7 (Certified Nurse ' s Assistant-CNA) said she cared for R1 on 3/9/14. E7 said she noticed at 4:00 PM that R1 was acting confused and disoriented which was a change in his behavior. E7 reported the changes to E5 RN. E7 states R1 had an emesis at about 8 PM that was reported to E5. R1 threw up again just before 10:00 PM, and this was reported to E5. On 6/27/14 at 2:45 PM E5 (RN) said that R1 started vomiting suddenly before the end of the second shift on 3/9/14. E5 was unsure when the emesis started but said it was the end of the shift around 9:00 or 9:30 PM. E5 did not recall any other changes in R1 ' s condition. E5 said a change in mental status would be a significant change especially after a fall. E5 reported the emesis to the next shift nurse, but did not notify R1 ' s physician. E2 DON (Director of Nursing) states the notification to the doctor should have happened sooner on 3/9/14. E2 states the nurses should have clarified the frequency and type of monitoring, and when to start the neurological flow sheet. Z1 ED (Emergency Department) Physician States any blow to the head of a patient on [MEDICATION NAME] should have a CT head scan the day of the fall. On 3/8/14 at 12:40 AM Z2 MD (Medical Doctor) was notified that R1 fell . Z2 does not recall being notified that R1 had a head injury or was on [MEDICATION NAME], an anticoagulant (blood thinner). Z2 said if he knew about the head injury and the [MEDICATION NAME] that Z2 would have sent R1 to the emergency room immediately. Z3 MD, Medical Director agrees saying, if a resident on [MEDICATION NAME] falls, they should be sent out to be evaluated at the hospital immediately and include imaging of the head. On 3/9/14 at 1:00 PM E4 documented in the nurses notes a bruise on the right hip of R1 with pain. Z2 was not notified until 4:30 PM by Fax, which Z2 states he did not see. Z2 said, that is a significant change in condition and that Z2 would have sent R1 to the emergency room for evaluation. Z2 said the facility knows not to fax him but to call Z2 at the office or use Z2 ' s personal cell phone number. On 3/9/14 at 10:10 PM according to the Nurse ' s notes, R1 had an emesis, sluggish pupils and was not responding to verbal questioning. Z2 was not notified. Z2 considers this a significant change of condition. Z2 states that Z2 or 911 should have been called at that time. Z3 states that sluggish pupils, altered mental status, and answering questions incoherently is a significant change in condition and 911 should be called immediately. Z2 states, when the facility calls me about a pharmacy recommendation for a PT/INR ([MEDICATION NAME] Time / International Normalized Ratio) it would be helpful to know the residents medications, and the last, and next time the lab will be drawn. Z3 states, when I order a lab for a specific time I would expect the facility to call me for approval of a time change. The undated Peterson Health Care, " Notification for Change in Resident Condition or Status " states the facility and/or facility staff shall promptly notify appropriate individuals of changes in the resident ' s medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the resident ' s attending Physician or on-call Physician when there has been any symptom, sign, or apparent discomfort that is sudden in onset, a marked change in relation to usual signs or symptoms unrelieved by measures already prescribed, a significant change in the resident ' s physical/emotional/mental condition. Based on observation, interview, and record review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation. A. March 10, 2014 DON in-serviced staff on Incident Protocol with emphasis on Residents on anticoagulants who fall and hit their heads be sent to the ED for evaluation. B. June 27, 2014 DON was in-serviced on Emergency Care-Head Trauma with specific emphasis on residents prescribed anticoagulants being sent to ED for evaluation by the Regional Clinical Director. C. June 27, 2014 DON was in-serviced on Neurological & Head Trauma Assessment and Documentation by the Regional Clinical director. D. June 27, 2014 was in-serviced on timely notification to MD regarding change in condition. E. June 27, 2014 DON initiated in-servicing for all licensed staff on Neurological and Head Trauma Assessment with specific emphasis on neurological deficits. F. June 27, 2014 DON initiated in-servicing for all licensed staff on Emergency Care-Head Trauma with specific emphasis on residents prescribed anticoagulants sustaining head trauma being sent to ED for evaluation. G. June 27, 2014 To ensure compliance with the Emergency Care-Head Trauma, Neurological and Head Trauma Assessment, and Notification of Change in Condition policy and procedure the facility will : a. Implement the AIM for Wellness Program. b. In-service on appropriate documentation and assessments monthly for 3 months. c. Staff who missed the initial in-service will be in-serviced before working a shift on the floor.

Based on interview and record review, the facility neglected to follow policies and procedures that direct staff to immediately call for emergency services (911) in the case of a medical emergency. Facility staff identified that R1 had a change in mental status on [DATE] at 4:00 PM but R1 was not assessed until [DATE] at 10:10 PM, over 6 hours later. The [DATE], 10:10 PM assessment shows R1 had a decline in mental status, sluggish pupils, and vomiting but emergency services and the physician was not notified until 40 minutes later. The facility neglected to follow the policy to notify the attending physician when a resident (R1) on a blood thinner presented with a decline in mental status following a head injury. The facility failed to follow policies and procedures to provide ongoing neurological assessments for over 45 hours after R1 fell and sustained a head injury while on a blood thinner. These failures resulted in R1 sustaining an [MEDICATION NAME] Hemorrhage, and expiring on [DATE]. On ,[DATE] at 4:30PM E1 (administrator) was informed of the Immediate Jeopardy. While the immediacy was removed on [DATE] at 10:15 PM, the facility remains out of compliance at Severity Level 2 due to the need to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 1 of 3 residents reviewed for falls with head injury in the sample of 20. The findings include: A. The undated policy " Emergency Care " states " Emergency care shall be provided in calm and confident manner in an effort to preserve life, prevent worsening of the situation and promote recovery " ... " Isolate the resident from further injury or worsening of condition ...Notify the physician of the need for emergency care and scope of care provided ...implement 911 for immediate assistance as indicated by the injury or condition " . The Nurses Notes dated [DATE] at 12:40 AM shows R1 fell at 12:20 AM while trying to use the urinal . The [DATE] at 12:40 PM note states " resident hit top of head on night stand. R1 ' s Nurse Notes dated [DATE] at 11:30 AM shows that R1 was noted to have a purple bruise to his right hip related to "recent fall". No assessment was done to look for change in size, swelling, etc. There is no assessment of R1 ' s bruise (size, color, swelling) after [DATE] at 1:00 PM. R1 ' s [DATE] at 10:10 PM Nurse Notes show " Resident had emesis of green bile ...Pupils reactive, but sluggish. Resident not responding to verbal questioning ... " R1 went from " neuro checks WNL " on [DATE] at 11:30 AM to " pupils sluggish, not responding to verbal questioning " on [DATE] at 10:10PM. There is no evidence that R1 ' s physician was notified of his change in condition and emesis. R1 ' s Hospital Neurology " Assessment and Plan dated [DATE] at 11:13 AM shows " [MEDICATION NAME] hemorrhage ...elevated INR was a contributing factor. Patient is unstable ...with a high risk of neurologic deterioration " . R1 ' s [DATE] consultation assessment shows " this is a massive dominant hemisphere hemorrhage ...permanent [MEDICAL CONDITION]; agraphia, alexia and inability to understand his surroundings are more likely of permanent nature as well as the right [MEDICAL CONDITION] " . R1 ' s Hospital Neurology progress assessment notes dated [DATE] at 10:55 AM shows Large left temporal [MEDICATION NAME] hemorrhage with intraventricular extension "due to fall and anticoagulation was supra therapeutic (above therapeutic range) on [MEDICATION NAME]" R1 ' s " Hospital Account/Patient Record " dated [DATE] shows final [DIAGNOSES REDACTED]. The [DATE] document shows R1 expired on [DATE]. On [DATE] at 3:17 PM, E5 (Registered Nurse-RN) said " I remember sending it (fax notification to Z1). E5 said " I don ' t ' recall getting a response " . On [DATE] at 2:22 PM, E7 (Certified Nursing Assistant -CNA) said she noticed R1 was acting different and " he appeared very confused and disoriented, it was a change in his normal condition " . E7 said she noticed the change in R1 around 4:00 PM and told the nurse (E5-RN). E7 said this lasted for about ,[DATE] hours, then (R1) fell asleep, and when he woke up he started throwing up. E7 said R1 appeared agitated, was yelling at the wall, and started " puking " around 8:00 PM, and again around 9:55PM. On [DATE] at 2:45 PM, E5 (RN) said he cared for R1 the evening of [DATE], the night R1 went to the hospital. E5 said R1 " started vomiting suddenly before the end of the shift and when it became apparent the vomiting was repetitive we called 911 " . E5 said R1 started vomiting around 9 or 9:30 PM, before the night shift nurse started her shift. E5 said he would consider a change in mental status a significant change especially if after a fall. There is no evidence of an assessment for R1 during the 2PM to 10PM shift on [DATE] and no evidence that R1 was assessed after the mental status changes were reported by E7. There is no documentation that R1 vomited prior to the 10:10 PM entry by E6 (Licensed Practical Nurse-LPN). On [DATE] at 2:15 PM, E6 (LPN) said she was working the night shift on [DATE]. E6 said she started her shift at 10:00 PM and was told R1 had vomited. E6 said she went to R1 ' s room and R1 ' s " pupils were sluggish, and he was not responding appropriately " . E6 said when asked a question, R1 would start the first part of the sentence ok and then would start saying different words that did not make sense, and he was not able to finish his sentence. E6 said this was not R1 ' s usual behavior. After leaving his (R1) room, E6 said "I went to the kitchen to get him some crackers and Sprite to settle his stomach. It was a little while before I went back to his room because I listened to report on both sides of the facility which takes " awhile " . When I went to his room after report he had thrown up again. E6 said R1 had a " bright green emesis and was looking sideways and incoherent, he was not able to verbally respond to my questions " . E6 said she did not call the physician after the first emesis and change in mental status. E6 said she called 911 after the second emesis and further decline in mental status (40 minutes after the first mental status change was identified). E6 said she did not assess the bump to R1 ' s head either time she was in the room. E6 said she did not assess the bruise on R1 ' s leg because " he had clothes on so I did not see his skin " . R1 ' s [DATE] at 10:45 PM Nurse Notes show " Resident had second emesis of green bile. Speaking more incoherently and not responding appropriately to verbal questions. " R1 ' s [DATE] at 10:50PM Nurse Notes show " 911 notified " and at 11:05 PM, " Fire/ambulance at bedside " . On [DATE] at 3:00 PM, Z1 (Emergency Department Physician) said anytime someone is on a blood thinner, falls, and injures their head they should have a CT scan done immediately to assess the level of injury. Z1 said the assessment changes in R1 (sluggish pupils, (R1) not responding to verbal questioning, and emesis) that occurred on [DATE] at 2210 was a " significant change " and R1 needed emergency services immediately, and physician notification immediately. On [DATE] at 12:30 PM, Z2 (Medical Doctor) said " when (R1) vomited the first time and had the neurological changes the nursing staff should have called me or sent him out to the hospital at that