Every finding on record at Shawnee Senior Living

Based on interview and record review the facility failed to follow physicians orders for weight monitoring and reporting of weight gain for a resident with Congested Heart Failure for 1 of 2 resident (R51) reviewed for respiratory care in sample of 54. This failure resulted in R51 being sent to the hospital for weight gain, wheezing, shortness of breath, with 11 lbs of excess fluid. Findings include:R51's admission record documents an admission date 03/30/23 with diagnoses including: chronic obstructive pulmonary disease (COPD), heart failure, type 2 diabetes mellitus, benign neoplasm of cranial nerves, chronic respiratory failure with hypoxia, venous insufficiency, chronic respiratory failure with hypercapnia, morbid obesity due to excess calories, anxiety disorder, polyosteoarthritis, gastro-esophageal reflux disease, emphysema, tachycardia, cognitive communication deficit, muscle wasting and atrophy, and pulmonary embolism. R51's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status of 5 indicating severe cognition impairment. R51's Care Plan documents a focus area of, R51 is at risk for nutrition/hydration issues related to: psychotropic med use, diuretic use, morbid obesity, insulin dependent diabetes mellitus, COPD, congestive heart failure (CHF) with desire for weight loss. Last revised 5/7/26. R51's order sheet documents an order dated 07/15/23 with an order status of active of daily weight: every day shift for heart failure, call MD (medical doctor) if weight is greater than 3 pounds in one day or greater than 5 pounds in one week. R51's weights and vitals summary dated 08/27/26 does not documents weights for the dates of: 07/01, 07/02, 07/06-07/11, 07/20, 07/21, 07/25, 07/30, 08/03-08/05, 08/08-08/10, 08/21 - 08/25. R51's weights and vitals summary documents weights of: 181.3 pounds on 07/22/26 and a weight of 188.4 pounds on 07/23/26 and a weight of 283.6 pounds on 07/24/26. On 07/05/26 a weight of 268.2 and on 07/14/26 a weight of 282.2 pounds. R51's weights and vitals summary documents weights on 8/7/26 as 179.3 pounds (sitting), 8/11/26 as 281.6 pounds (mechanical lift) and 8/12/26 as 280.2 pounds (mechanical lift). R51's progress notes do not document any physician notification of the fluctuations in weight. R51's Nursing Note dated 8/9/2026 at 1:06PM documents in part, Resident noted to have adventitious lung sounds and wet sounding non productive cough. Lung sounds not improved with neb treatment. On call provider notified. New order for chest x-ray and Prednisone 30 milligrams once daily for 5 days. POA (Power of Attorney) made aware of residents change of condition, vital signs and new orders. R51's Nursing Notes dated 8/10/26 at 4:28 PM documents in part as a late entry, x-ray called the facility to say they would not be able to do a chest x-ray for at least two day. Daughter was notified and requested her to be sent out if symptoms got worse. R51's Nursing Note dated 8/10/26 at 12:31PM, All-stat portable here to obtain chest x-ray. R51's Nursing Note dated 8/11/26 at 3:29PM documents, Chest x-ray results received which shows bibasilar opacities. Forwarded results to doctor. Order received for Levaquin 500 milligrams daily for 7 days. R51's Nursing Note dated 8/12/2026 at 1:40PM documents in part, this nurse spoke to residents daughter who was concerned about R51 gaining weight and having swelling in her face and stated she would like the resident sent out just to be sure the resident is not retaining fluid.R51's IDT (Interdisciplinary Team) note dated 8/12/26 at 4:43PM documents in part as a late entry, IDT team met and reviewed resident for continued assessment and monitoring related to COPD, heart failure, type 2 diabetes, chronic respiratory failure with hypoxia, sleep apnea, emphysema. Resident monitored for shortness of breath while lying flat related to CHF (congestive heart failure) and COPD. Encouraged to perform cough and deep breathing exercises due to decreased pulmonary function related to COPD, heart failure and emphysema. Wears oxygen continuously and trilogy at night. Daily weight related to CHF. Sent out to hospital today due to weight gain, wheezing, SOB, possible fluid overload. R51's Nursing Notes dated 8/19/26 at 2:30PM documents, Resident returned from local hospital at approximately 2:20PM. Report received from nurse. Resident was admitted for shortness of breath and fatigue. Diuresis of approximately 11 pounds while admitted . Discontinue Lantus, Levofloxacin, and Prednisolone. Increase Lasix to 40 milligrams daily. On 08/27/26 at 9:16 AM, V2 (Director of Nursing) stated if there is no weight in the electronic health record and no weight on the weight sheet then it is an error. V2 stated, she is not aware of any documentation in July or August of the physician being notified of weight changes for R51. On 08/27/26 at 9:21 AM, V18 (Licensed Practical Nurse) stated the nurse should be putting the weights into the electronic health record but then there should be an alert to notify the physician. On 08/27/26 at 10:06 AM, V1 (Administrator) stated staff should have definitely noticed when it was 100 pounds off and reweighed the resident, the CNAs should have been weighing the residents daily, and the physician should be notified if there was a weight change. The undated facility policy titled, Notification of Resident Change in Condition Policy documents: It is the policy of this facility to promptly notify the resident, their legal representative(s) and attending physicians of changes in the resident's health condition. The licensed nurse will document in the nurse's notes all assessment findings and all attempts to notify physician(s).

Based on observation, interview and record review, the facility failed to provide a sufficient amount of staff to meet the needs of the residents in a timely manner. These failures have the potential to affect all 93 residents living in the facility. Findings include: 1. R72's admission Record documents an admission date of 11/26/24 with included diagnoses of abnormalities of gait and mobility, repeated falls, unsteadiness on feet, and muscle wasting and atrophy. R72's MDS (Minimum Data Set) documents a BIMS (Brief Interview of Mental Status) of 12, indicating moderately impaired cognition. Section GG documents under Functional Abilities that R72 is substantial/maximal assistance for showering/bathing assistance. R72's Care Plan documents R72 has an ADL (Activities of Daily Living) self-care performance deficit related to activity intolerance, fatigue, and limited mobility initiated on 5/11/25 with included intervention of bathing/showering: R72 requires max assistance of one for bathing initiated on 5/11/25. On 8/24/26 at 10:29 AM, R72 stated she was told she had to eat breakfast in her room today because they didn't have enough staff to get all the residents to the dining room on time. R72 stated she likes eating in the dining room so she can see and talk to other residents. 2. R50's admission Record documents an admission date of 8/5/25. R50's MDS dated [DATE] documents a BIMS of 14, indicating intact cognition. On 8/26/26 at 8:50 AM, R50 stated there isn't enough staff in the facility. R50 stated last week in the evening, after supper, she put her call light on because she needed to go to the bathroom and she waited about 50 minutes for someone to answer the call light. R50 stated she has a cell phone, and she watched the time on it. 3. R99's admission Record documents an admission date of 10/10/24. R99's MDS dated [DATE] documents a BIMS of 09, indicating moderately impaired cognition. On 8/24/26 at 10:01 AM, R99 stated she usually goes to the dining room for meals, but she didn't get to today. R99 stated she was told by staff that they were short staffed and didn't have enough staff to pass trays in the dining room, so everyone had to eat breakfast in their rooms today. R99 was orientated to person, place, and time during interview. 4. R88's admission Record documents an admission date of 6/24/25. R88's MDS dated [DATE] documents a BIMS of 12, indicating moderately impaired cognition. On 8/24/26 at 9:21 AM, R88 stated he normally goes to the dining room for meals but today he was told everyone had to eat breakfast in their rooms because they didn't have enough staff to serve everyone in the dining room. R88 was orientated to person, place, and time during interview. 5. R100's admission Record documents an admission date of 2/15/26. R100's MDS dated [DATE] documents a BIMS of 12, indicating moderately impaired cognition. On 8/24/26 at 9:56 AM, R100 stated she usually goes to the dining room for meals but today she was told she had to eat breakfast in her room because they didn't have enough staff to get everyone served in the dining room. R100 was orientated to person, place, and time during interview. 6. R34's admission record documents an admission date of 4/27/22. R34's MDS dated [DATE] documents a BIMS of 14, indicating intact cognition. On 8/24/26 at 10:22 AM, R34 stated she ate in her bed today instead of going to the dining room because she was told by the staff that they didn't have enough staff to get everyone to the dining room for breakfast, so everyone had to eat in their room. R34 was orientated to person, place, and time during interview. 7. R22's admission Record documents an admission date of 11/18/25. R22's MDS dated [DATE] documents a BIMS of 12, indicating moderately impaired cognition. On 8/24/26 at 10:32 AM, R22 stated she was told she had to eat breakfast in the dining room today because there wasn't enough staff to serve everyone in the dining room this morning. R22 stated she likes going to the dining room to eat, it is a lot better than eating in her room alone. 8. R76's admission record documents an admission date of 06/25/25 with diagnoses including: type 2 diabetes mellitus with diabetic neuropathy, acquired absence of right leg below the knee, peripheral vascular disease, shortness of breath, depression, and essential hypertension. R76's MDS dated [DATE] documents a BIMS score of 15 indicating cognitively intact. R76's functional abilities document tub/shower transfer as supervision or touching assistance and shower/bathe self as supervision or touching assistance. On 08/25/26 at 1:45 PM R76 stated, he does not always get his showers. R76 stated that sometimes the staff does not have time. R76's bath and skin report sheet does not document showers were given on 06/16, 06/19, and 06/23, 06/26, and 06/30 in June and 07/21, 07/24, 07/27, and 07/31 in July which were R76's designated shower days. 9. R28's admission record documents an admission date of 05/09/24 with diagnoses including: localization related symptomatic epilepsy and epileptic syndromes with complex partial seizures, type 2 diabetes mellitus, chronic kidney disease, polyneuropathy, bipolar disorder, acute pyelonephritis, and paroxysmal atrial fibrillation. R28's MDS dated [DATE] documents a BIMS score of 14 indicating cognitively intact. R28's functional abilities document tub/shower transfer as supervision or touching assistance. On 08/25/26 at 1:45 PM R28 stated he does not always get his showers. R28 stated that sometimes the staff does not have time. R28's bath and skin report sheet does not document showers were given on 06/15, 06/18, and 06/22 in June and 07/07, 07/17, 07/20, and 07/24 in July which were R28's designated shower days. 10. R40's admission record dated 8/27/26 documents an admission date of 6/12/26. admission record documents diagnoses including congestive heart failure, cerebral infarction, type 2 diabetes, muscle wasting and atrophy, abnormalities of gait and mobility. R40's most recent care plan documents a focus area for a deficit in activities of daily living including toilet hygiene, bathing and personal hygiene with an initiation date of 6/12/26. Interventions for this focus area include R40 needing assistance to complete bathing of upper/lower extremities with an initiation date of 6/12/26. R40's minimum data set/MDS dated [DATE] documents R40 has a brief interview for mental status/BIMS score of 13 indicating R40 is cognitively intact. The MDS documents R40 is a partial to moderate assist for showering/bathing. MDS documents R40 is also dependent on tub/shower transfer. On 8/24/26 at 12:12 PM, R40 stated he gets shower only once a week or sometimes one every two weeks. R40 stated he has even requested to get a shower because it had been a few days and had gotten a weird look from the staff and never got the shower. R40 stated his regular shower days are Wednesday and Saturday. On 8/26/26 at 2:12 PM, R40 stated he does not remember the exact dates but does remember missing some showers. R40 stated he did not remember if anyone told him why he didn't get his showers done. R40's shower documentation for months June through mid-August of this year documents no shower documented between 6/15, Monday and 6/27, Sunday for a total of eleven days with no documented shower. Review of the August 2026 CNA (Certified Nursing Assistant) timecards and review of the daily CNA/nurse schedules shows multiple days with less than 8 CNA's working and multiple nights with less than 5 CNA's working. On 8/27/26 at 2:25 PM, V12 (CNA) stated that she has not been able to give showers when they are scheduled at times due to not having enough staff. On 8/26/26 at 9:33 AM, V5 (Licensed Practical Nurse) stated there have been several times that they do not have enough CNA's to get all the work done in a timely manner. V5 stated the CNA's do the best they can but unfortunately sometimes there are residents that get made because they have to wait to get help. On 8/26/26 at 9:48 AM, V24 (CNA) stated she has missed giving showers before due to not having enough staff to get the scheduled showers completed during her shift. V24 stated there have been several times they have had to make the residents eat in their room due to not having enough staff to get all the residents ready and to the dining room and not having enough help to get all the trays passed in the dining room and down the halls. V24 stated there are a lot of residents that don't like eating in their room. V24 stated she has also been late on bed checks due to not having enough CNA's to help. V24 stated the alert and orientated residents get agitated at times because it can take a while to answer call lights when they are short staffed. On 8/24/26 at 10:25 AM, V25 (CNA) stated that there were only 3 CNA's in the building for breakfast today so they had to tell the residents that they couldn't go to the dining room for breakfast, they served them all in their rooms. V25 stated they usually have 8-9 CNA's during the day. V25 stated staffing has gotten a little better recently, but they have been working short staffed often over the last several months. Resident Council meeting minutes for August 5, 2026, documents under Concerns, Questions, suggestions, and compliments; Nursing: not enough CNA's. Resident Council meeting minutes for July 8, 2026, documents in part under Nursing: residents are continuing to request more CNA staff. Showers are still not being completed as they should, or residents are being told staff is too busy to complete. Resident Council meeting minutes for June 3, 2026, documents under Nursing: hire more CNA's, especially at night. Resident Council meeting minutes for May 8, 2026, documents under Nursing: 1) Ongoing shower issues, 2) Not enough CNA's. On 8/31/26 at 9:03 AM, V1 (Administrator) stated she thinks there needs to be at least 8 CNA's working day shift and 5-6 CNA's working night shift to properly take care of all the residents. V1 stated they need 4 nurses during the day and 3 nurses at night. V1 stated she is aware staffing is an issue, and she stated they have hired a lot of new staff lately. The facilities Midnight Census Report documents there are 93 residents currently living in the facility.