point. I expect someone on [MEDICATION NAME] who falls and hits their head to get a call right away so that person can be sent out immediately for evaluation. " On [DATE] at 11:55 AM, Z3 (Medical Director) said the nurse should have called 911(emergency services) when R1 had sluggish pupils, vomiting, and a change from baseline in his mental status (40 minutes before 911 was called). On [DATE] at 1:45 PM, E2 (Director of Nursing- DON) said emergency services (911) should have been notified immediately after R1 had the first emesis and changes in his mental status at [DATE] at 10:10 PM. E2 said the change in mental status first documented on [DATE] at 10:10 would be considered a significant change. B. The undated facility policy " Notification for Change in Resident Condition or Status " states " The facility and/or facility staff shall promptly notify appropriate individuals ...Physician ...of changes in the resident ' s medical/mental condition and/or status ...The nurse ...will notify the resident ' s attending physician or on-call physician when there has been: a. Any symptom, sign of apparent discomfort that is: 1. Sudden in onset 2. A marked change (i.e. more severe) in relation to usual signs or symptoms ... A significant change in the resident ' s physical/emotional/mental condition; a need to alter the resident ' s medical treatment significantly ... A need to transfer the resident to a hospital/treatment center...abnormal complaints of pain...there is a significant change in the resident's physical, mental, or psychological status..." . On [DATE] at 12:30 PM, Z2 (Medical Doctor) said the bruise to R1 ' s thigh and pain (first documented on [DATE] at 11:30 AM) was a significant change in his condition, and the nurse should have notified Z2 immediately. Z2 was not notified for over 29 hours of the bruise, and was not called but instead faxed notification. Z2 said " falling when on [MEDICATION NAME] and getting a bruise with pain constitutes a significant change and should have been called right away " . Z2 said " when (R1) vomited the first time and had the neurological changes the nursing staff should have called me. I expect someone on [MEDICATION NAME] who falls and hits their head to get a call right away so that person can be sent out immediately for evaluation. " On [DATE] at 9:40 AM, E9 (RN) said she was the nurse caring for R1 the night he fell . E9 said she notified R1 ' s physician (Z2) of the fall and head injury but did not tell Z2 that R1 was on [MEDICATION NAME] (blood thinner). E9 said she did not ask Z2 for an order to check a PT/INR. C. The undated facility " Neuro/Head Trauma Assessment " shows neurological assessments to include blood pressure, temperature, pulse, headache, blurred vision, eyes misaligned, pupils assessment, dizziness, nausea/vomiting, equal hand grasps, ability to move all extremities, level of consciousness, ear and nasal drainage, altered behavior, and [MEDICAL CONDITION] are to be completed every 15 minutes x4, every 30 minutes x 2, every hour x 4, every 4 hours x 8, and every 8 hours for 72 hours. The undated facility policy " Head Trauma " states " It is the policy ...to evaluate head injuries for a minimum period of 72 hours, to determine any negative effects, and to allow for immediate treatment to minimize permanent damage. 8. Ongoing assessment (vital signs and neuro checks) should take place as follows: a. Initially and every 15 min for 1 hour b. Every 30 minutes for 1 hour. c. Every hour for 4 hours. d. Every 4 hours for 8 hours. e. Every shift for the remainder of 72 hours. 9. Assessment for the first 24 hours after injury shall be recorded on the Neuro/head Trauma Assessment form. Additional documentation shall be recorded in the clinical record. 11. Signs of increased cranial pressure must be reported to the physician immediately. Nausea and Vomiting, Diplopia, Lethargy, Elevation of systolic pressure, Eyes crossing, pupils unequal or non-reactive to light, Unable to move or change in strength of an extremity, Loss of consciousness ... On [DATE] at 3:00 PM, Z1 (Emergency Department Physician) said neurological assessments should have been completed at least every two hours for someone on anticoagulants who falls and has head trauma. Z1 said the assessment could have been done more frequently especially since R1 was on anticoagulants. Z1 said R1 was treated in the Emergency Department for a Cerebral Hemorrhage which could be a direct result from R1 hitting his head during the fall. Z1 said R1 ' s condition could have been improved with earlier treatment. On [DATE] at 12:30 PM, Z2 said the facility should follow the Neuro/Head Trauma Assessment sheet if someone falls and hits their head, and document the assessments according to the parameters on the sheet. On [DATE] at 2:00 PM, E4 (Licensed Practical Nurse) said the " Neuro/Head Trauma Assessment " should be completed on all residents who fall and hit their head, or if it is suspected a resident falls and hits their head. E2 said the " Neuro/Head Trauma Assessment " should have been completed after R1 fell according to the facility policy. E2 said this form and assessments should be completed on all residents who have a witnessed head injury or suspected head injury with a fall. E2 said the neurological assessments should be conducted as the sheet specifies: every 15 minutes x4, every 30 minutes x 2, every hour x 4, every 4 hours x 8, and every 8 hours for 72 hours. E2 said R1 did not have a " Neuro/Head Trauma Assessment " completed after his fall. E2 said the " bump " to the top of R1 ' s head should also have been assessed with [REDACTED]. E2 said the bruise to R1's thigh should have assessed at least once a shift until resolved. Based on observation, interview, and record review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation. A. [DATE] DON in-serviced staff on Incident Protocol with emphasis on Residents on anticoagulants who fall and hit their heads be sent to the ED for evaluation. B. [DATE] DON was in-serviced on Emergency Care-Head Trauma with specific emphasis on residents prescribed anticoagulants being sent to ED for evaluation by the Regional Clinical Director. C. [DATE] DON was in-serviced on Neurological & Head Trauma Assessment and Documentation by the Regional Clinical director. D. [DATE] was in-serviced on timely notification to MD regarding change in condition. E. [DATE] DON initiated in-servicing for all licensed staff on Neurological and Head Trauma Assessment with specific emphasis on neurological deficits. F. [DATE] DON initiated in-servicing for all licensed staff on Emergency Care-Head Trauma with specific emphasis on residents prescribed anticoagulants sustaining head trauma being sent to ED for evaluation. G. [DATE] To ensure compliance with the Emergency Care-Head Trauma, Neurological and Head Trauma Assessment, and Notification of Change in Condition policy and procedure the facility will : a. Implement the AIM for Wellness Program. b. In-service on appropriate documentation and assessments monthly for 3 months. c. Staff who missed the initial in-service will be in-serviced before working a shift on the floor.

Based on interview, and record review, the facility failed to provide nursing services by not identifying that a resident on a blood thinner was at high risk for bleeding after a fall with head trauma. The facility failed to complete ongoing neurological assessments for two residents who fell and sustained head trauma. The facility failed to identify a rapidly declining condition and mental status change for R1 and the facility failed to immediately call Emergency Services for a resident having mental status changes. These failures contributed to R1 sustaining an [MEDICATION NAME] Hemorrhage, and expiring on [DATE]. The Immediate Jeopardy was determined to have begun on [DATE] at 12:40 AM. On ,[DATE] at 4:30PM E1 (administrator) was informed of the Immediate Jeopardy. While the immediacy was removed on [DATE] at 10:15 PM, the facility remains out of compliance at Severity Level 2 due to the need to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 2 of 3 residents (R1, R3) reviewed for falls with head injury in the sample of 20. The findings include: 1. The undated facility Profile Face Sheet shows R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of [DATE] shows R1 was cognitively intact and required extensive staff assistance with ambulation, transfers, dressing, toilet use, and personal hygiene. R1 ' s February 2014, Physician order [REDACTED].*** Potential Drug Interaction Form*** " dated [DATE] shows " Anticoagulants/ [MEDICATION NAME] " , Severity level 2, "(International Normalizing Ratio) INR values should be closely monitored during and for several days after the conclusion of concurrent [MEDICATION NAME] or Tinidazole. Anticoagulants may need to be adjusted up to 10 days after concurrent therapy ends. The time of highest risk for a [MEDICATION NAME]-type drug interaction is when the precipitant drug is initiated or discontinued. Contact the prescriber before initiating, altering the dose, or discontinuing either drug " . R1 ' s [DATE] POS shows an order for [REDACTED]. The [DATE] Pharmacy Consultation Report shows " (R1) receives [MEDICATION NAME] and [MEDICATION NAME] (cardiac Medication) concurrently ...Please consider monitoring International Normalizing Ratio (INR) weekly for the first twelve weeks of concurrent therapy and every two weeks thereafter while the medications are co-administered " . On [DATE], Z2 (Medical Physician) documented " has already been ordered " , but the Request for Outpatient Services form shows the [MEDICATION NAME] Time/International Normalizing Ratio (PT/INR) was originally ordered to be drawn on [DATE]. The order was changed to not begin until [DATE]. R1 ' s most recent INR was collected on [DATE], over two weeks before the new order was written. R1' s Fall Risk assessment dated [DATE] identified R1 as being at high risk for falls. The Nurses Notes dated [DATE] at 12:40 AM, shows that R1 fell at 12:20 AM while trying to use the urinal with help from the Certified Nurse Assistant (CNA). The [DATE] at 12:40 PM note states "... During fall res hit top of head on night stand...doctor notified at 0040 (12:40 AM) wants to continue monitoring " . R1's Nurses Notes shows no other assessment of the bump to R1 ' s head prior to being transferred to the emergency roiagnom on [DATE] at 11:45PM. R1 ' s Nurse Notes dated [DATE] at 11:30 AM shows that R1 was noted to have a purple bruise to his right hip related to "recent fall". This note shows R2 was complaining of pain "feeling sore (generalized) ...Neuro checks WNL (within normal limits) " . R1 ' s Nurse Notes of [DATE] at 1:00 PM show R1 complained of right hip on the outside ("skin")..." No assessment was done to look for change in size, swelling, etc. No assessment of R1 ' s bruise (size, color, swelling) after [DATE] at 1:00 PM. On [DATE] at 4:30 PM (29 hours after the bruise and pain were initially noted by nursing staff), a fax notification sent to Z1 which stated " Since (R1) fell on [DATE], he has had pain in his right hip and a bruise on his right hip as well. Can we get an x-ray of his right hip? " On [DATE] at 3:17 PM, E5 (Registered Nurse-RN) said " I remember sending it (fax notification to Z1 on [DATE]). E5 said " I don ' t recall getting a response " . E5 said " if he (Z1) would have faxed back an order, I would have written it on a telephone order form, it would have definitely been on the Physician order [REDACTED]. R1's record had no evidence Z1 received this fax notification, and no evidence an order was written. On [DATE] at 7:15 AM R1 ' s Nurse Notes show " reassessed resident for injury ...no signs of concussion " . The facility's Neuro/Head trauma assessment was not completed after the incident. On [DATE] at 11:30 AM, R1 ' s nurse notes show " neuro checks WNL " . No other neurological assessment was documented until [DATE] at 10:10 PM, over 35 hours later. R1 ' s next assessment, on [DATE] at 10:10 PM in the Nurse Notes show, " Resident had emesis of green bile ...Pupils reactive, but sluggish. Resident not responding to verbal questioning ... " R1 went from normal neuro checks on [DATE] at 11:30 AM to " pupils sluggish, not responding to verbal questioning " on [DATE] at 10:10PM. R1's Nurses Notes have no evidence that R1 ' s physician was notified of his change in condition and emesis. R1 ' s [DATE] Nurse Notes at 10:45 PM show, " Resident had second emesis of green bile. Speaking more incoherently and not responding appropriately to verbal questions." R1 ' s [DATE] at 10:50PM Nurse Notes show " 911 notified " and at 11:05 PM, " Fire/ambulance at bedside " . On [DATE] at 8:55 AM Z4 (Confidential Interview) said she called to talk to R1 on Saturday "[DATE]th" in the "afternoon". Z4 said "I tried to call and check on him and couldn't understand him". On [DATE] at 2:40 PM, E8 (Certified Nurse Assistant -CNA) said she was with R1 when he fell . E8 said R1 was alert and oriented, and put his call light on for help to use the urinal. E8 said R1 was sitting on the side of the bed, and leaned to the side to read his clock. E8 said after R1 fell , he was alert and oriented, and did not have any complaints. On [DATE] at 1:40 PM, E9 (CNA) said she cared for R1 between [DATE] and [DATE]. E9 said R1 " didn ' t feel good, and we reported it to the nurses " . E9 said R1 had his tray brought to his room during that time, " but he did not eat, he did not feel well " . On [DATE] at 2:22 PM, E7 (CNA) said she cared for R1 on [DATE] for the 2:00PM to 10:00 PM shift. E7 said she noticed R1 was acting different and " he appeared very confused and disoriented, it was a change in his normal condition " . E7 said she noticed the change in R1 around 4:00 PM and told the nurse (E5-RN). E7 said " I was standing on the right side of (R1) and he was looking to the left wall, yelling, and trying to answer me " . E7 said this lasted for about ,[DATE] hours, then (R1) fell asleep, and when he woke up he started throwing up. E7 said R1 appeared agitated, was yelling at the wall, and started " puking " around 8:00 PM, and again around 9:55PM. On [DATE] at 2:45 PM, E5 (RN) said he cared for R1 the evening of [DATE], the night R1 went to the hospital. E5 said R1 " started vomiting suddenly before the end of the shift and when it became apparent the vomiting was repetitive we called 911 " . E5 said R1 started vomiting around 9 or 9:30 PM, before the night shift nurse started her shift. E5 said he would consider a change in mental status a significant change especially if after a fall. There is no evidence of an assessment for R1 during the 2PM to 10PM shift on [DATE] and no evidence that R1 was assessed after the mental status changes were reported by E7. There is no documentation that R1 vomited prior to the 10:10 PM entry by E6 (Licensed Practical Nurse-LPN). On [DATE] at 2:15 PM, E6 (LPN) said she was working the night shift on [DATE]. E6 said she started her shift at 10:00 PM and was told R1 had vomited. E6 said she went to R1 ' s room and R1 ' s " pupils were sluggish, and he was not responding appropriately." E6 said when asked a question, R1 would start the first part of the sentence ok and then would start saying different words that did not make sense, and he was not able to finish his sentence. E6 said this was not R1 ' s usual behavior. After leaving his (R1) room, E6 said " I went to the kitchen to get him some crackers and Sprite to settle his stomach. It was a little while before I went back to his room because I listened to report on both sides of the facility which takes " awhile " . When I went to his room after report he had thrown up again. E6 said R1 had a " bright green emesis and was looking sideways and incoherent, he was not able to verbally respond to my questions " . E6 said she did not call the physician after the first emesis and change in mental status. E6 said she called 911 after the second emesis and further decline in mental status (40 minutes after the first mental status change was identified). E6 said she did not assess the bump to R1 ' s head either time she was in the room. E6 said she did not assess the bruise on R1 ' s leg because " he had clothes on so I did not see his skin " . On [DATE] at 9:40 AM, E9 (RN) said she was the nurse caring for R1 the night he fell . E9 said R1 was alert and oriented, was not impaired or disoriented and was " a reliable source of information " . E9 said she notified R1 ' s physician (Z1) of the fall and head injury but did not tell Z1 that R1 was on [MEDICATION NAME] (blood thinner). E9 said she did not ask Z1 for an order to check a PT/INR. R1 ' s emergency room documentation dated [DATE] shows R1 was seen for " Cerebral Hemorrhage " . This document shows " was seen at approximately 11:29 PM ...transferred from nursing home because he vomited twice and they also report he is (not acting right). He fell and struck his head yesterday against a dresser but unknown whether he really had any type of medical assessment ...resident is unable to follow verbal questions and incoherent speech " . The untimed [DATE] Radiology Report at Emergengy room [ROOM NUMBER], shows R1 ' s head Computerized Tomography (CT) scan without contrast showed " 7.2 x 3.00 cm acute bleed left temporoparietal parenchymal and moderate surrounding [MEDICAL CONDITION] ...There is moderate mass effect in the left hemisphere with 7mm of midline left to right midline shift. ". The [DATE] emergency room Report shows " I (Emergency Physician) went and reevaluated the patient. He had a significant change in his condition. He is no longer able to move his left side. He now has a left side facial droop and he is no longer able to speak. The patient was then electively intubated due to the acute change in his status ...Primary Impression: [MEDICATION NAME] hemorrhage ...Transferred to (a different hospital for a higher level of care) " R1 ' s [DATE] at 12:17AM emergency room PT/INR shows a CRITICALLY HIGH LEVEL of 11.7. The [DATE] lab report shows an expected INR range for someone on [MEDICATION NAME] therapy as 2.0- to 3.0. R1 ' s head CT scan (at emergency room #2) without contrast, dated [DATE] at 0709 shows "Impression: " worsening large let temporoparietal intraparenchymal hemorrhage and mass effect ...increased midline shift and uncal herniation " . R1 ' s PT/INR drawn on [DATE] at 0338 was a " critical high " at 10.2 (normal 0.9 -1.1). R1 ' s [MEDICATION NAME] Time (PT) was 124.4 (normal 10XXX,[DATE].6 seconds). R1 ' s hospital Neurology " Assessment and Plan " dated [DATE] at 11:13 AM shows " [MEDICATION NAME] hemorrhage ...elevated INR was a contributing factor. Patient is unstable ...with a high risk of neurologic deterioration " . R1 ' s [DATE] consultation assessment shows " this is a massive dominant hemisphere hemorrhage ...permanent [MEDICAL CONDITION]; agraphia, alexia and inability to understand his surroundings are more likely of permanent nature as well as the right [MEDICAL CONDITION] " . R1 ' s Neurology progress notes assessment dated [DATE] at 10:55 AM shows: Large left temporal [MEDICATION NAME] hemorrhage (bleeding into brain tissue) with intraventricular extension "due to fall and anticoagulation was supra therapeutic (above therapeutic range) on [MEDICATION NAME]" R1 ' s " Hospital Account/Patient Record " dated [DATE] shows final [DIAGNOSES REDACTED]. The [DATE] document shows R1 expired on [DATE]. On [DATE] at 3:00 PM, Z1 (Emergency Department Physician) said anytime someone is on a blood thinner, falls, and injures their head they should have a CT scan done immediately to assess the level of injury. Z1 said R1 should have had a CT scan done the day of his fall and neurological assessments should have been completed at least every two hours. Z1 said the assessment could have been done more frequently especially since R1 was on anticoagulants. Z1 said the assessment changes in R1 (sluggish pupils, not responding to verbal questioning, and emesis) that occurred on [DATE] at 10:10 PM was a " significant change " and R1 needed emergency services immediately, and physician notification immediately. Z1 said R1 was treated in the Emergency Department for a Cerebral Hemorrhage which could be a direct result from R1 hitting his head during the fall. Z1 said R1 ' s condition could have been improved with earlier treatment. Z1 said as soon as R1 had condition changes, including the change in mental status and vomiting, he should have been sent to the emergency room and his condition could have been improved. Z1 said R1 ' s outcome could have been prevented had he had treatment immediately. On [DATE] at 11:55 AM, Z3 (Medical Director) said if a resident is on [MEDICATION NAME], falls and hits their head, the nurse should notify the physician the resident is on [MEDICATION NAME]. Z3 said if a resident is on [MEDICATION NAME] and falls and hits their head the physician should be notified immediately and the resident sent for emergency evaluation to include imaging of the head. Z3 said neurological assessments should be performed on a resident who falls and hit their head by the nursing staff every hour for 24 hours, and then at least every 4 hours for another 24 hours to determine any changes in assessment from the residents ' baseline. Z3 said any changes in a residents ' baseline assessment in level of consciousness, speech pattern, thought process, or presence of nausea or vomiting would be a significant change and would require immediate physician notification. Z3 said the nurse should have called 911(emergency services) when R1 had sluggish pupils, vomiting, and a change from baseline in his mental status (40 minutes before 911 was called). On [DATE] at 12:30 PM, Z2 (Medical Doctor) said the bruise to R1 ' s thigh and pain was a significant change in his assessment, and the nurse should have notified Z2 immediately. Z2 said " falling when on [MEDICATION NAME] and getting a bruise with pain constitutes a significant change and should have been called right away " . Z2 said " when (R1) vomited the first time and had the neuro changes the nursing staff should have called me or sent him out to the hospital at that point. I expect someone on [MEDICATION NAME] who falls and hits their head to get a call right away so that person can be sent out immediately for evaluation. " Z2 said the facility should follow the Neuro Assessment sheet if someone falls and hits their head, and document the assessments according to the parameters on the sheet. On [DATE] at 2:00 PM, E4 (Licensed Practical Nurse- LPN) said the " Neuro/Head Trauma Assessment " should be completed on all residents who fall and hit their head, or if it is suspected a resident falls and hits their head. On [DATE] at 12:50 PM, E10 (LPN) said if a resident is on a blood thinner and they fall and hit their head the nurses " call 911 and send the resident to the ER immediately, no matter what " . On [DATE] at 1:45 PM, E2 (Director of Nursing- DON) said " continue monitoring " should have been clarified when the nurse initially notified the physician of R1 ' s fall. E2 said how often to assess the resident, and what type of assessments should have been identified instead of "continue monitoring " . E2 said the "Neuro/Head Trauma Assessment" should have been completed after R1 fell according to the facility policy. E2 said this form and assessments should be completed on all residents who have a witnessed head injury or suspected head injury with a fall. E2 said this should also be completed even if the resident is evaluated in the Emergency Department for injuries. E2 said the neurological assessments should be conducted as the sheet specifies: every 15 minutes x4, every 30 minutes x 2, every hour x 4, every 4 hours x 8, and every 8 hours for 72 hours. E2 said R1 did not have a " Neuro/Head Trauma Assessment " completed after his fall. E2 said the " bump " to the top of R1 ' s head should also have been assessed with [REDACTED]. E2 said emergency services and the physician should have been notified immediately after R1 had the first emesis and changes in his mental status. E2 said the change in mental status first documented on [DATE] at 10:10 would be considered a significant change. On [DATE] at 8:50 PM, Z5 said the facility protocol is to send a resident who falls and hits their head to the emergency room (ER) for evaluation. Z5 said if the physician is notified and says not to send the resident to the emergency room , the nurse should tell the physician it is the facility policy to send to the ER, and send the resident anyway. 