Based on observation, interview, and record review, the facility failed to ensure a pest free environment was maintained. This has the potential to affect all 93 residents residing in the facility. Findings include:1. R88's MDS (Minimum Data Set) documents a BIMS (Brief Interview of Mental Status) of 12, indicating moderate cognitive impairment. On 8/24/26 at 9:21 AM, R88 was observed lying in bed with 5 flies on top of his blanket that he was covered up with. R88 stated the flies are a problem, all over the facility. R88 stated that when he is in the dining room there are always flies landing on his food. On 8/26/26 at 2:43 PM, R88 was in his bedroom sitting in his wheelchair, there was a cup of tan colored liquid sitting on his bedside tablet with 7 gnats that were floating in the cup and multiple alive gnats and flies crawling around on the rim of the cup and on the bedside table. R88 stated that was his protein drink from the day prior that he didn't drink. 2. R45's MDS dated [DATE] documents a BIMS of 13, indicating intact cognition. On 8/24/26 at 9:25 AM, R45 stated flies are a problem in his room. At that time it was noted R45 had a feeding tube pump on a stand in his room and there was feeding tube solution all down the stand and all over the legs of the stand, with several flies landing on the spilled solution. 3. R1's MDS dated [DATE] documents a BIMS of 12, indicating moderate cognitive impairment. On 8/24/26 at 9:42 AM, R1 was lying in bed and there were flies flying around R1. R1 stated the flies bother him in his room. R1 had a flyswatter on his bedside table that he stated he tries to hit them, but he isn't fast enough. 4. R95's MDS dated [DATE] documents a BIMS of 13, indicating intact cognition. On 8/24/26 at 12:05 PM, R95 was sitting at a table in the dining room eating lunch. A fly landed on her food and she shewed it away. R95 stated the flies are a problem in the dining room. R95 stated the flies are always landing on her food. 5. On 8/25/2026 at 8:49 AM, R70, who was alert and oriented, stated house flies are everywhere. R70 stated the flies are worse in the dining area during meals. R70 stated, Can't hardly eat because of the flies. On 8/25/26 at 12:11 PM,1 fly on R70's glass of milk. R70 shooed it away. On 8/26/26 at 9:18 AM, V22, Family Member stated house flies at dinner time have been awful recently. V22 stated he carries a fly swatter to keep them off his wife's (R70) food. V22 stated everyone complains about the flies, even the workers. V22 stated he had not reported his concerns about flies to anyone at the facility. 6. On 8/25/26 at 12:18 PM in the dining room, there was 1 fly on R34's sandwich. R34 didn't notice it. There was a smaller fly on R50's dessert. R50 did not see it. 7. Resident grievance form completed on 6/26/26 on behalf of R84 documents a complaint of house flies in the resident's room. Administration's solution to the grievance was to educate nursing and Certified Nurse Aide staff to notify maintenance through a work order or grab a flyswatter and address if see houseflies. On 8/25/26 at 12:30 PM, V6, Family Friend of R31 stated at times house flies can be bothersome at meals and even in R31's room at times. V6 stated the flies are not so bad today but have been periodically over the past week. On 8/25/26 at 12:31 PM, R27 and R28, who are both alert and oriented, agreed house flies are frequently bothersome at meals. On 8/26/26 at 12:39 PM in the Dining Room there were four flies on one table including plates eaten from and on napkins. There were no residents sitting at the table. On 8/26/26 at 10:52 AM, V13, Certified Nurse Aide/ CNA stated the facility does seem to have a problem with house flies. V13 stated she would consider the problem very bad as far as how many flies in the facility. V13 stated the flies are worst at the patio door in the dining room. On 8/26/26 at12:45 PM, while this surveyor was speaking to R57 in her room noticed a house fly land on her drinking straw laying on her overbed table. On 8/26/26 at 1:34 PM V11, CNA stated the facility does seem to have a lot of house flies in it, but it's not because they're (administration) not trying. V11 stated there are a lot of people in and out of the door from the patio to large dining area and it allows flies in. On 8/27/26 at 9:37 AM, V17, Maintenance Director stated he does know the facility has had a problem with house flies. V17 stated there are three blue light traps in main dining, 1 on [NAME] Hall, 1 on Dream Island Hall, and 3 on Reclaim Hall, including the one in the small dining. V17 stated the facility also has air curtains at the kitchen entrance, employee entrance, and patio door in main dining room and one at exit on [NAME] Lane Hall. V17 stated these two interventions have been in place at least 5 years. V17 stated the sticky traps were just changed in blue light traps last week. V17 stated the sticky traps are not changed routinely but changed as needed, they are checked weekly. V17 stated the facility usually doesn't open windows due to central air, but some residents may open their windows of their own accord. V17 stated those windows should have screens though to block pest entry. V17 stated as far as he knew there were no openings or torn screens the flies could be coming through but admitted he doesn't check for this routinely. V17 stated he did have a yard maintenance person who lets him know if he sees anything outside. V17 stated they also have fly swatters at the nurses' station and on housekeeping carts. V17 stated there are fly trap bags also at the main entrance, and employee entrance, kitchen and ambulance doors. V17 stated as far as he knew their pest control company does not do any special treatments for house flies. On 8/27/26 at 12:20 PM, V1, Administrator agreed the house flies in the facility were a problem. V1 stated to combat flies, We use fly swatters. We have the blue light traps throughout the facility on each hall, three in the main dining room and one in the small dining room, air curtains at the patio door in large dining room, employee entrance and the exit door from [NAME] Lane Hall, and fly traps outside entrances. V1 stated she was not aware of any broken screens or open windows or broken windows. V1 stated their pest control company did not provide any services for fly control. The facilities Midnight Census Report documents there are 93 residents currently living in the facility. Facility's Pest Control Policy and Procedure dated revised 2/3/22 documents, This facility shall maintain an effective pest control program.

Based on observation, interview, and record review, the facility failed to maintain a clean environment for 4 or 4 (R1, R2, R4, R5) residents reviewed for cleanliness in a sample of 5. Findings include:1. R1's admission Record documents an admission date of 3/30/23 with included diagnoses of anxiety, cognitive communication deficit, weakness, and muscle wasting and atrophy. R1's MDS dated [DATE] documents a BIMS of 05, indicating severe cognitive impairment. R1's Care Plan documents R1 has an ADL (Activities of Daily Living) self-care performance deficit related to activity intolerance, fatigue, and limited mobility initiated 5/11/25. On 7/28/26 at 9:36 AM, R1 stated the mess on her bedside table is hers but the trash on the floor is not hers. R1's floor was observed to have multiple items of debris on it and looked dirty. The pump on R1's air mattress had a brown substance on it, and it was splashed down the tubing that goes to the mattress. On 7/29/26 at 7:45 AM, R1 was lying in bed. The floor in R1's room was observed to have trash scattered over it and there was a dirty depend hanging halfway out of the trashcan. There was also still a brown substance on R1's air mattress pump box and tubing that runs from the box to the mattress. On 7/28/26 at 1:02 PM, V5 (Family Member) stated R1's room is always dirty when she comes into the facility and there is always trash in the floor. V5 stated there was what looked to be feces on the air mattress pump box and down the tubing that goes to the mattress and V5 stated she told the staff about it about 1 month ago. On 7/28/26 at 2:00 PM, V6 (Certified Nurse's Aide/CNA) just finished cleaning R1 up and was walking out of the room, this surveyor asked V6 if she knew what the brown substance was on R1's air mattress pump box and tubing and she stated she didn't know. 2. R2's admission Record documents an original admission date of 10/12/22 with included diagnoses of weakness, difficulty in walking, anxiety, abnormalities of gait and mobility, lack of coordination, and fatigue. R2's MDS dated [DATE] documents a BIMS of 13, indicating intact cognition. R2's Care Plan documents R2 has an ADL self-care deficit related to activity intolerance initiated 5/10/25. On 7/28/26 at 9:17 AM, R2 stated it depends on the day whether her room is kept clean or not but sometimes the floor is dirty and has trash on it, like today. R2's floor was observed to have trash scattered throughout the floor. On 7/28/26 at 11:00 AM, R2's floor in her room was observed to be dirty with trash scattered throughout the floor. 3. R4's admission Record documents an admission date of 4/10/25 with included diagnoses of major depressive disorder, muscle wasting and atrophy, and cognitive communication deficit. R4's MDS dated [DATE] documents a BIMS of 12, indicating moderate cognitive impairment. R4's Care Plan documents R4 has an ADL self-care deficiency initiated 7/22/20. On 7/28/26 at 9:05 AM, R4's room was observed to have trash scattered throughout the floor and food on the floor. R4 stated her floor is always dirty, she doesn't think it gets cleaned very often. 4. R5's admission Record documents an admission date of 2/14/25 with included diagnoses of weakness, depression, muscle wasting and atrophy, and cognitive communication deficit. R5's MDS dated [DATE] documents a BIMS of 09, indicating moderate cognitive impairment. On 7/29/26 at 9:13 AM, observed 2 cups that had a small amount of tan colored liquid in them on R5's bedside table. There were multiple gnats observed in the cups and flying around the cups. R5 stated the cups had a nutritional drink in them and they are from the day prior. On 7/29/26 at 4:12 PM, V2 (Director of Nursing) stated it is not acceptable for excess trash to be in the floors of residents rooms and stated now, do I think we can pick up every single little napkin, no. V2 stated it is not acceptable for feces appearing substance to be left on anything after staff clean a resident up. V2 stated she expects that if a CNA sees something on any part of the bed that resemble feces, then they should clean it up. On 7/30/26 at 2:25 PM, V1 (Administrator) stated when the nutritional drink is given, the nurse should stand with the resident and encourage them to drink it and then the cup should be thrown away immediately. V1 stated if there is a cleaning issue brought to the attention of a CNA, like brown substance on R1's air mattress pump and the tubing, the CNA should immediately clean it off with a cleaning wipe or notify housekeeping so they can come and clean it.