2. R3 ' s Nurse Notes dated [DATE] at 7:00 PM show " Took a step back and fell back. Landed on Bottom and rolled back. Head touched a chair ...911 ambulance called " . R3 ' s Nurse Notes show an assessment on [DATE] at 0215 (2:15 AM). Another assessment was not documented until ,[DATE] at 1:30 PM, over 11 hours later. On [DATE] at 7:30 PM, E2 said R3 did not have a completed " Neuro/Head Trauma Assessment " . E2 said even if a resident is evaluated at the hospital, they still need to have a " Neuro/Head Trauma Assessment " completed according to the time frames listed on the form (every 15 minutes x4, every 30 minutes x 2, every hour x 4, every 4 hours x 8, and every 8 hours for 72 hours). E2 said the assessment should be initiated from the time the resident returns to the facility. The undated facility " Neuro/Head Trauma Assessment " shows neurological assessments to include blood pressure, temperature, pulse, headache, blurred vision, eyes misaligned, pupils assessment, dizziness, nausea/vomiting, equal hand grasps, ability to move all extremities, level of consciousness, ear and nasal drainage, altered behavior, and [MEDICAL CONDITION] are to be completed every 15 minutes x4, every 30 minutes x 2, every hour x 4, every 4 hours x 8, and every 8 hours for 72 hours. The undated facility policy " Head Trauma " states " It is the policy ...to evaluate head injuries for a minimum period of 72 hours, to determine any negative effects, and to allow for immediate treatment to minimize permanent damage. Ongoing assessment (vital signs and neuro checks) should take place as follows: Initially and every 15 min for 1 hour; Every 30 minutes for 1 hour; Every hour for 4 hours; Every 4 hours for 8 hours; Every shift for the remainder of 72 hours. Assessment for the first 24 hours after injury shall be recorded on the Neuro/head Trauma Assessment form. Additional documentation shall be recorded in the clinical record. Signs of increased cranial pressure must be reported to the physician immediately. Nausea and Vomiting, Diplopia, Lethargy, Elevation of systolic pressure, Eyes crossing, pupils unequal or non-reactive to light, Unable to move or change in strength of an extremity, Loss of consciousness ... " The undated policy " Emergency Care " states " Emergency care shall be provided in calm and confident manner in an effort to preserve life, prevent worsening of the situation and promote recovery " ... " Isolate the resident from further injury or worsening of condition ...Notify the physician of the need for emergency care and scope of care provided ...implement 911 for immediate assistance as indicated by the injury or condition " . The undated facility policy " Notification for Change in Resident Condition or Status " states " The facility and/or facility staff shall promptly notify appropriate individuals ...Physician ...of changes in the resident ' s medical/mental condition and/or status ...The nurse ...will notify the resident ' s attending physician or on-call physician when there has been any symptom, sign of apparent discomfort that is: Sudden in onset; a marked change (i.e. more severe) in relation to usual signs or symptoms ...; A significant change in the resident ' s physical/emotional/mental condition; a need to alter the resident ' s medical treatment significantly ... Based on observation, interview, and record review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation. A. [DATE] DON in-serviced staff on Incident Protocol with emphasis on Residents on anticoagulants who fall and hit their heads be sent to the ED for evaluation. B. [DATE] DON was in-serviced on Emergency Care-Head Trauma with specific emphasis on residents prescribed anticoagulants being sent to ED for evaluation by the Regional Clinical Director. C. [DATE] DON was in-serviced on Neurological & Head Trauma Assessment and Documentation by the Regional Clinical director. D. [DATE] was in-serviced on timely notification to MD regarding change in condition. E. [DATE] DON initiated in-servicing for all licensed staff on Neurological and Head Trauma Assessment with specific emphasis on neurological deficits. F. [DATE] DON initiated in-servicing for all licensed staff on Emergency Care-Head Trauma with specific emphasis on residents prescribed anticoagulants sustaining head trauma being sent to ED for evaluation. G. [DATE] To ensure compliance with the Emergency Care-Head Trauma, Neurological and Head Trauma Assessment, and Notification of Change in Condition policy and procedure the facility will : a. Implement the AIM for Wellness Program. b. In-service on appropriate documentation and assessments monthly for 3 months. c. Staff who missed the initial in-service will be in-serviced before working a shift on the floor.

Based on observation, interview, and record review staff willfully neglected to assist and protect a confused resident who was caught in bed linens and hanging off the side of her bed while taking a picture and then video taping the resident. This failure resulted in a resident being left in an unsafe situation for an undetermined amount of time, without intervention. These failures resulted in an immediate Jeopardy that was identified on 11/30/2011. It began on August 28, 2011. The Immediacy was removed on 12/02/2011. The facility remains out of compliance at a level 2 due to the need for the facility to assure assistance is provided to residents who need intervention to prevent injury. This applies to 1 of 3 residents (R3) reviewed for supervision in the sample of 9. The findings include: On 11/23/2011 at 9:00 AM, Z1 said a telephone memory card (SD)was found outside of the facility. Z1 said the SD card belonged to E15 (Certified Nursing Assistant - CNA). Z1 said the card was reviewed and a video of R3 was seen. Z1 said the video showed R3 "about ready to fall off the bed". It was said the resident's head was no more than 12-16 inches from the floor. Z1 said the only thing keeping R3 from falling on the floor, face and head first, were the blankets. Z1 said the resident's bed linens were tucked in the bed. The interviewee said, "It is almost as if it was staged." Z1 said there is audio and shows R3's roommate, R4, asking if R3 is all right. Z1 said the entire time R3 was hanging off the bed, E15 was saying 'good morning (R3), good morning beautiful'. Z1 said, "I was floored when I saw what went on!" Z1 said he showed the video to E8 (housekeeping supervisor), E2 (Director of Nursing), and E1 (Administrator). Z1 said, " (E2) was shocked. She said 'she's fired'!" The interviewee said, "When E1 saw the video she said nothing except asked who the CNA was. (E1) took the SD card. Z1 said, "It is not acceptable to take pictures of residents. Even more disturbing and weird was that E15 took videos of (R3)." On 11/23/2011 at 10:10 AM, R4 was interviewed. The resident was able to answer questions of orientation (date, time, name). R4 was asked if she had ever seen staff take pictures of other residents or if staff had taken pictures of her. R4 said, "One morning E15 came into our room. (R3) was hanging out of bed and E15 was taking pictures of her. I asked why she (E15) was doing that. (E15) put her finger to her mouth and said 'shhh don't tell any one'. I thought it was weird. She used to work 2nd and 3rd shift. She doesn't work here any more." R4 said E9 (CNA) was working the 3rd shift that night with E15. On 11/23/2011 at 3:45 PM, the SD card was viewed with Z3 and E1 present. A video time stamped 8/28/2011 was viewed. The length of the video is 41 seconds. R3 was observed with her sheet and blanket tucked under the mattress. The sheet and blanket were neatly folded over, just under her chin. Her arms were secured within the bed linens, restricting her movement. The resident's call light is observed to be on the floor. The resident's body is off of the bed. Her head appears to be resting on the metal frame, that supports the mattress of the bed. There is a nightstand within 12 inches of R3's head. R3 is held in the described position by the tucked - in bed linens, creating an unsafe situation. If the bed linens would have become untucked, R3 would have rolled onto the floor, between the nightstand and the bed, potentially striking her head on the corner of the nightstand. The floor does not have a fall mat next to the bed. The resident's head appears to be approximately 1 foot off of the floor. R3 was hanging off of her bed for an undetermined amount of time. While shooting the 41 second video of R3 hanging off of the bed, E15 would zoom in closely on R3's face. E15 repeatedly called out R3's name, without taking any action to protect the resident from injury. During the video, R15 panned the camera to shoot video of R3's roommate (R4). R4 could be heard saying, "Is she okay? Oh God!" E15 responded by saying, "She should be all right." R3's color appeared ashen and she exhibited no movement. It is not known how long R3 hung off of the bed prior to the video footage and after the video taping. R3's MDS of 8/22/11 shows the resident is cognitively impaired. She requires assistance with transfers, ambulation, dressing, eating, and bathing. On 11/23/2011 at 10:00 AM, R3 was interviewed. The resident was not able to answer questions of orientation (date, time, place). R3's undated Abuse Care Plan shows she is at risk for abuse because of impaired cognition, dependence on others, medication, other wandering residents, and frailty. On 11/30/2011 interviews were done with E1 (8:30 AM) , E11 & E12 (Licensed Practical Nurses - @ 8:35 AM), and E13 & !4 (Certified Nursing Assistants @ 8:40 AM). All interviewees said that if a resident is found hanging out of bed, staff should immediately ensure the resident's safety and get them back into bed. The facility's Abuse Prevention Program (11/11/11) defines Neglect as the failure to provide, or willful withholding of...personal care or assistance with activities of daily living that is necessary to avoid physical harm..." The policy states, "Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment...This also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain and/or maintain physical, mental, and psychological well being..." On 11/30/2011 at 11:15 AM the facility administrator was notified of the immediate jeopardy. Through record review and interview the surveyor confirmed the facility took the following actions to remove the immediacy: ? E15 resigned from the facility as of 10/25/2011 ? 11/23/2011, 11/25/2011, and 11/30/2011 Staff were educated on the facility's Abuse and Neglect Policy and Procedure ? 11/30/2011 Staff were educated on the facility's "reporting policy and procedure". A background check audit was conducted of all staff to ensure resident safety. ? R3 has been monitored since 11/23/2011 for signs and symptoms of decline/distress. ? 11/23/2011, 11/25/2011, and 11/30/2011 Staff received education, given by the administrator, on the facility's cell phone policy and procedure. Education will continue 4 times annually. ? On 11/23/2011 Quality Assurance measures have been implemented to ensure staff compliance by: 1. Inservicing staff quarterly on the facility Abuse and Neglect Policy and Procedure for one calendar year and on a regular basis thereafter. 2. Quarterly staff will be inserviced on the reporting policy from the Abuse policy, for one calendar year and on a regular basis thereafter. 3. Background checks will be audited by Corporate Regional Director for 6 consecutive months, and randomly thereafter. 4. Once each quarter staff will be inserviced on cell phone policy and procedure for one calendar year, and randomly there after. 5. Once each quarterly staff will be in-serviced on the reporting policy and procedure from the Abuse Policy, including but not limited to reporting suspicious activities, and randomly thereafter. 6. The system will be monitored and changes will be made as appropriate to the system and education will be provided as necessary on an ongoing basis. 7. The Medical Director approved the removal plan.