Based on interview and record review the facility failed to assist residents with applying their CPAP (Continuous Positive Airway Pressure) mask for 2 of 3 (R1, R3) residents reviewed for ADL (Activities of Daily Living) care in a sample of 5. Findings include:1. R1's admission Record documents an admission date of 3/30/23 with included diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and obstructive sleep apnea. R1's MDS dated [DATE] documents a BIMS of 05, indicating severe cognitive impairment. R1's Order Summary Report documents an order for R1 to wear Trilogy (Sleep apnea machine) at bedtime and as needed every night shift and to document in a progress note if resident refuses to wear the trilogy started 10/16/23. R1's Care Plan documents R1 has an ADL self-care performance deficit related to activity intolerance, fatigue, and limited mobility initiated 5/11/25 with included intervention of personal hygiene/oral care: R1 requires max assistance of one for performing personal hygiene and moderate assistance for oral care. There is no care area related to R1 having a sleep apnea machine on R1's Care Plan. R1's June 2026 Medication Administration Record (MAR) is missing documentation of sleep apnea machine use for 6/27/26. R1's July 2026 MAR is missing documentation of sleep apnea machine use for 7/4/26, 7/5/26, and 7/9/26. R1's document titled Trilogy Detail that documents the use log for R1's sleep apnea machine documents that for the months of May 2026, June 2026, and July 2026 there were multiply days that shows no usage. On 7/29/26 at 7:45 AM, R1 stated she didn't wear her sleep apnea machine last night because the nurse that was putting it on her couldn't get it put on correctly, it was too tight, and R1 tried to loosen the face straps and the nurse got frustrated with R1 and walked out of R1's room without helping R1 put it back on correctly. R1 was orientated to person and place but was unable to recall the date. On 7/28/26 at 1:02 PM, V5 (Family Member) stated R1 was in the hospital at the beginning of May 2026 for sepsis. V5 stated when R1 arrived at the hospital her CO2 (carbon dioxide) was elevated and the hospital staff told her that it was more than likely from her not wearing her sleep apnea mask at night. V5 stated that while R1 was in the hospital her confusion got better and her CO2 blood level improved and she thinks it's because she actually was wearing a sleep apnea machine at night for her sleep apnea. V5 stated she talked to V1 (Administrator) about R1 needing help putting her sleep apnea mask on at night. 2. R3's admission Record documents an original admission date of 7/14/25 with included diagnoses of acute and chronic respiratory failure with hypercapnia, chronic respiratory failure with hypoxia, chronic diastolic heart failure, weakness, fatigue, lack of coordination, muscle wasting and atrophy, secondary pulmonary arterial hypertension, and dyspnea. R43's MDS dated [DATE] documents a BIMS of 12, indicating moderately impaired cognition. R3's Order Summary Report documents an order for R3 to wear Trilogy (Sleep apnea machine) at bedtime and as needed started 9/9/25. R3's Care Plan documents R3 is at risk for pain, discomfort, and/or complications/hospitalization related to heart failure, chronic respiratory failure, chronic kidney disease, non-ST-segment elevation myocardial infarction, depression, transient ischemic attack, rheumatoid arthritis, physical deconditioning, BiPAP (sleep apnea machine) dependence at bedtime, diuretic use, hypertension, type 2 diabetes, and hypothyroidism initiated 8/26/25 with included interventions of administer medication/puffers as ordered, monitor for effectiveness and side effects initiated 4/21/26 and R3 has an ADL self-care performance deficit in dressing, transfer, bed mobility, toileting, and ambulation, activity intolerance, impaired balance initiated 7/15/25 with included intervention of personal hygiene/oral care: R3 is ablet o complete oral hygiene with set up and personal hygiene with verbal cues/supervision initiated 7/15/25. R3's document titled Trilogy Detail documents that for the months of May 2026, June 2026, and July 2026 there were multiple days that shows no usage. The same document also documents that on the night of July 28th the sleep apnea machine was only worn for a short amount of time. On 7/29/26 at 11:17 AM, R3 stated she is only able to wear her sleep apnea mask when the nurse remembers to come help her get it on because she isn't able to get it on herself. R3 stated she has had some chest pressure for a few days and last night when the nurse came and put the sleep apnea mask on her it made her chest tightness worse so she put her call light on and the CNA (Certified Nurse Aide) came in and helped her get the sleep apnea mask off and the CNA told her she would get the nurse for her. R3 stated the nurse never came to her room and she slept all night without her sleep apnea machine on. R3 stated she really only gets to wear her sleep apnea machine about 4 out of 7 nights a week due to the nurses forgetting to help her get it on. R3 stated some nurses will try to put it on her and the straps will be over her eye or not put on correctly and it will be uncomfortable. R3 stated most of the nurses don't know how to put the mask on correctly. R3 stated she thinks her sleep apnea mask isn't the correct size. The facilities Resident Council meeting minutes from July 8, 2026, documents under Nursing: Cpap (continuous positive airway pressure machine for sleep apnea) masks are not being put on residents correctly and tightened and adjusted correctly. A facility form titled Grievance Form dated 6/16/26, signed by V1 documents under description: R3's family member called to discuss R3's care. R3's family member stated that R3 is reporting that nursing staff are not putting her mask on her at night. R3's family member stated she wants to be notified if R3 refuses to wear her sleep apnea mask. R3's family member stated R3's CO2 was very high at the hospital, and the hospital staff told her this could be caused by the sleep apnea machine not being worn. Under Summary/Findings: R3 refusing mask at times. Under Recommendations/Action Taken: Education was provided to R3 and staff. Order to call R3's family member about non-compliance. On 7/30/26 at 12:39 PM, V11 (CNA) stated she was working on the night of 7/28/26 when R3 put her call light on and said her sleep apnea mask was making her chest pressure worse and she stated she told R3 she would get the nurse. V11 stated she went and told the nurse about it, and she thought the nurse went down there and talked to her. V11 stated she thinks R3's mask is too small because it looks too small and R3 always complains that it hurts her face. V11 stated she has seen the nurses forget to put the residents sleep apnea machines on the residents at times because they are trying to do their nighttime medication pass then they forget. V11 stated she thinks about 99% of the time the masks get put on the residents by midnight, but she has seen them not get them on all together. On 7/30/26 at 3:26 PM, V12 (License Practical Nurse) stated she was working on the night of 7/28/26 and was taking care of R3. V12 stated V11 came to her and told her R3 took her mask off but she didn't tell her why and V12 stated she did not go and talk to R3 after that. V12 states she thinks R3's sleep apnea machine mask is too small and V12 stated she has reported it before in the shift communication book. V12 stated she also put R1's sleep apnea mask on her but she was messing with it and eventually took it off. V12 stated the residents have rights and they have a right to not wear their sleep apnea mask if they don't want to. On 7/29/26 at 4:12 PM, V2 (Director of Nursing) stated she received new masks for sleep apnea machine Monday of this week, 7/27/26, but they have not been given to the residents yet. On 7/30/26 at 2:25 PM, V1 (Administrator) stated she talked with R3 months ago, she thinks it was in April 2026 about her sleep apnea mask and how to put it on correctly because R3 had come to her and told her she was having problem with it. V1 stated she did an in-service training with the nurses at that time also. V1 stated if a nurse is having difficulties getting a residents mask to fit properly then she would expect them to ask another nurse for help. V1 stated V5 called her regarding R1's sleep apnea machine but she doesn't remember when. V1 stated V5 told to her that she didn't think the sleep apnea machine was set up correctly because her mom was short of breath more often. V1 stated she went down and looked at the machine and the settings were correct. V1 stated if a staff member feels a residents sleep apnea machine mask is not fitting correctly or they are saying it is uncomfortable, they can get a different size ordered or they can call their local respiratory company they use and have them come in a get them fitted for a new mask. On 7/30/26 at 9:15 AM, V8 (Physician) stated R1 has COPD (Chronic Obstructive Pulmonary Disease) and sleep apnea so an elevated CO2 level could be caused by both issues. V8 stated R1's CO2 levels in her blood was elevated at her last hospital stay. V8 stated that since R1's CO2 level decreased during her hospital stay it is possible that her elevated CO2 level was caused by not wearing her sleep apnea machine as ordered prior to her hospitalization. A facility policy titled CPAP/BiPAP Support dated April 2007 documents under Purpose: 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote residents' comfort and safety.

Based on observation, interview, and record review the facility failed to provide sufficient staff to ensure residents receive showers and assistance with care. These failures have the potential to affect all 97 residents living in the facility.Findings include:1. R1's admission Record documented an admission date of 12/5/23 and included diagnoses of anxiety disorder, abnormal involuntary movements, and chronic pain. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 was cognitively intact.On 7/16/26 at 1:25 PM, R1 was lying in bed watching television. R1 said she had been a licensed nurse for several years and was aware of how a facility should operate and the facility's care was poor. R1 said she attended resident council meetings regularly and several residents were complaining there were not enough nursing staff. R1 said dayshift and night shift were usually short staffed of both licensed nurses and Certified Nursing Assistants (CNA) but night shift was worse. R1 said she was independent with bathing but dependent residents have complained of missing showers on their scheduled days. R1 said staffing on night shift caused call light wait times to be up to an hour if the facility was really short staffed.2. R2's admission Record documented an admission date of 11/26/24 and included diagnoses of abnormalities of gait and mobility, unsteadiness on feet, and muscle wasting and atrophy. R2's MDS assessment dated [DATE] documented a BIMS score of 12, indicating moderate cognitive impairment. On 7/16/26 at 1:20 PM, R2 was sitting in the recliner in her room with dried food down the front of her shirt and unkept oily hair. R2 said she preferred to go to the dining room for meals but had been told by staff earlier in the day they were not able to get R2 out of bed and to the dining room due to being short staffed. R2 said her shower days were supposed to be Tuesdays and Fridays but showers were routinely missed due to lack of staff. R2 said call lights take a long time to be answered but was unable to give an estimate of wait times. R2 said night shift was the worst and the girls (Certified Nursing Assistants/CNA's) try but they need more help.R2's Bath and Skin Report Sheet documented R2 was to be assisted to bathe on Tuesdays and Fridays and documented R2 was assisted to bathe on 7/3/26, 7/7/26, 7/10/26, and 7/17/26, indicating R2's 7/14/26 shower was not completed.3. R3's admission Record documented an admission date of 5/20/22 and included diagnoses of dementia, Alzheimer's disease, and other lack of coordination. R3's MDS assessment dated [DATE] documented a BIMS score of 2, indicating severe cognitive impairment.R3's Bath and Skin Report Sheet documented R3 was to be assisted to bathe on Tuesdays and Fridays and documented R3 was assisted to bathe on 7/3/26 and 7/7/26, indicating R3's 7/10/26, 7/14/26, and 7/17/26 were not completed.On 7/17/26 at 11:52 AM, R3 was sitting in her wheelchair in the dining room. R3's appearance was unclean as if she had not been assisted to bath recently. R3's hair was oily and unkempt with brownish/black debris under her fingernails. 4. R4's admission Record documented as admission date of 3/8/24 and included diagnoses of depression, spinal stenosis, and muscle wasting and atrophy. R4's MDS assessment dated [DATE] documented a BIMS score of 14, indicating R4 was cognitively intact.On 7/21/26 at 1:30 PM, R4 said the facility was always short staffed causing call light wait times being long, especially on night shift.On 7/16/26 at 1:40 PM, V5 (CNA) said resident showers don't always get completed due to the facility being short staffed. V5 said night shift was chronically short staffed and usually did not get any resident showers completed. V5 said the unit she was currently working was supposed to have 3 CNA's scheduled but there were only 2 CNA's currently working on the unit. V5 said when the unit only had 2 CNA's working it was hard to get all the resident care tasks completed.On 7/17/26 at 12:23 PM, V7 (CNA) said she usually worked night shift. V7 said night shift is usually short staffed. V7 said when they were short staffed resident care tasks such as assisting residents to shower were not always completed. V7 said if a resident shower was not completed she would pass that information on to dayshift in report with hopes dayshift would have time to complete the shower. V7 said she was not sure who was responsible for verifying residents were being assisted to bathe.On 7/17/26 at 1:26 PM, V2 (Assistant Director of Nursing/ ADON) said the nursing supervisors were responsible for ensuring resident showers were being completed when they did their morning rounds. V2 said she was not sure why resident showers had been missed.On 7/17/26 at 10:48 AM, V6 (Registered Nurse/RN) said the facility had some difficulties with staffing. V6 said she started out her shift with 3 CNA's working on her unit, but one had to leave. V6 said when there were only 2 CNA's on her unit it was difficult to get all of the resident needs met. V6 said getting the scheduled resident showers completed was difficult and they did not always get completed.On 7/17/26 at 1:06 PM, V11 (Licensed Practical Nurse/LPN) said she worked night shift in the facility. V11 said when the night shift only had 5 CNA's working, it was impossible to get all of the resident care tasks done. V11 said due to the acuity of the residents and their needs, the facility was understaffed more often than not. V11 said when the CNA's were short staffed it caused the licensed nurses to run behind on their tasks due to the CNA's being pulled to different halls to help with residents that required a 2 person assist. V11 said management was aware of the staffing problems but they haven't done a thing about it. V11 said there have been shifts she has been responsible for up to 45 residents and that was not safe. V11 said when the CNA's are short staffed she would call the on call nurse and would be told they would try to get someone to come in but they would not be coming in.On 7/16/26 at 11:17 AM, V4 (RN) said the facility was supposed to have 4 licensed nurses on day shift, 3 to 3.5 licensed nurses on night shift, 8 CNAs on day shift, and 7 CNAs on night shift. V4 said the facility used agency staff to try to fill any gaps in the schedule for licensed nurses but did not use agency staff to fill CNA positions. V4 said if there was a call-in or a shift that was short staffed, the nurse on call was supposed to come in to fill the position. V4 said she was not sure why the on-call nurse was not coming in to fill vacant positions. V4 presented daily assignment sheets verified on 6/25/26, 7/5/26, 7/12/26, and 7/13/26 in which night shift was staffed with only 5 CNA's. V4 verified on 6/25/26, the day shift was staffed with 5 CNA's from 6:00 AM to 10:00 AM then 6 CNA 's from 10:00 AM to 2:00 PM, and 7 CNA's from 2:00 PM to 6:00 PM. The facility's 5/8/26 Resident Council meeting minutes documented in part . Last months concerns are showers not being given in a timely manner and concerns about limited CAN [sic] staff, especially at night . Concerns, Questions, suggestions, and complaints. Nursing: 1) Ongoing shower issue. 2) Not enough CAN's [sic].The facility's 6/2/26 Resident Council meeting minutes documented in part .Residents were asked for suggestions, complaints, and complements for each department. Nursing: Hire more CAN's [sic], especially at night.The facility's 7/8/26 Resident Council meeting minutes documented in part . Residents were asked for suggestions, complaints, and complements for each department. Nursing. Residents are continuing to request more CNA staff. Showers are still not being completed as they should or residents are being told staff is too busy to complete.The facility's Facility Assessment Tool 04/2025 through 03/2026 documented in part . Based on your resident population and their needs for care and support, describe your general approach for staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Enter number of staff needed or an average or range:. Position. Licensed nurses providing direct care. Total Number Needed or Average or Range. 8 nurses on 12hr (hour) shifts. Position. Nurse aides. Total Number Needed or Average or Range. 14 CNA on 12 hr shifts.The facility's 7/15/26 census documented 97 residents residing in the facility.