Based on observation, interview, and record review the facility failed to ensure a resident's safety by not immediately assisting a resident who was hanging off the edge of her bed and who was in danger of falling on 8/26/2011. These failures resulted in an immediate Jeopardy that was identified on 11/30/2011. It began on August 28, 2011. The Immediacy was removed on 11/23/2011. The facility remains out of compliance at a level 2 due to the need for the facility to assure assistance is provided to residents who need intervention to prevent injury. This applies to 1 of 3 residents (R3) reviewed for supervision in the sample of 9. The finding includes: On 11/23/2011 at 9:00 AM, Z1 said a telephone memory card (SD)was found outside of the facility. Z1 said the SD card belonged to E15 (Certified Nursing Assistant - CNA). Z1 said the card was reviewed and a video of R3 was seen. Z1 said the video showed R3 "about ready to fall off the bed". It was said the resident's head was no more than 12-16 inches from the floor. Z1 said the only thing keeping R3 from falling on the floor, face and head first, were the blankets. Z1 said the resident's bed linens were tucked in the bed. The interviewee said, "It is almost as if it was staged." Z1 said there is audio and shows R3's roommate, R4, asking if R3 is all right. Z1 said the entire time R3 was hanging off the bed, E15 was saying 'good morning (R3), good morning beautiful'. Z1 said, "I was floored when I saw what went on!" Z1 said he showed the video to E8 (housekeeping supervisor), E2 (Director of Nursing), and E1 (Administrator). Z1 said, " (E2) was shocked. She said 'she's fired'!" The interviewee said, "When E1 saw the video she said nothing except asked who the CNA was. (E1) took the SD card. Z1 said, "It is jot acceptable to take pictures of residents. Even more disturbing and weird was that E15 took videos of (R3)." A confidential interviewee said the administrative staff were told not to say anything about the videos on the SD card. On 11/23/2011 at 10:10 AM, R4 was interviewed. The resident was able to answer questions of orientation (date, time, name). R4 was asked if she had ever seen staff take pictures of other residents or if staff had taken pictures of her. R4 said, "One morning E15 came into our room. (R3) was hanging out of bed and E15 was taking pictures of her. I asked why she (R15) was doing that. (E15) put her finger to her mouth and said 'shhh don't tell any one'. I thought it was weird. R4 said there were no other staff members in the room at the time of the incident. She used to work 2nd and 3rd shift. She doesn't work here any more." R4 said E9 (CNA) was working the 3rd shift that night with E15. On 11/23/2011 at 10:30 AM, E9 was interviewed. She said she had never seen videos or pictures of residents, that were taken by CNAs. E9 said resident's are never put to bed with the sheets and blankets tucked under the mattress. E9 said, "I would consider that a restraint." On 11/23/2011 at 12:35 PM, a confidential interviewee said she saw the video E15 took of R3. I saw (R3) hanging off the bed, she looked dead! She was wrapped like a cocoon. The video showed R3's roommate, (R4). She was talking on the video. I was told the SD card was given to E1 and she gave the card to her boss. The interviewee said E2 and E6 (Minimum Data Set Coordinator) were told to 'keep it to themselves'. On 11/23/2011 at 1:00 PM, E8 said she saw the video of R3. E8 said she did not know who took the video or exactly what was on the video due to her poor vision. E8 said the SD card was shown to E1, who gave it to the corporate nurse, Z3. On 11/23/2011 at 1:05 PM, E2 said she was aware of the video of R3. E2 said, "As soon as I saw it I immediately took the SD card to E1." E2 said, "All I saw was (R3) laying in bed. It is not appropriate for staff to take pictures of residents. The staff are not to have cell phones in the building. What would possess someone to do that? It is an invasion of privacy. I don't know if there was an investigation into the video. (E1) handles all abuse allegations. (E15) had given her 2 weeks notice prior to the discovery of the videos. I called her and told her we no longer needed her services. Her last day of employment here was 9/29/2011. I was instructed not to discuss the video with her. I don't know if she is working somewhere else. I was not specifically told to keep quiet, but I wouldn't speak of this with other staff. On 11/23/2011 at 1:25 PM, E1 said she viewed the SD card. She said she heard a female voice. She said the SD card had been found outside of the facility. E1 said Z3 (Corporate Nurse) has the SD card. E1 said she saw R3 laying on the side of the bed. E1 said, "I don't remember her off of the bed, but at the edge of the bed. I was disturbed. The person taking the videos did not have permission to take the pictures. I didn't talk to E15 because I have no proof it belonged to her. I didn't want to make a big deal of it." On 11/23/2011 at 3:30 PM, Z3 (Corporate Registered Nurse) brought the SD card to the facility. She said she had had the card for approximately 1 week. She said she did not have a way to view the SD card. On 11/23/2011 at 3:45 PM, the SD card was viewed with Z3 and E1 present. E1 verified pictures of E15 on the SD card. A video time stamped 8/28/2011 was viewed. The length of the video is 41 seconds. R3 was observed with her sheet and blanket tucked under the mattress. The sheet and blanket were neatly folded over, just under her chin. Her arms were secured within the bed linens, creating a restrictive environment. The resident's call light is observed to be on the floor. The resident's body is off of the bed. Her head appears to be resting on the metal frame, that supports the mattress of the bed. R3 is held in the described position by the tucked - in bed linens, creating an unsafe situation. If the bed linens would have become untucked, R3 would have rolled onto the floor. The floor does not have a fall mat next to the bed. The resident's head appears to be approximately 1 foot off of the floor. R3 was hanging off of her bed for an undetermined amount of time. R3's MDS of 8/22/11 shows the resident is cognitively impaired. She requires assistance with transfers, ambulation, dressing, eating, and bathing. On 11/23/2011 at 10:00 AM, R3 was interviewed. The resident was not able to answer questions of orientation (date, time, place). R3's Falls Careplan (8/22/11) shows she is a fall risk. The facility's Resident Incident Log shows R3 has fallen 5 times between 5/2011 and 11/2011. On 11/30/2011 interviews were done with E1 (8:30 AM) , E11 & E12 (Licensed Practical Nurses - @ 8:35 AM), and E13 & !4 (Certified Nursing Assistants @ 8:40 AM). All interviewees said that if a resident is found hanging out of bed, staff should immediately ensure the resident's safety and get them back into bed. All interviewees verified staff should never take pictures or videos of residents because it is an invasion of their privacy. The facility's Fulfilling Fall Prevention Responsibilities document (undated) states, All Staff : Know resident fall status (high risk); Know resident strengths/weakness with regard to fall risk; Take a final look before leaving each room each time for safety concerns...Remove potential hazards from resident access..." On 11/30/2011 at 8:30 AM, E1 said she contacted E15 on 11/25/2011, regarding the SD card. E15 said, "If you knew it was my card why didn't you give it back to me? I can't talk to you anymore about this I have to go to dinner with my boyfriend. On 11/30/2011 at 11:15 AM the facility administrator was notified of the immediate jeopardy. Through record review and interview the surveyor confirmed the facility took the following actions to remove the immediacy: ? 11/23/2011 R3 has been monitored for signs and symptoms of decline/distress. ? 11/30/2011 Administrator educated staff on the facility accident and incident policy and procedure, including resident positioning and mobility. ? 11/23/2011, 11/25/2011, and 11/30/2011 The administrator educated staff on reporting suspicious activities for immediate investigation. Education will continue 4 times a year. ? 11/23/2011, 11/25/2011, and 11/30/2011 Staff received education, given by the administrator, on the facility's cell phone policy and procedure. Education will continue 4 times annually. ? 11/30/2011 The administrator educated staff on the Health Insurance Portability and Accountability Act (HIPPA). ? 11/23/2011 A systematic review of the facility's Accident and Incident Policies and Procedures was done to ensure regulatory compliance. ? 11/23/2011 Quality Assurance measures have been implemented to ensure staff compliance with the facility's Accident and Incident Policies and Procedures and HIPPA by providing education on a quarterly basis. ? 12/14/2011 The Medical Director will review all Illinois Department of Public Health reportables on a quarterly basis.

Based on observation, interview, and record review the facility administrator failed to ensure policies and procedures regarding cellular phone use, staff conduct, resident abuse, and resident rights were implemented after a cell phone memory card was found showing staff mentally abusing and neglecting 3 residents. These failures resulted in an immediate Jeopardy that was identified on 11/30/2011. It began on August 28, 2011. The Immediacy was removed on 12/02/2011. The facility remains out of compliance at a level 2 due to the need for the facility to assure policies and procedures regarding cellular phone use, staff conduct, resident abuse, and resident rights are implemented and followed. This applies to 3 of 9 residents (R1, 2, & R3) reviewed for abuse in the sample of 9. The findings include: On 11/23/2011 at 9:00 AM, Z1 said a telephone memory card (SD)was found outside of the facility. Z1 said the SD card belonged to E15 (Certified Nursing Assistant - CNA). Z1 said the card was viewed on a cellular phone. On 11/23/2011 at 1:05 PM, E2 said she was aware of the video of R3. E2 said, "As soon as I saw it I immediately took the SD card to E1." E2 said, "All I saw was (R3) laying in bed. It is not appropriate for staff to take pictures of residents. The staff are not to have cell phones in the building. What would possess someone to do that? It is an invasion of privacy. I don't know if there was an investigation into the video. (E1) handles all abuse allegations. (E15) had given her 2 weeks notice of employment termination prior to the discovery of the videos. I called her and told her we no longer needed her services. Her last day of employment here was 9/29/2011. I was instructed not to discuss the video with her. On 11/23/2011 at 1:25 PM, E1 said she was aware of video that had been taken of R3. She said the SD card had been found outside of the facility by E3 (Maintenance). E1 said she viewed the SD card on E3's cellular phone. E1 said Z3 (Corporate Nurse) has the SD card. E1 said she saw R3 laying on the side of the bed. E1 said, "I don't remember her off of the bed, but at the edge of the bed. I was disturbed. The person taking the videos did not have permission to take the pictures. The staff are not supposed to have their cellular telephones in the building. I didn't talk to E15 because I have no proof it belonged to her. I didn't want to make a big deal of it." E1 said she did review with staff the policy and procedure regarding cellular phone use while in the facility, after the discovery of the memory card. E1 said she did not do an investigation of the incident and did not notify the state agency, the resident's physicians, or their families. E1 said she did not interview any residents or staff who may have been witness to the incidents. E1 said she did not interview E15 because she no longer works at the facility. E1 said, "I didn't even think about why the SD card was out of the cellular phone it was in, or that there might be pictures of other residents on the SD card. I did not notify the registry of R15's termination of employment with the facility." On 11/23/2011 at 3:30 PM, Z3 (Corporate Registered Nurse) brought the SD card to the facility. She said she had had the card for approximately 1 week. She said she did not have a way to view the SD card. On 11/23/2011 at 3:45 PM, the SD card was viewed with Z3 (Corporate Registered Nurse) and E1 present. While viewing various pictures on the SD card, E1 verified pictures of E15 and her sister on the SD card. E1 concluded the SD card belonged to E15. A video time stamped 8/28/2011 was viewed. The length of the video is 41 seconds. R3 was observed with her sheet and blanket tucked under the mattress. The resident's body is completely off of the bed. Another video time stamped 9/18/2011 was observed. R1 & R2 were video taped at 4:30 AM while E15 (Certified Nursing Assistant) was trying to wake them up by pulling bed linens off R2's head, and video of his exposed legs. E15 took close up frames of R1 & R2 sleeping in their wheel chairs and video of E15 pulling R1's nose, shaking his chin, and tapping him on the sides of his face. On 11/23/2011, after viewing the videos, E1 said she had not previously seen all of the videos. E1 said, "I had no way to view the SD card. If I had seen all of those videos I would have done an investigation ." The facility's Administrator job description states, "The Administrator is responsible for directing day-to-day functions of the facility in accordance with current federal, states, and local standards, guidelines and regulations that govern long term care facilities to assure that appropriate care is provided for the residents in the facility. The Administrator is responsible for delegating the administrative authority, responsibility necessary for carrying out the assigned duties." The job description states the Administrator has responsibilities which include administrative functions. Some of those functions are as follows: a. Plan, develop, organize, implement and direct the facility's programs and activities b. Maintain written policies and procedures that govern the operation of the facility. c. Assist department managers in the use of departmental policies and procedures e. Interpret the policies and procedures to employees, residents, family members, visitors, government agencies, etc. as necessary. f. ensure that all employees, residents and visitors follow established policies and procedures j. Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed n. Ensure that appropriate policies and procedures are followed when conducting background checks and when providing information to the Nurse Aide Registry. Other Administrator responsibilities are staff development and safety (personnel, visitor, resident), and resident rights. The facility Employee Handbook (1/1/2001) states, "Personal phone calls should be made or received only when an emergency occurs or on your breaks...No personal cell phone use is allowed in the facility." The Residents' Rights for People in Long Term Care Facilities, given to each of the resident when admitted to the facility states, "Your facility must provide services to keep your physical and mental health, and sense of satisfaction with yourself, at their highest practical levels...You must not be abused by anyone - physically, verbally, mentally, or sexually...Your medical and personal care are private..." The facility's Abuse Prevention Program (11/11/11) states, "This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment..." The policy documents, "Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation." The Abuse Prevention Program defines Neglect as the failure to provide, or willful withholding of...personal care or assistance with activities of daily living that is necessary to avoid physical harm..." The policy states, "Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment...This also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain and/or maintain physical, mental, and psychological well being..." The Abuse Program states,"The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), otherwise the report must be made no later than 24 hours after forming the suspicion. A written report shall be sent to the Department of Public Health... The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment, neglect, and abuse of resident and misappropriation of resident property and that an investigation is being conducted..." The Investigation Procedures states: "Regardless of the specific nature of the allegation (physical, sexual, verbal/mental, theft or neglect), the investigation shall consist of: ? A review of initial written reports; ? Completion of a written report on the status of the investigation of the occurrence; ? An interview with the person(s) reporting the incident; ? Interviews with any witnesses to the incident; ? Where appropriate, an interview with the resident's attending physician or psychiatrist; ? A review of the medical records of any residents involved in the occurrence; ? If the accused individual is an employee, review the personnel file to check for references, background check, and documentation of orientation and training; ? An interview with staff members having contact with the resident and accused individual during the period of the alleged incident; ? Where appropriate, interviews with the resident's roommate, family members, visitors or others who were in the vicinity of the incident; ? Interviews with other residents to which the accused individual has regular contact; ? Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused individual; ? Obtain address, phone number and social security number of the accused individual; ? An interview with the accused individual or individuals (with a witness present); and ? A review of all circumstances surrounding the incident." On 11/30/2011 at 11:15 AM E1 was informed of immediate jeopardies related to abuse, neglects, and the administrators responsibilities related to the videos of residents.. Through record review and interview the surveyor confirmed the facility took the following actions to remove the immediacy: 11/23/2011 ? All suspicious activities will be immediately investigated, and overseen by the Corporate Regional Director for one calendar year, and during random checks thereafter. All deviations will be addressed to improve the system and monitored closely by the Administrator and the Corporate Regional Director. ? Staff will have in-servicing quarterly on policy and procedure for reporting including but not limited to reporting suspicious activities. ? The system will be monitored and changes will be made as appropriate to the system and education will be provided as necessary on an ongoing basis. 10/25/2011 E15 had resigned from the facility as of 10/25/2011 11/30/2011 ? Administrator and Director of Nursing have been educated on the Abuse and Neglect Policy and Procedure by the Corporate Regional Director. ? Administrator and Director of Nursing have been educated on the investigation process by the Corporate Regional Director. ? Administrator and Director of Nursing have been educated on the investigation of suspicious activity and injury of unknown origin by Corporate Regional Director. ? Staff were education on the reporting of suspicious activity. ? Administration will be in-serviced monthly for six consecutive months in the calendar year on the Abuse and Neglect Policy and Procedure including the investigative processes by the Corporate Regional Director, and randomly thereafter. Administration will be in-serviced monthly for six consecutive months in the calendar year on the investigative process by the Regional Corporate Director, and randomly thereafter. ? All staff will have thorough background checks, audited by Regional Corporate Directors for six consecutive months of the calendar year, and randomly thereafter. 11/23/2011, 11/25/2011, 11/30/2011 ? Staff have been educated on the Abuse and Neglect Policy and Procedure ? Staff were eduction on the reporting policy and procedure.