Based on observation, interview, and record review the facility failed to provide necessary care and services to maintain the highest practicable physical and psychosocial well-being for 3 of 3 residents (R1, R2, and R3) reviewed for quality of care in the sample of 4.Findings include:1. R2's admission Record documented an admission date of 11/26/24 and included diagnoses of abnormalities of gait and mobility, unsteadiness on feet, and muscle wasting and atrophy. R2's 5/17/26 MDS assessment dated [DATE] documented a BIMS score of 12, indicating moderate cognitive impairment. On 7/16/26 at 1:20 PM, R2 was sitting in the recliner in her room with dried food down the front of her shirt and unkept oily hair. R2 said she preferred to go to the dining room for meals but had been told by staff earlier in the day they were not able to get R2 out of bed and to the dining room due to being short staffed. R2 said her shower days were supposed to be Tuesdays and Fridays but showers were routinely missed due to lack of staff. R2 said call lights take a long time to be answered but was unable to give an estimate of wait times. R2 said night shift was the worst and the girls (Certified Nursing Assistants/ CNA) try but they need more help.R2's Bath and Skin Report Sheet documented R2 was to be assisted to bathe on Tuesdays and Fridays and documented R2 was assisted to bathe on 7/3/26, 7/7/26, 7/10/26, and 7/17/26, indicating R2's 7/14/26 shower was not completed. 2. R3's admission Record documented an admission date of 5/20/22 and included diagnoses of dementia, Alzheimer's disease, and other lack of coordination. R3's MDS assessment dated [DATE] documented a BIMS score of 2, indicating severe cognitive impairment.R3's Bath and Skin Report Sheet documented R3 was to be assisted to bathe on Tuesdays and Fridays and documented R3 was assisted to bathe on 7/3/26 and 7/7/26, indicating R3's 7/10/26, 7/14/26, and 7/17/26 were not completed.On 7/17/26 at 11:52 AM, R3 was sitting in her wheelchair in the dining room. R3's appearance was unclean as if she had not been bathed recently. R3 R3's was oily and unkempt and she had brownish/black debris under her fingernails. 3. R1's admission Record documented an admission date of 12/5/23 and included diagnoses of anxiety disorder, abnormal involuntary movements, and chronic pain. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 was cognitively intact.On 7/16/26 at 1:25 PM, R1 was lying in bed watching television. R1 said she had been a licensed nurse for several years and was aware of how a facility should operate and the facility's care was poor. R1 said she attended resident council meetings regularly and several residents have complained there were not enough nursing staff. R1 said dayshift and night shift were usually short staffed of both licensed nurses and Certified Nursing Assistants (CNA) but night shift was worse. R1 said she was independent with bathing but dependent residents have complained of missing showers on their scheduled days. R1 said staffing on night shift caused call light wait times to be up to an hour if the facility was really short staffed.On 7/16/26 at 1:40 PM, V5 (CNA) said resident showers don't always get completed due to the facility being short staffed. V5 said night shift was chronically short staffed and usually did not get any resident showers completed. V5 said the unit she was currently working was supposed to have 3 CNA's scheduled but there were only 2 CNA's currently working on the unit. V5 said when the unit only had 2 CNA's working it was hard to get all the resident care tasks completed.On 7/17/26 at 12:23 PM, V7 (CNA) said she usually worked night shift. V7 said night shift is usually short staffed. V7 said when they were short staffed, resident care tasks such as assisting residents to shower were not always completed. V7 said if a resident shower was not completed she would pass that information on to dayshift in report with hopes dayshift would have time to complete the shower. V7 said she was not sure who was responsible for verifying residents were being assisted to bathe.On 7/17/26 at 1:26 PM, V2 (Assistant Director of Nursing/ ADON) said the nursing supervisors were responsible for ensuring resident showers were being completed when they did their morning rounds. V2 said she was not sure why resident showers had been missed.The facility's 5/8/26 Resident Council meeting minutes documented in part . Last months concerns are showers not being given in a timely manner and concerns about limited CAN [sic] staff, especially at night . Concerns, Questions, suggestions, and complaints. Nursing: 1) Ongoing shower issue. 2) Not enough CAN's [sic].The facility's 6/2/26 Resident Council meeting minutes documented in part .Residents were asked for suggestions, complaints, and complements for each department. Nursing: Hire more CAN's [sic], especially at night.The facility's 7/8/26 Resident Council meeting minutes documented in part . Residents were asked for suggestions, complaints, and complements for each department. Nursing. Residents are continuing to request more CNA staff. Showers are still not being completed as they should or residents are being told staff is too busy to complete.

Based on observation, interview and record review the facility failed to identify severe weight loss of three residents and failed to provide needed interventions to prevent further weight loss for 3 of 3 residents (R1, R3 and R7) reviewed for weight loss in a sample of 7. This failure resulted in R1, R3 and R7 experiencing severe weight loss.Findings include:1.R1's admission record documents an admission date of 6/27/2024 and includes diagnoses of Chronic Systolic Heart Failure, Dysphagia, Emphysema, Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Anxiety, Dementia, Depression and Atrial Fibrillation. R1's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 5 suggesting severe cognition impairment. R1's section GG documents R1 requires supervision or touching assistance with eating. R1's Care Plan documents R1 is at risk for nutrition/hydration issues related to Insulin Dependent Diabetes Mellitus, Chronic Obstructive Pulmonary Disease Congestive Heart Failure (CHF), Dysphagia, Anxiety, Depression, Chronic Respiratory Failure. Interventions include to monitor/record/report to MD (Medical Doctor) as needed of malnutrition, Emaciation, muscle wasting, significant weight loss: >5% 1 month, >7.5% in 3 months, >10% in 6 months, date initiated 6/28/24. Provide regular pureed texture diet with regular consistency liquids as ordered and monitor intake and record every meal, with a revision date of 7/22/25. RD (Registered Dietitian) to evaluate and make diet change recommendations as needed; On date initiated 6/28/2024. R1's Physician's Order Summary Report documents R1 in on a regular diet, pureed texture, regular consistency, super cereal at breakfast, whole milk at breakfast for diet. Order start date is 10/16/2024. R1's Weights and Vitals Summary printed 1/15/26 documents R1's weights were taken daily some of these weights include:12/2/25= 135.4 pounds, 12/10/25= 121.4 pounds, 12/14/25= 113.8 pounds, 12/17/25= 116 pounds, 12/24/25= 115.9 pounds, 12/30/25= 120.2 pounds. 1/3/26= 119.5 pounds, 1/7/26= 116.5 pounds, 1/13/26= 106.6 pounds.R1's 1/13/26 weight triggered a warning on the summary that documented: Comparison weight 12/14/25, 113.8 pounds, indicating a 6.3 % weight loss over 30 days with weight loss of 7.2 pounds. Comparison weight for 10/15/25, 135.2 pounds, indicating a 21.2% weight loss of 28.6 pounds in 3 months. Comparison weight 7/18/25, 134 pounds, indicating a 20.1% weight loss of 27 pounds in 6 months. Weight calculations for 30 days, 3 months, and 6 months signify a severe weight loss for all three intervals calculated. R1's Electronic Health Record documents the last visit R1 had with V10 (Previous Registered Dietitian/RD) was on 6/9/25. This note documents R1's weight was 134 pounds and that R1 had a weight gain of 11.7% in 6 months. This note documented R1's meal intakes were 51-100% that R1 was on daily weights due to CHF and was on comfort measures. R1's pureed diet was to be continued. R1's Nutritional intakes sheet for the month of January 1st through 13th document as follows: Breakfast meal intakes documents 4 days of 0 - 25% eaten, 3 days of 26-50% eaten, 2 days of 51-75% eaten, and 3 days of 76-100% eaten. Lunch intake documents, 6 days of 0-25% eaten, 1 day of 51-75% eaten, 3 days of 76-100% eaten and 1 day without documentation. Dinner meal documents, 2 days of 0-25% eaten, 3 days of 26%-50% eaten, 2 days of 51%-75% eaten, 1 day of 75-100% eaten and 3 days of no documentation. On 1/15/2026 at 12:07PM, V2 stated when R1 admitted on [DATE] she was admitted on hospice and discharged from hospice on 10/4/2025. V2 stated the last time the RD saw R1 was on 6/9/2025 but she (V2) had sent information to the RD about R1 but never got a response. V2 stated the RD would review the weights and would see who she felt needed seen. On 1/15/2026 at 2:30PM, V2 (Director of Nursing) reviewed R1's weights with this surveyor and confirmed that R1 had a significant weight loss for the last 1 month, 3 months and 6 months. V2 was asked if any new interventions were put into place for R1 regarding R1's weight loss and V2 stated, No, I already looked but I did reach out to the previous RD but she didn't respond. V2 presented weight notifications (Progress notes) and emails with the following dates 6/2/2025, 8/6/2025, and 9/23/2025 that were sent to the previous RD but they all contained notifications of weight gains. No documentation was provided of notifications of weight losses. V2 then stated they didn't put in any interventions in place for R1's weight loss and verified that R1 had not been seen by the RD since 6/9/2024. V2 stated she reviews the monthly weights herself. V2 was asked if they had IDT (Interdisciplinary Team Meetings) that involve the Dietary Manager, herself, Administrator, Care Plan Coordinator, and assistant Director of Nursing, V2 stated they do not have IDT meetings. V2 stated they look at weights in morning meeting everyday if there are weights done. V2 was asked if she sends a list of new residents, residents with weight losses, and residents with wounds to the RD so they can be seen on next visit and V2 stated, No the RD comes in and gets the monthly weights and she sees whoever she feels needs to be seen. V2 stated that the previous RD has been fired because they were not satisfied with her services, and she has been replaced by a new RD that started this month (January) but the new RD has not been in the facility yet and she is doing telehealth visits at this time. V2 stated she is the only one that reviews the monthly weights. On 1/16/2025 at 11:45AM, V2 (Director of Nursing/DON) provided a list made by the new RD of visits that occurred on 1/8/2026 and R1 was not seen. V2 stated this list was from the new RD who has not yet been in the facility, so visits have been through telehealth. On 1/15/2026 at 11:59AM, V5 (Certified Nursing Assistant/ CNA) stated she took care of R1 most days and she had noticed the last week before R1 was sent to the hospital that R1 was not hardly eating anything and that was even with assistance. V5 stated R1 required total care except she could fed herself most of the meals when she would eat. V5 stated she does- not remember if she notified of R1's decreased appetite. On 1/15/2026 at 12:05PM, V6 (CNA) stated he also helps care for R1 and stated R1 usually fed herself. On 1/15/2026 at 2:45PM, V8 (Nurse Practitioner/NP) stated she is familiar with R1, and she sent her out to the hospital on 1/13/2026. V8 stated she saw her on 1/13/2026 nd R1 did look bad, so she sent her out. V8 stated she was notified on December 8th that R1 wasn't eating very good, so she did labs and KUB (images of Kidneys, Ureters, and Bladder) resulted with a Urinary Tract Infection and was treated for that infection. V8 checked R1's chart and stated she did not receive anything recently about R1's weights. V8 stated she was notified in August 2025 of a weight gain but that was the last notification for R1 in regard to R1's weights. V8 looked through R1's electronic chart for notifications from the RD or nursing in regard to R1's weight loss but could not find any notifications. V8 also looked through a stack of RD recommendations in a folder for notifications from the previous and new RD for recommendations on R1's weight loss and did not have any for R1. V8 stated if there are concerns presented to her from the RD and discussion would have been had and she would normally agree to whatever recommendation the RD would have. R8 said she would then sign the recommendation and turn them in to the DON. On 1/15/2026 at 12:17PM, V7 (Physician/Medical Director) stated he had never seen R1 at the facility. V7 was asked about weight losses and V7 stated the weights and things of that sort are handled by V8 NP. V7 stated V8 gets the recommendation and address those while in the facility on her rounds.During this investigation no observations were made of R1 due to R1 being hospitalized at the time of this survey.2. R3's admission Record documents admission date of 10/25/2025 and includes diagnoses of Type 2 Diabetes Mellitus, Fracture of Left Pubis, Candidal 26, Epilepsy, Anxiety, Muscle wasting and Atrophy and Dysphagia. R3's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 13 suggesting cognition is intact. Section GG-Functional Abilities documents R3 requires supervision or touching assistance for eating and oral hygiene. R3 requires partial/moderate