Based on observation, interview, and record review the facility failed to ensure residents were free of mental abuse including harassment and humiliation. Residents were video taped at 4:30 AM while a Certified Nursing Assistant was trying to wake them up by pulling bed linens off a resident's head, who did not want to get up; taking video of a resident's exposed legs; taking close up pictures of resident's sleeping; pulling a resident's nose; shaking a resident; and tapping a resident on the sides of his face. These failures resulted in R1 & R2 being harassed and humiliated and R3 being left in a dangerous position, without intervention, while being filmed. This applies to 2 of 3 residents (R1, & R2) reviewed for abuse in the sample of 9 residents. The findings include: On 11/23/2011 at 9:00 AM, Z1 said a telephone memory card (SD)was found outside of the facility. Z1 said the SD card belonged to E15 (Certified Nursing Assistant - CNA). Z1 said the card was viewed in his phone and video of R1 & 2 were seen. Z1 said the video showed R1 and R2 being woke up early in the morning. Z1 said, "I was floored when I saw what went on!" Z1 said there was video of R2 in bed, being woke up at 4:00 AM. He didn't want to get up, he held the sheet over his head. Z1 said there was also video of R2's roommate, R1, sitting up in his wheel chair, sleeping, with his tee shirt just over his head, and around his neck. Z1 said E15 shook the resident's face and tapped both sides of his face, trying to get the resident to open his eyes. Z1 said another video was taken at 4:30 AM, showing both R1 & R2 sitting up in their wheel chairs, next to each other, asleep. Z1 said he showed the video to E8 (housekeeping supervisor), E2 (Director of Nursing), and E1 (Administrator). Z1 said, " (E2) was shocked. She said 'she's fired'!" Z1 said, "When E1 saw the video she said nothing except asked who the CNA was. (E1) took the SD card. Z1 said, "It is not acceptable to take pictures of residents." On 11/23/2011 at 9:10 AM, R1 and R2 were interviewed. Neither resident could answer questions of orientation (time, date, month, next holiday). R1's Minimum Data Set (MDS) of 7/1/2011 shows the resident is cognitively impaired. The resident requires total staff assistance with transfers, dressing, and extensive assistance with eating. The resident does not ambulate. R1 is rarely understood and he sometimes is able to understand what others are saying to him. His vision is highly impaired. The MDS documents R1 is easily distracted, out of touch, or has difficulty following what was said. An Abuse careplan (10/1/11) identifies that R1 is at risk for abuse because of his impaired cognition, dependence on others, and maladaptive behaviors. R2's MDS of 8/26/2011 scores the resident's cognition a 5, showing the resident has severe cognitive deficits. The MDS show the resident requires total assistance with transfers, dressing, and hygiene. He does not ambulate. An 8/22/2011 Abuse careplan shows the resident is at risk for abuse because of his impaired cognition, dependence on others, and he is verbally abusive to others. On 11/23/2011 at 12:35 PM, a confidential interviewee said she saw the video E15 took of R1 & R2. The interviewee said, "I walked up to others viewing the videos." E15 was telling the residents it was 4:30 AM and to get up. She pulled the blanket off of (R2's) head and tapped R1 on the face. R1's shirt was pulled over his head, but not pulled over his shoulders. Another video was taken after (R1 & R2) were up in the wheel chairs, she was trying to get them to wake up. I was told the SD card was given to E1 and she gave the card to her boss. The interviewee said E2 and E6 (Minimum Data Set Coordinator) were told to 'keep it to themselves'. On 11/23/2011 at 1:05 PM, E2 said she was aware of the videos. E2 said, "As soon as I saw it I immediately took the SD card to E1. It is not appropriate for staff to take pictures of residents. The staff are not to have cell phones in the building. What would possess someone to do that? It is an invasion of privacy. I don't know if there was an investigation into the video. (E1) handles all abuse allegations. (E15) had given her 2 weeks notice of employment termination, prior to the discovery of the videos. I called her and told her we no longer needed her services. Her last day of employment here was 9/29/2011. I was instructed not to discuss the video with her. I don't know if she is working somewhere else. I was not specifically told to keep quiet, but I wouldn't speak of this with other staff." On 11/23/2011 at 1:25 PM, E1 said she viewed the SD card on E3's (Maintenance)telephone. She said she heard a female voice. She said the SD card had been found outside of the facility by E3. E1 said Z3 (Corporate Nurse) has the SD card. I was disturbed. The person taking the videos did not have permission to take the pictures. I didn't talk to E15 because I had no proof it belonged to her. I didn't want to make a big deal of it." On 11/23/2011 at 3:45 PM, the SD card was viewed with Z3 (Corporate Registered Nurse) and E1 present. While viewing various pictures on the SD card, E1 verified pictures of E15 and her sister on the SD card. E1 concluded the SD card belonged to E15. A video time stamped 9/18/2011 was observed. A video clip was taken of R2 in bed, his legs were completely exposed, but his head and upper body were covered with bed linens. E15 did a close-up span of R2, with his head covered. E15 was observed shaking the resident saying, "It's time to get up." R2 responded, "I don't want to." E15 continued to attempt to awaken the resident. R2 was heard to say to E15, "I heard you....ouch!" Another video clip showed R1 up in his wheelchair. E15 was heard saying, "(R1) I know it's early, will you look at me. A close-up shot of R1's face showed the resident appearing to be asleep. The resident yawned. E15 did another close-up view of R1 and said, "Oh look at him yawn...(R1) are you tired?" Another video clip, taken on the same day, showed R2 up in his wheel chair. E15 said to the resident, "Smile (R2)." A final video clip taken on 9/18/2011 shows both R1 & R2 up in their wheel chairs. E15 is heard narrating the video saying, "It's 4:00 AM, and these guys are ready to go for the day." Each of the resident's appeared to be sleeping. E15 did a close up shot of R1. E15 said, "Hi (R1)...(R1)...(R1)..." The resident did not respond by opening his eyes. E15 was observed pulling his nose, shaking his chin, and tapping his face, in an effort to wake him. On 11/12/2011, after viewing the videos, E1 said she had not seen all of the videos. E1 said, "I had no way to view the SD card." The facility's Abuse Prevention Program (11/11/11) states, "This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment..." The policy documents, "Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation."

Based on observation, interview, and record review the facility failed to immediately investigate and report to the state governing agency allegations of a staff member mentally abusing andf neglecting 3 residents. These failures resulted in R1 & R2 being harassed and humiliated and R3 being left in a dangerous position, without intervention, while being filmed. This applies to 3 of 9 residents (R1,2,3) reviewed for abuse in the sample of 9 residents. The finding includes: On 11/23/2011 at 9:00 AM, Z1 said a telephone memory card (SD)was found outside of the facility. Z1 said the SD card belonged to E15 (Certified Nursing Assistant - CNA). Z1 said the card was viewed on his cellular phone. Videos of R1,2, & R3 were seen. Z1 said the video showed R3 "about ready to fall off the bed". Z1 said the only thing keeping R3 from falling on the floor, face and head first, were the blankets. Z1 said there is audio and video of R3's roommate, R4, asking if R3 is all right. Z1 said the entire time R3 was hanging off the bed, E15 was saying 'good morning (R3), good morning beautiful'. Z1 said the card also had video of R1 & R2. Z1 said the video showed R1 and R2 being woke up early in the morning. Z1 said, "I was floored when I saw what went on!" Z1 said there was video of R2 in bed, being woke up at 4:00 AM. He didn't want to get up, he held the sheet over his head. Z1 said there was also video of R2's roommate, R1, sitting up in his wheel chair, sleeping, with his tee shirt just over his head, and around his neck. Z1 said E15 shook the resident's face and tapped both sides of his face, trying to get the resident to open his eyes. Z1 said another video was taken at 4:30 AM, showing both R1 & R2 sitting up in their wheel chairs, next to each other, asleep. Z1 said he showed the video, from his cell phone, to E8 (housekeeping supervisor), E2 (Director of Nursing), and E1 (Administrator). Z1 said, "When E1 saw the video she said nothing except asked who the CNA was. (E1) took the SD card. On 11/23/2011 at 1:25 PM, E1 said she was aware of video that had been taken of R3. She said the SD card had been found outside of the facility by E3 (Maintenance). E1 said she viewed the SD card on E3's cellular phone. E1 said she heard a female voice talking on the video. E1 said she saw video of R3 laying on the side of the bed. E1 said, "I don't remember her off of the bed, but at the edge of the bed. I was disturbed. The person taking the videos did not have permission to take the pictures. I haven't talked to E15 because I don't have proof it belongs to her. I didn't want to make a big deal of it." E1 said Z3 (Corporate Nurse) has the SD card. E1 said she did not do an investigation of the incident and did not notify the state agency, the resident's physicians, or their families. E1 said she did not interview any residents or staff who may have been witness to the incidents. E1 said she did not interview E15 because she no longer works at the facility. E1 said, "I didn't even think about why the SD card was out of the cellular phone it was in, or that there might be pictures of other residents on the SD card. I did not notify the registry of R15's termination of employment with the facility. I had heard she was working at an assisted living facility." On 11/23/2011 at 3:30 PM, Z3 (Corporate Registered Nurse) brought the SD card to the facility. She said she had had the card for approximately 1 week. She said she did not have a way to view the SD card. On 11/23/2011 at 3:45 PM, the SD card was viewed with Z3 (Corporate Registered Nurse) and E1 present. While viewing various pictures on the SD card, E1 verified pictures of E15 and her sister on the SD card. E1 concluded the SD card belonged to E15. A video time stamped 8/28/2011 was viewed. The length of the video is 41 seconds. R3 was observed with her sheet and blanket tucked under the mattress. The resident's body is completely off of the bed. Another video time stamped 9/18/2011 was observed. R1 & R2 were video taped at 4:30 AM while E15 (Certified Nursing Assistant) was trying to wake them up by pulling bed linens off R2's head, and video of his exposed legs. E15 took close up frames of R1 & R2 sleeping in their wheel chairs and video of E15 pulling R1's nose, shaking his chin, and tapping him on the sides of his face. On 11/23/2011, after viewing the videos, E1 said she had not seen all of the videos. E1 said, "I had no way to view the SD card. If I had seen all of those videos I would have done an investigation ." The facility's 11/11/11/ Abuse Prevention Program states,"The facility must ensure that all alleged violation involving mistreatment, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrate of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), otherwise the report must be made no later than 24 hours after forming the suspicion. A written report shall be sent to the Department of Public Health. The written report should contain the following information, if known at the time of the report; ? Name, age, [DIAGNOSES REDACTED]. ? Type of abuse reported (physical, sexual, theft, neglect, verbal or mental abuse); ? Date, time, location and circumstances of the alleged incident; ? Any obvious injuries or complaints of injury; and, ? Steps the facility has taken to protect the resident. The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment, neglect, and abuse of resident and misappropriation of resident property and that an investigation is being conducted..." The Investigation Procedures state: "Regardless of the specific nature of the allegation (physical, sexual, verbal/mental, theft or neglect), the investigation shall consist of: ? A review of initial written reports; ? Completion of a written report on the status of the investigation of the occurrence; ? An interview with the person(s) reporting the incident; ? Interviews with any witnesses to the incident; ? Where appropriate, an interview with the resident's attending physician or psychiatrist; ? A review of the medical records of any residents involved in the occurrence; ? If the accused individual is an employee, review the personnel file to check for references, background check, and documentation of orientation and training; ? An interview with staff members having contact with the resident and accused individual during the period of the alleged incident; ? Where appropriate, interviews with the resident's roommate, family members, visitors or others who were in the vicinity of the incident; ? Interviews with other residents to which the accused individual has regular contact; ? Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused individual; ? Obtain address, phone number and social security number of the accused individual; ? An interview with the accused individual or individuals (with a witness present); and ? A review of all circumstances surrounding the incident."