assist with personal care. Section K- Swallowing/ Nutrition documents that R3 has no swallowing issues.R3's diet orders dated 5/25/2025 show upon admission R3 had orders for a pureed diet, high protein, 75 GM (gram)Carbs, 2 GM Sodium, no sweetened beverages. On 10/31/2025 diet was changed to regular diet, regular texture, regular consistency for liquids. On 11/18/2025 diet was changed to regular, mechanical soft, with regular liquids. On 11/26/2026 diet was changed to a regular diet, regular texture, regular fluid consistency, bite size-staff may need to assist if patient is unable to cut with fork/knife, offer diet drinks/condiments. R3's current Care Plan documents a focus area of: Usual ADL (Activities of Daily Living) Performance, R3 is able to eat with supervision, created on 10/28/25. Interventions include: R3 is able to eat with supervision from staff. R3's Care Plan does not address any focus areas related to nutrition or weight loss.R3's Weights and Vitals Summary printed 1/15/26 documents R3's weights as follows: Height is 71 inches. admission weight on 10/26/2025 = 129 pounds, 11/21/2025 = 123 pounds, 11/25/2025 = 121.6 pounds, 12/9/2025 = 124.4 pounds, 1/7/2026 = 115.8 pounds. R3 's weight record had 2 inaccurate weights entered on 12/2/2025 of 155.2 pounds and on 12/16/2025 weight of 167.8 pounds. On 1/15/2025 at 2:30PM, V2 verified that these weights were inaccurate and should have prompted reweighs. These weights document that R3 had a 6.9% weight loss from 12/9/25 to 1/7/26 with a loss of 8.6 pounds and a 13.2 pound weight loss or 10.2% since admission (3 months). R3's weight calculations show severe weight loss for 30 days and 3 months. According to the Adult BMI (Body Mass Index) Calculator located at https://www.cdc.gov/bmi/adult-calculator/index.html. R3 has a BMI of 17.1 indicating R3 is considered underweight.On 1/16/2025 at 1:00PM requests were made for R3's intake sheets to both V1 and V2. During this investigation none were provided via email or paper copy. R3's Nutrition/Dietary Note authored by V10 dated 12/8/25 documents R3 consumes 51-100% of meal intakes, has a weight of 155 pounds, a weight range of 121-129 pounds and needs assistance at times to cut up meats. Continue regular diet, include diet drinks/condiments to help control glucose levels. On 1/15/2025 at 2:30PM, V2 was asked about R3's weight loss and V2 stated when R3 admitted she had several diet changes but mainly the consistency of her food is what was altered. V2 stated R3 was a very picky eater and will ask for substitutes at times especially grilled cheese. V2 stated she knew R3 was not eating good. V2 acknowledged that R3 had a weight loss. V2 verified that the weight given to V10 for R3 on 12/8/25 was an inaccurate weight and V10 based her assessment off of the inaccurate weight on 155 pounds. R3's Nutritional Care Report made by V11 (new RD) dated 1/8/2025, documents R3, under Summary reads: Recommend continuing current diet and encourage intake. On this same document under action reads: weight needed (reweight. Weekly weight, etc.) On 1/16/2026 at 9:42AM, R3 was observed sitting in the dining room visiting with other residents while they colored. R3 was asked if she was aware of having a weight loss, R3 stated, yes I know I have lost some weight. R3 was asked if she knew why she was losing weight, R3 stated, Yes I hate the food here and they serve our food cold, and I just can't stand to eat it. R3 was asked if she ever ask for alternates and R3 stated, I have at times, and they usually will give me a grilled cheese, but I can't live on grilled cheese alone. R3 was asked if she is offered snacks in between meals or at bedtime and R3 stated, They will not give us snacks in between meals and they tell us we will have to wait for our next meal. R3 stated we sometimes get offered snacks at bedtime but sometimes we don't. R3 was asked if a dietitian has visited her at the facility to talk about her diet and/weights, R3 stated, no I have not seen a dietitian and no there has not been anyone talk to me about my weight loss. R3 stated she gets weighed but it is different ones that weighs her. R3 stated, they do help me when I need help, but I just don't like the food here. R3 was well groomed and stated her only complaint is the cooks and the food. On 1/16/2026 at 9:15AM, V9 (CNA) stated she works mostly on Reclaim 1 hall and takes care of R3. V9 stated the weights are done by whoever is working on the assigned days to obtain weights. V9 was asked if they ever must do reweighs and V9 stated occasionally we are asked to reweigh. V9 stated we the CNAs do the weights and then give them to the nurse and the nurse puts them in the computer. V9 stated the CNA's record the intakes of meals as well. V9 was asked if snacks are offered in between meals and at bedtime, V9 stated we don't offer snacks throughout the day but try to offer snacks at bedtime. V9 stated if a resident asks for a snack throughout the day we try to get snacks for them. V9 stated sometimes we run out of specific snacks and sometimes the kitchen does not put out the bedtime snacks because sometimes they run out of snacks. V9 stated R3 does not like a lot of the foods we offer, and she does not eat that good and will sometimes want a substitute. V9 stated there have been times that R3's son will bring her in food, and she will eat that good. V9 was asked if everyone knew about the weight losses with R3 and V9 stated we do the weights and turn those in to the nurses. V9 also stated we keep a weight book at the nurse's station as well and it keeps a record of the weights and who is to be weighed daily, weekly, and monthly. V9 stated the nurses review the weights and puts them in the computer and the DON reviews the weights as well. 3. R7's admission Record documents an admission date of 12/16/2024 and includes diagnoses of Alzheimer's Disease, Unspecified Dementia, Essential Hypertension, Hypothyroidism, Insomnia, Anxiety, Muscle Wasting and Atrophy. R7's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 6 suggesting severe cognition impairment. Section GG Functional Abilities documents R7 receives set up/or clean up assistance for eating. oral hygiene, toileting, upper body dressing and personal hygiene. Section K-Swallowing/Nutritional Status documents R7 has no swallowing issues. Under weight loss section it is documented that R7 had loss of 5% more in the last month or loss of 10% or more in last 6 months and R7 is not on physician-prescribed weight-loss regimen. R7's document titled Order Summary Report documents R7's has an order dated 12/17/2024, Regular Diet, regular texture and consistency, offer super cereal at breakfast, whole milk at breakfast, health shakes three times a day and offer ice cream at lunch. On 4/15/2025 and order was started for a dietary supplement of a health shake three times a day by dietary. May supplement with med pass if health shakes are not available.R7's Care plan documents R7 is at risk for nutrition/hydration issues related to Alzheimer's, Dementia, Cognition Communication deficit, Hypertension, and Hypothyroidism with revision date of 7/28/2025. Goal: R7 will be able to maintain weight without experiences any significant gains or losses with revision on 7/28/2025 and target date of 10/22/2025. Interventions include, R7 needs a calm, quiet settings at mealtimes with adequate eating times. R7 prefers to sit with current roommate. Encourage R7 socialization and interaction with table mates during meals, dated 7/28/2025. Monitor/document/report to physician for signs and symptoms of dysphagia and refusing to eat dated 7/28/2025. Monitor/record/report to physician signs and symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss:>5% in 1 month, >7.5% in 3 months, and >10% in 6 months, dated 7/28/2025. R7's Weights and Vitals Summary printed 1/16/26 documents R7's weights to include:1/9/26= 106.2 pounds, 12/2/25= 118.6 pounds, 11/11/25= 116.8 pounds, 10/2/25= 123.4 pounds, 9/2/25= 132.6 pounds, 8/4/25= 135.6 pounds, 7/15/25= 131.6 pounds. R7's 1/6/26 weight triggered a warning on the summary that documented: Comparison weight 12/2/25, 118.6 pounds, indicating a 10.3 % weight loss over 30 days with weight loss of 12.4 pounds. Comparison weight for 7/5/25, 132 pounds, indicating a 19.7% weight loss of 26 pounds in 6 months. Weight calculations for 30 days and 6 months signify a severe weight loss. R7's Nutritional Intake sheets reviewed for month of January 2026, Breakfast resulted with 3 days of 0= 0-25% intake for breakfast, 6 days of 1=26%-50%, 4 days of 3= 76%-100%. Lunch resulted with 5 days of 0-25%, 5 days of 26-50%, 2 days of 51-75%, and 3 days of 76-100%. Dinner resulted with 6 days of 0-25%, 3 days of 26-50%, 1 day of 51-75%, 1 day of 76-100% and noted 5 days with no documentation.R7's Nutrition/Dietary Note by V10 dated 12/8/25 documents R7 has a 10.5% weight loss within the last three months with a weight of 119 pounds. R7 feeds self after set up with 50-100% meal intakes. Advanced age with increasing dementia. Continue reg diet with house supplement three times a day. Super Cereal at breakfast whole milk as B milk, Ice Cream at lunch. Resident being offered additional calories/protein. Encourage intakes, monitor intakes and weights, refer as needed. R7's Nutrition/Dietary Note by V10 dated10/20/25 documents RD Annual Assessment completed, refer as needed. Reviewed the Annual Assessment via electronic record with no significant changes. Assessment entailed risk for nutritional issues, labs, and current weights. R7's Nutrition/Dietary Note by V10 dated 10/14/25 documents R7 with a 7.5% weight loss within 1 month, weight fluctuating. Weight 123 pounds. R7 feeds self after set up with 50-100% meal intakes. Advanced age with increasing dementia. Continue reg diet with house supplement three times a day. Super Cereal at breakfast whole milk as B milk, include Ice Cream at lunch or additional calories. Encourage intakes, monitor intakes and weights, refer as needed. R7's Progress Notes documents with dates as follows: R7 was seen by Registered Dietitian (RD) on 12/8/2025, 10/20/2025, 10/14/2025, 7/14/2025, with new intervention on 10/14/2025 of Ice Cream at lunch. On 6/9/2025 RD notes documents to discontinue fortified foods, offer Super cereal at Breakfast, whole milk as B milk. The last intervention implemented for R7 was on 10/14/2025.On 1/16/2026 at 12:10PM, R7 was observed sitting in the dining room, slowly eating her lunch. R7 did not consume her whole meal, she mainly picked at her food. Staff was queuing R7 a few times but R7 was not eating much. R7 had a health shake and R7 was sipping on the health shake. R7 ate less than 50% of meal. R7 was not interview able during observation. When R7 was assisted by staff by staff reminding her to eat, R7 would start back to be picking at the food but not really eating much. On 1/19/2026 at 4:29PM, V2 stated R7 continues to feed herself but does require verbal ques and encouragement. V2 stated R7 does continue to eat in the dining room and enjoys visiting with the other residents. V2 stated they had the V11 (new RD) look at her again via telehealth today and will put in a new intervention for the significant weight loss. V2 stated the V11 reviewed R7's weights and has put in a new intervention today for Remeron for appetite stimulant to start tomorrow 1/20/2026. V2 stated hopefully this will help her to eat better and gain back some of her weight. On 1/16/2025 at 2:00PM, V1 (Administrator) stated the team discuss weights every morning in their meeting and V1 stated that monthly weights are reviewed by V2 as well. V1 stated they do not meet weekly to review weights because they do the review daily. On 1/16/2026 at 2:15PM, V2 was about R7's weight loss. V2 stated, well we have a lot of interventions in place for R7. When V2 was asked about the most recent weight loss not being addressed with new interventions V2 stated we will have her looked at by V11(new RD) and see what she wants us to do about the weight losses. On 1/15/2026 at 2:00PM an attempt was made to call V10 (previous RD) with no answer but message was left on voice mail. An attempt was then made again at 2:30 with no success.On 1/16/2026 at 10:00AM, V2 stated V11 (New RD) was not present in the facility. At that time an attempt was made to reach V11 by phone and was unsuccessful. On 1/15/2026 at 2:56PM this surveyor went to the dietary department to speak with Dietary Manager but told dietary manager was not there.On 1/16/2026 at 9:50AM this surveyor went to the dietary department and was told the Dietary manager was not available at this time. No interview was able to be conducted with the Dietary manager during this survey. Policy titled Weight Assessment and Intervention dated with revision date of August 2008, documents the nursing staff and the Dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss or gain for our residents. Policy #6 defines Significant Weight Changes are defined as: more or less than 5% within 30 days, 7.5% or less within 90 days, and more or less than 10% within 6 months. Under #8 document shows, if a weight loss or gain meets the definition of Significant, the Dietitian should discuss with the Interdisciplinary Team if a Significant Change MDS is necessary. Under #10 the document shows, Interventions for undesirable weight loss or gain should focus first on food (e.g extra food, snacks, calorie-dense foods, etc.) Interdisciplinary Team members should consider possible interventions relevant to their discipline. The physician may order test, appetite stimulants, or medications as appropriate.

Based on interview and record review, the facility failed to provide the identified level of supervision and assistance required to prevent PICA behaviors for one of three residents (R4) reviewed for supervision in the sample of 11. Findings include:R4's admission record documents an admission date of 10/31/19 with the following diagnoses in part; Brief psychotic disorder, other specified eating disorder, delusional disorders and depression.R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 3, indicating R4 is severely cognitively impaired. In section E-Behavior, R4 is coded to have other behavioral symptoms not directed towards others occurring 1 to 3 days. In section I-Active Diagnoses, R4 is coded to have malnutrition and a psychotic disorder (other than Schizophrenia).R4's current care plan documents a focus area of (R4) is at risk for psychosocial issues related to communication issues, impaired cognitive functioning due to dementia, behaviors such as physical and verbal aggression towards staff and wandering, (resident requires a 1:1 sitter), resident has a PICA behavior often eating cigarette butts, plastic, Styrofoam, and pages from books, chronic pain from osteopenia, chronic back pain, and left hip pain, use of psychotropic medications to help manage anxiety, depression, and for behavioral management. Resident is a current smoker but needs supervision due to PICA behavior and unsafe smoking habits. Date initiated 8/11/25. With interventions including, 1:1 R/T (related to) Dx: PICA requiring close observation. (no initiation date listed).R4's Documentation Survey Report dated September 2025 under Intervention/Task- putting non-food items in mouth documents R4 attempted to ingest non-food items on 9/3, 9/4, 9/5, 9/10, 9/11, 9/12, 9/15, 9/16, 9/17, 9/18, 9/22, 9/23, 9/24, and 9/28. There were no notes documented for any of these dates with specifics on the behavior. R4's Documentation Survey Report dated October 2025 under Intervention/Task- putting non-food items in mouth documents R4 attempted to ingest non-food items on 10/1, 10/2, 10/4, 10/8, 10/11, 10/12, 10/14, 10/20, 10/28, 10/29, and 10/31. There were no notes documented for any of these dates with specifics on the behavior. R4's Documentation Survey Report dated November 2025 under Intervention/Task- putting non-food items in mouth documents R4 attempted to ingest non-food items on 11/1, 11/4, 11/5, 11/6, 11/9, 11/12, 11/19, 11/22, 11/25, 11/26 and 11/30. There were no notes documented for any of these dates with specifics on the behavior. R4's Documentation Survey Report dated December 2025 under Intervention/Task- putting non-food items in mouth documents R4 attempted to ingest non-food items on 12/2, 12/3, 12/4, 12/6, 12/7, 12/8, 12/9 12/12 12/15, 12/25, and 12/26. There were no notes documented for any of these dates with specifics on the behavior. R4's progress notes dated 10/4/25 at 4:07pm, Resident has had 3 loose stools and has been putting the stool in her mouth each time CNA (Certified Nursing Assistant) reported.R4's progress note dated 10/4/25 at 11:59am, Was Resident Safety Check sheet completed? every shift for resident safety. Was a behavior observed? YES. Resident was found rummaging through a desk drawer behind the nurse's station where she had found a package of cigarettes. She took a bite out of one of them before staff intervention occurred.R4's progress note dated 12/9/25 at 8:39am, Reported to this nurse by night shift nurse that res. was inappropriately handling own BM (bowel movement) when the night shift CNA was doing bed check. (V2) RN DON notified. (V14) NP (Nurse Practitioner) . notified. Verbal orders received from NP to d/c (discontinue) seroquel 25mg and start abilify 5mg. Called .POA (Power of Attorney)/daughter to update on orders. (Name of daughter) gave verbal consent to start abilify and stated she would like her mom to be fed at all meals. (Name of daughter) thanked this nurse for update and stated she will be here at noon to feed her. On 12/31/25 at 10:34am, V8 (Licensed Practical Nurse) stated he was R4's dayshift nurse on 12/9/25. V8 stated R4 had been found ingesting her own feces on night shift, he spoke with R14 (Nurse Practitioner) and her medications were changed around and she was immediately placed back on 1:1 supervision. V8 stated if a behavior is observed, it is documented in a resident's chart so that management can review it and address it accordingly. V8 stated Certified Nursing Assistants complete behavior tracking, but anyone aware of a behavior should be charting on it and CNA's should be reporting behaviors to the nurse.On 12/31/26 at 11:35am, V1 (Administrator) stated R4 was not on 1:1 from 9/19-12/9 because she was not exhibiting PICA behaviors, which is putting nonfood items in her mouth. V1 stated R4 was on safety checks which meant that staff rounded on her once every 15 minutes.On 1/5/25 at 9:47am, V14 (NP) stated she had not received report of R4 having PICA behaviors or ingesting her own feces until 12/9. V14 stated if it would have been reported to her, 1:1 would have been the first intervention initiated.On 1/7/26 at 10:21am, V11 (Certified Nursing Assistant/CNA) stated if she marked yes under the behavior tracking for Putting nonfood items in her mouth, the behavior was occurring. V11 stated sometimes it might just be her hair, but she will put anything in her mouth she can get her hands on, hair ties, cigarettes, paper towels, toilet paper. V8 stated management took R4 off 1:1 for a while because they believed that if they kept her room really clean and a close eye on her she would not have the behaviors as much. V8 stated in the behavior tracking if you check yes on putting nonfood items in her mouth, a box will pop up where you can type in what behavior she is having, like a little note. V8 stated she tries to put in a note. V8 stated no one asks any follow-up questions to behavior tracking.On 1/7/26 at 10:48am, V2 (Director of Nursing/DON) stated she reviews behavior tracking/progress notes once every 72 hours and results are discussed in IDT (Interdisciplinary Team). V2 stated the reason that R4 was not on 1:1 from 9/19-12/9 was because she was not having PICA behaviors. V2 stated when staff trigger a behavior it should give CNA's the option to write a note that shows up in the progress note and they should be putting what the behavior is.On 1/7/26 at 1:38pm, V1 stated she was not aware of R4 having any behaviors between 9/19 and 12/9. V1 stated V2 (DON) reviews behavior tracking and progress notes and will report findings at morning meetings. V1 stated when they were notified of R4's behavior on 12/9, they immediately placed her back on 1:1.Undated facility policy titled, Behavior Management Policy states in the section titled Standards . 6. Staff will increase observation of the resident as per plan of care and behavior management plan . 10. Behavior tracking forms are used to document the frequency of occurrence of target problem behaviors. Staff on all shifts will document observations so that occurrences may be periodically tabulated and analyzed.

Based on interview and record review, the facility failed to provide person-centered interdisciplinary behavioral health services and appropriate supervision to 1 of 3 residents (R4) reviewed for behavioral health services in the sample of 11. Findings include:R4's admission record documents an admission date of 10/31/19 with the following diagnoses in part; Brief psychotic disorder, other specified eating disorder, delusional disorders and depression.R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 3, indicating R4 is severely cognitively impaired. In section E-Behavior, R4 is coded to have other behavioral symptoms not directed towards others occurring 1 to 3 days. In section I-Active Diagnoses, R4 is coded to have malnutrition and a psychotic disorder (other than Schizophrenia.R4's current care plan documents a focus area of (R4) is at risk for psychosocial issues related to communication issues, impaired cognitive functioning due to dementia, behaviors such as physical and verbal aggression towards staff and wandering, (resident requires a 1:1 sitter), resident has a PICA behavior often eating cigarette butts, plastic, Styrofoam, and pages from books, chronic pain from osteopenia, chronic back pain, and left hip pain, use of psychotropic medications to help manage anxiety, depression, and for behavioral management. Resident is a current smoker but needs supervision due to PICA behavior and unsafe smoking habits. Date initiated 8/11/25. With interventions including: 1:1 R/T (related to) Dx: PICA requiring close observation. (no initiation date listed). Monitor behavior episodes and attempt underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. (no initiation date listed).R4's Documentation Survey Report dated September 2025 under Intervention/Task- putting non-food items in mouth documents R4 attempted to ingest non-food items on 9/3, 9/4, 9/5, 9/10, 9/11, 9/12, 9/15, 9/16, 9/17, 9/18, 9/22, 9/23, 9/24, and 9/28. There were no notes documented for any of these dates with specifics on the behavior.R4's Documentation Survey Report dated October 2025 under Intervention/Task- putting non-food items in mouth documents R4 attempted to ingest non-food items on 10/1, 10/2, 10/4, 10/8, 10/11, 10/12, 10/14, 10/20, 10/28, 10/29, and 10/31. There were no notes documented for any of these dates with specifics on the behavior.R4's Documentation Survey Report dated November 2025 under Intervention/Task- putting non-food items in mouth documents R4 attempted to ingest non-food items on 11/1, 11/4, 11/5, 11/6, 11/9, 11/12, 11/19, 11/22, 11/25, 11/26 and 11/30. There were no notes documented for any of these dates with specifics on the behavior.R4's Documentation Survey Report dated December 2025 under Intervention/Task- putting non-food items in mouth documents R4 attempted to ingest non-food items on 12/2, 12/3, 12/4, 12/6, 12/7, 12/8, 12/9 12/12 12/15, 12/25, and 12/26. There were no notes documented for any of these dates with specifics on the behavior.R4's progress notes dated 10/4/25 at 4:07pm, Resident has had 3 loose stools and has been putting the stool in her mouth each time CNA (Certified Nursing Assistant) reported.R4's progress note dated 10/4/25 at 11:59am, Was Resident Safety Check sheet completed? every shift for resident safety. Was a behavior observed? YES. Resident was found rummaging through a desk drawer behind the nurse's station where she had found a package of cigarettes. She took a bite out of one of them before staff intervention occurred.R4's progress note dated 12/9/25 at 8:39am, Reported to this nurse by night shift nurse that res. was inappropriately handling own BM (bowel movement) when the night shift CNA was doing bed check. (V2) RN DON notified. (V14) NP (Nurse Practitioner) . notified. Verbal orders received from NP to d/c (discontinue) seroquel 25mg and start abilify 5mg. Called .POA (Power of Attorney)/daughter to update on orders. (Name of daughter) gave verbal consent to start abilify and stated she would like her mom to be fed at all meals. (Name of daughter) thanked this nurse for update and stated she will be here at noon to feed her. On 12/31/25 at 10:34am, V8 (Licensed Practical Nurse) stated he was R4's dayshift nurse on 12/9/25. V8 stated R4 had been found ingesting her own feces on night shift, he spoke with R14 (Nurse Practitioner) and her medications were changed around and she was immediately placed back on 1:1 supervision. V8 stated if a behavior is observed, it is documented in a resident's chart so that management can review it and address it accordingly. V8 stated Certified Nursing Assistants complete behavior tracking, but anyone aware of a behavior should be charting on it and CNA's should be reporting behaviors to the nurse.On 12/31/26 at 11:35am, V1 (Administrator) stated R4 was not on 1:1 from 9/19-12/9 because she was not exhibiting PICA behaviors, which is putting nonfood items in her mouth. V1 stated R4 was on safety checks which meant that staff rounded on her once every 15 minutes.On 1/5/25 at 9:47am, V14 (NP) stated she had not received report of R4 having PICA behaviors or ingesting her own feces until 12/9. V14 stated if it would have been reported to her, 1:1 would have been the first intervention initiated.On 1/7/26 at 10:21am, V11 (Certified Nursing Assistant/CNA) stated if she marked yes under the behavior tracking for Putting nonfood items in her mouth, the behavior was occurring. V11 stated sometimes it might just be her hair, but she will put anything in her mouth she can get her hands on, hair ties, cigarettes, paper towels, toilet paper. V8 stated management took R4 off 1:1 for a while because they believed that if they kept her room really clean and a close eye on her she would not have the behaviors as much. V8 stated in the behavior tracking if you check yes on putting nonfood items in her mouth, a box will pop up where you can type in what behavior she is having, like a little note. V8 stated she tries to put in a note. V8 stated no one asks any follow-up questions to behavior tracking.On 1/7/26 at 10:48am, V2 (Director of Nursing/DON) stated she reviews behavior tracking/progress notes once every 72 hours and results are discussed in IDT (Interdisciplinary Team). V2 stated the reason that R4 was not on 1:1 from 9/19-12/9 was because she was not having PICA behaviors. V2 stated when staff trigger a behavior it should give CNA's the option to write a note that shows up in the progress note and they should be putting what the behavior is.On 1/7/26 at 1:38pm, V1 stated she was not aware of R4 having any behaviors between 9/19 and 12/9. V1 stated V2 (DON) reviews behavior tracking and progress notes and will report findings at morning meetings. V1 stated when they were notified of R4's behavior on 12/9, they immediately placed her back on 1:1.Undated facility policy titled, Behavior Management Policy states in the section titled Policy It is the policy of this facility that all residents shall be assisted and monitored for mental, emotional, and behavioral changes as well as physical condition and appropriate interventions initiated. Staff actions will be directed toward symptom awareness, symptom description and monitoring in order to identify goals interventions and approaches.Undated facility policy titled, Behavior Management Policy states in the section titled Policy Specifications: To designate responsibilities of the interdisciplinary team when residents exhibit inappropriate, problematic or disruptive behavior symptoms which are potentially harmful to the health or welfare of the resident or other residents or staff, and address guidelines for facility staff interventions. To assure appropriate assessments are conducted to rule out environmental or medical causes of behavior.