Based on interview and review of records, the facility failed to follow its abuse prevention program by not identifying residents who are at risk for abuse or who are potential abusers; The facility failed to monitor R47 every 15 minutes, per plan, once an incident of inappropriate touching was identified; The facility failed to protect other residents from further potentially abusive behavior; The facility failed to notify the department when an allegation of inappropriate touching was made and failed to conduct a thorough investigation of the incident. As a result R18 was inappropriately touched on the skin of her breast on 2/2/11 by (R47). These failures apply to 5 of 12 sampled residents (R18,R47, R44, R21, R16) and 1 additional resident (R2). The examples include: 1. Review of R18's 1/2011 Physician order [REDACTED]. Review of the 12/2010 Minimum Data Set assessed R18 as having severe cognitive impairment, both long and short term memory, totally dependent for all activities of daily living, and both upper and lower extremity range of motion impairments with the inability to speak. The Care Plan for R18 dated: 3/4/10, 6/4/10, 9/3/10, 12/7/10 identifies the problem of 'risk for abuse due to impaired cognition related to dependence on others'. Approaches/Interventions: background check on all employees, inservice on abuse regularly, report any signs of abuse to supervisor immediately, resident prefers to be called ----, social service admission assessment.' No interventions are included to implement, monitor, and provide for the safety of R18 from abuse by residents or staff. Nurse's Notes/ Notes & Comments dated '2/2/11, at 6:15, a resident at the facility informed nurse that a male resident was hovering over the resident and had his hand inappropriately on the resident. Nurse separated resident and male resident and placed on 15 minute checks.' No assessment of R18's physical or mental condition was done following the incident, and there is no mention of the incident or interventions on R18's care plan to provide for her physical safety and mental health. Notes/Comments dated 2/2/11 6:15 'Resident's daughter phoned and situation explained to her. Resident's daughter concerned but appreciated information, but was worried that her mother was in room alone. Nurse reported that her mother had a room-mate who could express all needs which really relieved resident's daughter.' 2. R47's Minimum (MDS) data set [DATE] and Nurses Notes/Notes and Comments show R47 was admitted on '2/1/2011 at 10:35 am. Resident ambulated with walker with slow and steady gait. Resident likes to hug staff frequently. Noted inappropriate with this writer trying to touch breast and buttocks as well as private part. Redirected per this writer and son with success. Will continue to monitor. 2/211 12 mn, Groping 2 CNA's personal body parts. Resident informed his behavior inappropriate and unacceptable. 2/2/11 5:54pm, Resident laying on couch and encouraged to come to dinner by nurse and states he has already eaten twice today and wanted nurse to lay down with him. 2/2/11 6:45pm, One of the residents reported that another resident (R47) was touching another female resident inappropriately. Nurse separated the residents and reported to resident that he was not allowed to touch another person in the facility. 1:1 supervision placed on resident until administrator called. Administrator contacted and instructed nurse to place on 15 min monitoring. 2/3/11 2pm, Resident inappropriate with CNA when CNA assisting with peri care asking her to wash harder. Redirected with little success. Resident needs staff direction to where his room is. 2/2/11 2:05pm, Resident has appointment at behavioral hospital. 2/5/11 1:45pm, Resident up walking with quad cane today with slow steady gait. Resident reaching arms out to this writer stating he wants a kiss, and I owe you a kiss. 2/8/11 0600, Resident awake off and on throughout the noc. Ambulating in hallways. Inappropriate sexual comments to CNA's. 2/8/11 12:25pm, call placed to doctor's office requested to send resident to behavioral health to get behaviors under control. Called and spoke to son, explained to him about inappropriate behaviors last night and concern for residents and his father. R47's care plan dated 2/1/11, identifies 'category :9 Behavior problem(P) resident is known/has a history of displaying inappropriate behavior and or resisting care/services specific behavior exhibited touching others inappropriately, asking others to come and sit in his lap related diagnosis/condition dementia and depression with anxiety other risk factors resident specific information, has history of being sexually inappropriate Goals:(G) resident will calmly accept redirection during episodes of inappropriate behavior of <> thru next 90 days. Resident will reduce number of episodes of inappropriate behavior of <> to no more than <> episodes per <> thru next 90 days Approaches (A) Initiate behavior monitoring program to attempt to identify patterns, precursors and causes of behavior to attempt to understand the meaning of behavior Introduce self upon contact. During periods of inappropriate behavior, use a consistent, calm firm approach. Use resident's name to help divert inappropriate behavior. Maintain a calm environment with limited clutter/distraction Review abnormal behaviors with IDT Encourage family input as needed to assist in identifying issues of concern. Encourage psychotherapy and or psychiatric consult as indicated/tolerated If resident has socially inappropriate behavior, explain why behavior is inappropriate, consequences of behavior. Determine cause of behaviors and try to rectify.' The 2/1/11 care plan shows a start date of all above approaches to be 2/4/11. The administrator ordered 15 Minute. Monitoring All Day Long sheets, starting 2/2/11. The record shows the 15 minute monitoring lasted until 9:45pm 2/2/11. From 10pm 2/2/11 until discharge on [DATE], R47 was not monitored every 15 minutes as the administrator had instructed. The facility failed to complete the 15 minutes monitoring checks 172 times between 2/2/11 and 2/8/11, when R47 was discharged to a psych hospital. The facility failed to identify R47 for an at risk abuser and abusee, after the inappropriate sexual behavior had began immediately after admission, and failed to institute interventions to protect residents to include (R18), and R47 from possible abusive behavior from staff and residents. On 2/15/2011 at 3PM E1 (Administrator) stated, "The incident of R47 inappropriately touching R18's breast afer putting his hands under her top, was not reported to the department, and there was no official investigation completed." E1 was unable to state why the Department was not notified and an investigation was not completed concerning R47's sexual assault of R18. E1 was also unable to state why there was no assessment of R18's mental or physical condition after the assault, and reassessments on the following days to ascertain if R18 was experiencing any ill effects from the assault, and why the common area, where the attack occurred, was not being monitored by staff as evidenced by a resident having to report R47's hands on R18's breast to the staff. E1 was also unable to state why there were no specific interventions addressing R18 being at risk for abuse due to being a total care resident diagnosed as having Dementia, unable to express herself, and concerning any ill effects from the assault of 2/2/11 or why no interventions developed or implemented concerning R47's inappropriate sexual behavior that started immediately after admission. E1 was unable to state why, when the daughter expressed worry about her mother, the staff informed her R18's room-mate could express all needs. When asked if it was the room-mate's responsibility to monitor R18 for safety, E1 stated, "(R18) room-mate could put on the light and report if there was something wrong while in their room." E1 was unable to identify who would report if something was happening to R18 if the room-mate was not present or asleep, or what type of monitoring of the residents is done to maintain their safety. E1 did not state why the 1:1 monitoring that was initially started after R18's assault, or why R47's repeated inappropriate sexual behavior monitoring was discontinued. E1 stated the facility put a bed alarm on R47's bed for monitoring. E1 made no statement concerning the 172 missed, 15 minute checks on R47. When asked if R47 had assaulted any other residents, E1 was not able to definitely state no. On 2/15, 2/16, and 2/17/11, residents were observed in the common areas, before and after lunch, and at 4pm with no staff present. When ask the location of R18's assault, E1 stated, during the 2/15/11 interview, ''(R18) and (R47's) incident happened in the large common area after the evening meal." The facility layout shows, R47 was in room [ROOM NUMBER] which is located more than half way down the hall around a corner from the nurses station, not under visual supervision. There were no (camera) monitors observed at the facility. The approach of 'Behavior Monitoring program' was not started as per care plan on 2/4/11, and there was no on going monitoring of R47, 2/1/11 thru the day of discharge 2/8/11 at 8:35 PM. 3. Review of the facility abuse investigations for the past year found the following: R44 was reported to have slapped a Certified Nursing Assistant (CNA) on the buttocks because he was angry at another CNA who had entered his room and shut his call light off without assisting him. The facility could provide no evidence the incident had been investigated. E1 (Administrator) verified on 2/17/11 at 2:30 PM the incident had not been reported to the State Agency. R44's care plan dated 12/10/10 identifies a problem of "Altered Mood State (anger/easily upset) potential for altered social reaction ... can be sexually inappropriate at times ... grabbing ..." There are no specific interventions to ensure R44 is kept safe from abuse/being abused due to his behaviors. On 2/9/11, R2 was reported to have patted a CNA on the buttocks and touch her breasts. R2 has no care plan for abuse prevention. The care plan updated 11/23/10 identifies R2 is at risk for abuse related to impaired cognition and dependence on others with an intervention of "report any signs of abuse to supervisor immediately." Review of R21's medical record showed multiple nursing notes identifying R21's aggressive and combative behaviors towards others. Some of the examples are as follows: 6/1/10 - had verbal outbursts towards staff and residents. "Res. has been exhibiting verbal outbursts towards staff & table mates during meals". 6/11/10 - "Res continues with verbal outbursts towards staff and other residents near her". 9/1/10 - "Res. kicked her (CNA) in face, right cheek bone with her (R21's) shoe when CNA getting her out of wheelchair". 9/8/10 - "Res yelling out ... res heard all over South Hall". 10/9/10 - "...yelled, cursed, hit, and attempted to bite staff members". 10/31/10 - "Resident is moody, mean, rude to staff and other residents". 11/22/10 (Activity Note) - "R21 continues to have negative behaviors towards other residents". 11/30/10 - "Resident is moody, rude, to staff & other residents". 12/6/10 - Resident is moody & rude to staff and other residents". 1/23/11 - "Threw supper plate onto floor at dinner and broke it".R21's interdisciplinary care plan review dated 6/8/10 identifies R21 has a problem of "behaviors of daily anger with staff/residents, resisting care and striking out during care". R21's current care plans dated 11/24/10 have no identification no interventions placing R21 at risk for abuse or as at risk for abusing others. The facility's policy and procedure on abuse dated 3/5/09 states, (pg 1), "This facility affirms the right of our residents to be free from abuse ... to assure the facility is doing all that is within its control to prevent occurrences of mistreatment ... by: ... Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, Identifying occurrences and patterns of potential mistreatment; . . . Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences ..." (pg. 4), "...staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict." (pg. 5), "The investigator will report the conclusions of the investigation in writing to the administrator of designee within five working days." (pg. 7), "the Department of Public Health shall be informed within 24 hours." 4. Nursing Notes show that on multiple occasions R16 displayed behaviors of arguing with her roommate over clothing, noise and the lights on in their room ( 4/20/2010, 6/9/2010, 6/11/10), grabbing at other residents, attempting to scratch them (1/17 & 1/18/2011), and being combative with staff during care (2/11/2011). A Pre-screening/Screening Assessment for Harmful Behaviors, dated 2/12/2010, shows that the resident has a history of considerable anger and hostility. She harbors strong dislikes towards others that may include racial prejudices. The resident's care plan of 12/14/2010 shows that the resident is at risk for abuse. The interventions include the following: Background check on all employees, depression and/or geriatric dementia screening, harmful behavior screening upon admission, in service staff on abuse regularly, remind resident to use call light if other residents wander into her room, report any signs of abuse to supervisor immediately, and Social Service admission assessment. The care plan has no specific interventions on how the facility plans to protect other resident's from R16's behaviors or how they are going to protect R16 from other residents. The care plan does not identify that R16 has verbal and physical aggression toward others. There are no updated interventions after each episode of verbal/physical aggression. The goal of the care plan is to maintain a safe homelike environment. The plan shows that the goal has been met on 6/15/10, 9/15/10, & 12/14/10. The behavior monitoring sheets (November & December 2010, and January 2011) for R16 shows that the facility was only monitoring the resident for negative statements made to staff and other residents. The facility's Abuse Prevention Program, dated 3/5/2009, states, "As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment for [REDACTED]."