Based on observation, interview and record review, the facility failed to ensure a sink located in the kitchenette of the resident's dining room was maintained and in good repair. This has the ability to affect all 98 residents residing in the facility. Findings Include:On 12/2/2025 at 11:22 AM, the sink area of the kitchenette was observed to have a copious amount of black substance to the bottom shelf and to both sides of the sink cabinet wall, with multiple dead gnats on the bottom drawer face. The bottom shelf was also noted to be broken. Black substance was also sporadically noted in areas around the ceiling vent located above the refrigerator in this same area. On 12/2/2025 at 11:23 AM, V8 (Maintenance Director) stated he had been notified by the kitchen staff about 2-3 weeks ago regarding the sink area located in the kitchenette. V8 stated the same black substance was noted to the area at that time, but he had been busy with the remodeling of the facility, and had not had time to remove the sink. V8 stated the sink will need to be removed completely and replaced. V8 acknowledged there did appear to be dead gnats on the bottom drawer of the cabinet as well. On 12/2/2025 at 11:32 AM, V1 (Administrator) stated her expectation were for V8 (Maintenance Director) to reach out to her if he is needing anything he does not have on hand to fix an item, including repairs to the sink in the kitchenette. V1 stated V8 should have taken care of the sink when notified by staff. The facility's Resident Daily Census Report documented 98 residents in house on 12/1/2025.The facility's Environmental Services Policy (undated) documented under Policy To assure that the facility is constructed, equipped and maintained to carry out all service functions protecting the health safety of residents, personnel and the public in compliance with all applicable Federal, state and local regulations. Under Policy Specifications: 21. The Dietary Service Department is designed and equipped for preparation and serving of meals and complies with all required Federal, state and local regulations for the provision and maintenance of food service facilities.

Based on interview and record review the facility failed to safely transfer a resident with a mechanical lifting device for 1 of 3 (R1) residents reviewed for accidents in a sample of 3. This failure resulted in R1 sustaining an impacted fracture of the right humeral neck.This past noncompliance occurred from 10/10/25 to 10/16/25.Findings include:R1's admission Record documents an admission date of 1/29/21, with diagnoses including unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, unspecified fracture of upper end of right humerus, initial encounter for closed fracture, muscle wasting and atrophy, not elsewhere classified, other lack of coordination.R1's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 9, indicating R1 is moderately cognitively impaired. Section GG-Functional Abilities documents that R1 is Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity for transfers.R1's current Care Plan documents that R1 is at risk for falls related to impaired mobility, with a history of falls, suprapubic catheter, and a history of cerebral vascular accident with hemiplegia. The focus area documents R1 is dependent on staff with lower body dressing, putting on/taking off footwear, transfers and toilet hygiene, with interventions including, transfers require a sling lift, with an initiation date of 6/17/2024. The same Care Plan also documents that R1 requires assist with all ADL's (Activities of Daily Living) related to impaired mobility and right sided weakness with interventions including Bed mobility requires ext (extensive) assist of 2 with an initiation date of 10/21/19.R1's Physician's Order Sheet with a print date of 10/21/25 documents an order for R1 to be transferred via sling lift, with an initiation date of 6/17/24.R1's Injury Investigation Summary with an incident date of 10/10/25, that was completed by V2 (Director of Nursing/DON) states in the final summary/conclusion On 10/10/25 R1 was being transferred with a sit to stand by R5 (CNA) when she experienced a syncopal episode and was then lowered back to wheelchair.the employee who performed the transfer was given 3-day suspension, coaching on Kardex and provided further transfer training.R1's final Serious Injury Incident and Communicable Disease Report documents an incident date and time of 10/10/25 at 8:07pm. Under detailed incident summary documents (R1) is. dependent upon staff for transfers and ambulation and requires max assist for most ADL's. On 10/10/25, (R1) was being transferred with the sit to stand when she experienced a syncopal episode then lowered back to wheelchair. Resident was assessed by nurse and no obvious injuries were noted. Resident complained of right shoulder pain and heat pack applied. (V8 Nurse Practitioner) notified and ordered stat imaging. In house imaging showed impacted fracture of the humeral neck with no significant displacement.Resident was sent to (local hospital) ER (Emergency Room) for further evaluation.R1's Progress Notes document on 10/10/25 at 9:19pm, X-ray performed and results of x-ray faxed to facility. Res. (resident) has possible Fx (fracture) to Right humeral head. X-ray results show impacted transverse Fx of the humeral neck with no significant displacement. Per results, clinical correlation is requested to determine the age of the fracture. POA (Power of Attorney) notified of x-ray results and POA stated he was made aware of incident that possibly caused fracture earlier on this date. POA requesting res. be sent to hospital for further evaluation/tx (treatment.) Resident made aware of x-ray results and POA request and thanked this nurse for update. Res. stating she is in constant pain and hopes the hospital will help with the pain.R1's Progress Notes document on 10/10/25 at 11:13pm, Late entry: (local) EMS (Emergency Medical Services) arrive at approx. (approximately) 2130 (9:30PM) for transport resident to hospital.R1's ED (Emergency Department) Provider Notes from the local hospital with a date of service of 10/10/25 at 10:12pm documents that R1 presented to the Emergency department for a right humerus fracture. This document states that R1 fell at the facility out of a sit to stand lift.On 10/20/25 at 10:34am, R1 stated she could not remember how she was injured.On 10/21/25 at 11:16am, V1 (Administrator) stated on 10/11/25 they identified a failure with the incident that occurred the evening of 10/10/25 involving R1. V1 stated they immediately started an investigation as soon as they were notified of the incident and the Quality Assurance Committee immediately started to develop a plan of correction.On 10/22/25 at 12:37pm, V5 (Certified Nursing Assistant/CNA) states that R1 needed to go to the bathroom. V5 stated he was unsure how R1 transferred, so he asked her, and she told him the sit to stand. V5 stated that she transferred to the toilet with the sit to stand without incident. V5 stated when he lowered her back into her chair, it appeared she passed out. V5 stated he immediately alerted the nurse. V5 stated he was suspended while investigated, he was trained on how to find out what someone's transfer needs were and general training on transfers.On 10/22/25 at 1:03pm, V3 (Licensed Practical Nurse/LPN) stated she did not witness the incident that occurred on 10/10/25, but she was R1's nurse that day and assessed her immediately after. V3 stated that V5 had transferred R1 with the sit to stand lift, and stated she passed out when transferring her back to the wheelchair. V3 stated that R1 had no visible injuries but complained of right shoulder pain. V3 stated she immediately contacted the physician and R1's power of attorney. V3 stated pain relief and stat x-rays were ordered and R1 was sent out later when Xray results were received. V3 stated she was under the impression that everyone in the facility knew that R1 was to be transferred using a sling lift. V3 stated that R1 had right side paralysis. V3 stated if someone is unsure of how someone is to be transferred, they can reference the Kardex or they can always ask a nurse, as they can find it in the chart.On 10/21/25 at 11:14am, V2 (DON) stated if staff is unsure how to transfer a resident, they can utilize the Kardex to find the information. V2 also stated the information is in the residents' medical record in a few different places, the nursing staff can access that information. The facility policy titled, Safe Lifting and Movement of Residents with a revision date of August 2008, states in the section for the use of mechanical lifts; Mechanical lifting devices shall be used for any resident needing a two person assist. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. Prior to the survey date, the facility took the following actions to correct the noncompliance:1. The facility held a meeting with Quality Assurance Committee on 10/11/25 with V1 (Administrator) and V2 (DON) to develop a plan of Correction for the 10/10/25 incident.2. On 10/10/25 R1 was transferred with a sit to stand by V5 (CNA). V3 (LPN) called V8 (Nurse Practitioner/NP) with resident complaints of shoulder pain. Hot pack, Tylenol and x-rays ordered.3. On 10/10/25 V4 (LPN) received x-ray results, notified V8 and R1 was sent to the emergency room for evaluation for determination of age of fracture.4. On 10/11/25 R1 returned to the facility with sling to right shoulder, Norco for pain and follow-up with orthopedics.5. On 10/11/25 V5 (CNA) was suspended pending investigation.6. On 10/16/25 V5 was reinstated and received additional training on reviewing Kardex, Hoyer lift, sit to stand and having two people while using a mechanical lift.7. Starting on 10/16/25 Administrator or designee will conduct daily audits of high risk rounding form, resident Kardex, Care Plans and staff/resident transfers to ensure correct transfers lift and practice are being followed.8. QAPI (Quality Assurance and Performance Improvement) committee will continue to monitor the facilities' performance to ensure corrective actions are effective.9. Completion date systemic changes will be completed: 10/16/25.

Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. This failure resulted in R1 stabbing R2 in the back multiple times with an ink pen and both R1 and R2 being sent to the emergency room for evaluations. This past noncompliance occurred between 7/11/25 and 7/12/25.The findings include:R1's admission Record documented an admission Date of 5/30/24 and listed diagnoses including Unspecified Dementia, Major Depressive Disorder, and Anxiety Disorder. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Inventory for Mental Status (BIMS) Score of 8, indicating R1 has moderate deficits in cognition. R1's Care Plan dated 6/9/25 documented a problem area, (R1) has been the recipient and aggressor of verbal and physical aggression related to dementia, and continual reorganization of personal belongings and environment.R2's admission Record documented an admission Date of 6/26/24 and documented diagnoses including Epilepsy and Cerebral Palsy. R1's MDS dated [DATE] documented a BIMS score of 13, indicating R2 has minimal deficits in cognition. R2's Care Plan dated 5/21/25 documented a problem area, (R2) has been the recipient and aggressor of verbal and physical aggression related to poor coping skills.A Facility Incident Report Form dated 7/6/25 at 9:20 AM, authored by V1, Administrator, documented, Altercation reported to Abuse Coordinator by nursing staff. (R1) and (R2) were arguing in the hall over a jacket. (R2) called (R1) a curse word and attempted to take the jacket away from (R1) resulting in (R1)'s arm being scratched. Both residents were immediately separated and the jacket was taken to determine who the jacket belonged to. Residents were assessed. (R1)'s scratch was cleansed and treatment [sic] as ordered. No other signs of injury or pain were noted. Notified Power of Attorney and Nurse Practitioner of incident for both residents. Investigation begun.A Facility Incident Report Form dated 7/11/25 at 8:30am, authored by V1 documented, (R2) reported that (R1) stabbed her in the back with a pen. (R1) was assessed and multiple puncture marks were visualized on (R1)'s back. (R1) and (R2) both were sent to the hospital for evaluation. (Local Police Department) (was) notified. Geriatric Psychiatry and Family Practice Nurse Practitioners notified. Power of Attorney/Family notified for both residents. Investigation begun.A Facility Incident Report Form dated 7/11/25 at 10:30am, authored by V1 documented, During investigation of previous incident (7/11/25 at 8:30am), (R1) informed (V1) that (R1) had a bruise on her forehead. (R1) stated she did not report the bruise or incident to anyone. Both residents are separated. Both residents sent to ER (Emergency Room) for evaluation. (Local Law enforcement), Geriatric Psychiatry and Family Practice Nurse Practitioners notified. Power of Attorney/Family notified for both residents. Investigation begun.R1's History of Present Illness from the local ER dated 7/11/25 documented, (R1) is a [AGE] year old female brought to ER for a mental health exam following stabbing another patient at a local nursing home. She reports an incident at her nursing home where she used a ballpoint pen to defend herself against another resident who she describes as, 'feisty,' and, 'argumentative.' This documentation goes on to state, She mentions a bruise on her forehead, which she attributes to being hit by the same resident two days ago. Review of Systems: Psychiatric: She exhibits impaired recent memory. Patient does seem to have appropriate judgement, but lost control after repeated offenses from the fellow resident she stabbed. Medical decision making: Urinalysis is slightly positive for infection. Patient was started on Ceftin. Patient will be returned to the nursing home. Nursing home staff will need to take appropriate measures to keep the two residents apart. I do not have concern patient will attack anyone else outside of being attacked herself.R2's History of Present Illness from the local ER dated 7/11/25 documented, The patient was stabbed at her facility with a pen by another patient, in her right upper back. 10 total superficial wounds noted to right shoulder and back. Patient states, I was visiting my friend and another person who wasn't supposed to be in the room stabbed me with a pen in the back. Resident is alert and oriented to person, place, time, and purpose. There were no signs of infection, but I will put her on Bactrim for infection prevention. There was no documentation in the ER records as to R2 causing a bruise on R1's forehead, or any evidence of a psychiatric evaluation being done on R2. On 7/15/25 at 8:55am, R1 was alert only to herself. R1 was observed to be on one to one observation with CNA (Certified Nursing Assistant) staff. R1 was noted to have a large healing bruise to the left forehead. When asked about the bruise, R1 stated, She did that to me. It was another resident. R1 stated she could not remember the other residents name, but referred to her with feminine pronouns. R1 stated this resident, date unknown, saw R1 in the hall and accused R1 of stealing her jacket, which R1 denied. R1 stated that was all she remembered about that incident, but stated the other resident must have stayed mad about the jacket, because at some point after, she came into R1's room and punched R1 on the forehead. R1 stated R1 then stabbed the other resident in the back with an ink pen, In self- defense. I was trying to get her off me. R1 stated she did not remember anything about going to the hospital. R1 stated she did not know what, if anything, the facility did in response, and could not remember if she told any of the staff about getting punched in the forehead. On 7/15/25 at 9:05am, R2 was alert and oriented to person, place, and time. R2 was observed to be under one to one observation from CNA staff. R2 was observed to have ten pinprick sized scabs over her upper back. R2 stated R1 has a habit of coming into R2's room, taking R2's clothing items, leaving the room with them, and then throwing them away. R2 stated a few days ago R1 was in another residents room and she didn't belong in there, so R2 told R1 to get out, which R1 refused to do. R2 stated at that point, R1 began sticking her in the back with an ink pen. R2 stated R2 left the room and was then going down the hallway and R2 was crying, which one of the nurses noticed. R2 stated she told the nurse what happened, and the nurse examined her and saw the marks made by the ink pen. R2 stated she was sent to the ER to be examined and was given an antibiotic in case the areas became infected. R2 stated she did not recall any incidents between her and R1 over a jacket. R2 denied ever hitting R1 on the forehead or scratching R1's arm. R2 stated after the incident, staff moved R1 to the other side of the building, and R1 has one to one at all times with CNA staff, To protect her from (R1).On 7/15/25 at 9:38am, V1 stated on 7/11/25, V2, Director of Nurses, brought R2 to her to report what happened with R1. V1 stated she interviewed R2 who said R2 asked R1 to leave the other resident's room, and R1 started poking R2 in the back with a pen. V2 stated she then interviewed R1, who showed V1 a bruise on R1's forehead and indicated it was caused by R2 punching R1 in the head. V1 stated she was unaware of the bruise to R1's forehead until that time and of R1's report that it was caused by R2. V2 stated both residents were sent to the ER, and V1 requested they both receive a psychiatric evaluation, which the ER did not do. V1 stated when both residents returned to the facility on 7/11/25, both were immediately placed on one to one staff supervision. V1 stated there have been no further interactions between R1 and R2. V1 stated R1 was moved to a room at the farthest part of the building away from R2. V1 stated neither R1 nor R2 have any history of assaulting peers. On 7/15/25 at 11:40am, V1 stated she was notified immediately about the incident with R2 scratching R1 in the hallway, and an immediate investigation was initiated. V1 stated through the investigation it was determined that R2 scratched R1 accidentally while attempting to take the jacket from R1.The facility's Abuse Prevention Program Policy dated October 2022 documented, Federal and state laws and regulations mandate that a nursing home resident has the right to be free from verbal, sexual, physical, and mental abuse, exploitation, corporal punishment, and involuntary seclusion.Prior to the survey date, the facility took the following actions to correct the non-compliance:1. On 7/11/25, the Quality Assurance Committee developed a Plan of Correction for the 7/11/25 incident.2. On 7/11/25, (R1) and (R2) were sent to ER for evaluation and the facility requested both residents receive a psychiatric evaluation.3. On 7/11/25, V1 called local law enforcement to report the incident on 7/11/25.4. On 7/11/25, V1 contacted both residents Primary Care Nurse Practitioner and Psychiatric Nurse Practitioner to complete medication reviews. A new order was given to give R1 the as needed antianxiety medication already on file. A new order was received to start R2 on an antihistamine for the treatment of anxiety as needed for 14 days.5. On 7/11/25, V1 educated staff on the Abuse Prevention Policy.6. On 7/11/25, R2 returned to the facility, and R2's Care Plan was updated to include one to one supervision during waking hours and 1 hour safety checks while asleep.7. On 7/11/25, R1 returned to the facility and R1's Care Plan was updated to include one to one supervision all weekend, with reassessment 7/14/25. R1's room was moved to the other end of the building (away from R2).8. On 7/12/25, V1 and V2 completed Abuse Risk Assessments on all residents.9. Starting on 7/12/25, V1 or designee will audit all residents that are high risk of abuse weekly for 4 weeks to ensure care plan interventions are in place and are being followed.10. The Quality Assurance Committee will continue to monitor the facility's performance to ensure the corrective actions are effective.11. On 7/12/25, all the above systemic changes were completed.

Based on interview, observation, and record review, the facility failed to investigate a bruise of unknown origin as potential physical abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4.R1's Face Sheet documented an admission Date of 5/30/24 and listed diagnoses including Unspecified Dementia, Major Depressive Disorder, and Anxiety Disorder. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Inventory for Mental Status (BIMS) Score of 8, indicating R1 has moderate deficits in cognition. R1's Care Plan dated 6/9/25 documented a problem area, (R1) has been the recipient and aggressor of verbal and physical aggression related to dementia, and continual reorganization of personal belongings and environment.R2's Face Sheet documented an admission Date of 6/26/24 and documented diagnoses including Epilepsy and Cerebral Palsy. R1's MDS dated [DATE] documented a BIMS score of 13, indicating R2 has minimal deficits in cognition. R2's Care Plan dated 5/21/25 documented a problem area, (R2) has been the recipient and aggressor of verbal and physical aggression related to poor coping skills.A Facility Incident Report Form dated 7/11/25 at 8:30am, authored by V1 documented, (R2) reported that (R1) stabbed her in the back with a pen. (R1) was assessed and multiple puncture marks were visualized on (R1)'s back. (R1) and (R2) both were sent to the hospital for evaluation. (Local Police Department) (was) notified. Geriatric Psychiatry and Family Practice Nurse Practitioners notified. Power of Attorney/Family notified for both residents. Investigation begun.A Facility Incident Report Form dated 7/11/25 at 10:30am, authored by V1 documented, During investigation of previous incident (7/11/25 at 8:30am), (R1) informed (V1) that (R1) had a bruise on her forehead. (R1) stated she did not report the bruise or incident to anyone. Both residents are separated. Both residents sent to ER (Emergency Room) for evaluation. (Local Law enforcement), Geriatric Psychiatry and Family Practice Nurse Practitioners notified. Power of Attorney/Family notified for both residents. Investigation begun.A Nursing Progress Note in R1's medical record dated 7/9/25, authored by V7, Assistant Director of Nurses, documented, Resident seen walking in the hallway and noted to have a bruise to forehead above left eye/eyebrow. Appears to be in different stages of healing indicating this may be an old bruise. This nurse asked resident if she had fallen and she was unsure but thought she may have. She was unable to recall when, where, how, or any details pertaining to a possible fall. Bruise to face approximately 4 centimeters measured by this nurse. Resident denies any adverse effects such as pain or headache at this time. (Residents current) Nurse notified of events who stated he will continue to monitor.On 7/15/25 at 8:55am, R1 was alert only to herself. R1 was observed to be on one to one observation with CNA (Certified Nursing Assistant) staff. R1 was noted to have s a large healing bruise to the left forehead. When asked about the bruise, R1 stated, She did that to me. It was another resident. R1 stated she could not remember the other residents name, but referred to her with feminine pronouns. R1 stated this resident, date unknown, saw R1 in the hall and accused R1 of stealing her jacket, which R1 denied. R1 stated that was all she remembered about that incident, but stated the other resident must have stayed mad about the jacket, because at some point after, she came into R1's room and punched R1 on the forehead. R1 stated R1 then stabbed the other resident in the back with an ink pen, In self- defense. I was trying to get her off meOn 7/15/25 at 9:05am, R2 was alert and oriented to person, place, and time. R2 was observed to be under one to one observation from CNA staff. R2 was observed to have at least ten pinprick sized scabs over her upper back. R2 denied ever hitting R1 on the forehead or scratching R1's arm.On 7/15/25 at 9:38am, V1 stated on 7/11/25, V2, Director of Nurses, brought R2 to her to report what happened with R1. V1 stated she interviewed R2 who said R2 asked R1 to leave the other residents room, and R1 started poking R2 in the back with a pen. V2 stated she then interviewed R1, who showed V1 a bruise on R1's forehead and R1 indicated it was caused by R2 punching R1 in the head. V1 stated she was unaware of the bruise to R1's forehead or of R1's report that it was caused by R2. On 7/15/25 at 10:05am, V7, Assistant Director of Nurses, stated she was walking past R1 in the hallway on 7/9/25, when she saw R1 and noticed R1 had a bruise over the left eye. V7 asked R1 what happened, and initially R1 said she couldn't remember but then said she didn't want to talk about it, which is often her response to questions. V7 stated during the conversation, R1 stated she thought maybe she fell but wasn't sure. V7 stated she consulted with V2, Director of Nurses, who told V7 to measure the bruise, which measured 4 centimeters. V7 stated V2 advised V7 that since the bruise was under 7 centimeters in diameter, the bruise did not have to be reported to V1 as the Abuse Coordinator as possible abuse. On 7/15/25 at 10:15am, V2 stated on 7/9/25, V7 approached V2 about the bruise to R1's forehead. V2 stated she told V7 that since the bruise was less than 7 centimeters in diameter, it did not need to be reported to V1. On 7/15/25 at 11:40am, V1 stated her understanding was that V7 thought the bruise was caused by a fall, therefore V7 did not suspect it could have been caused by abuse, and did not report it to V1. On 7/15/25 at 3:05pm, V1 stated nursing staff including V2 and V7 have now been reeducated on reporting injuries of unknown origin to V1 so that an immediate abuse investigation can be initiated. An Abuse Prevention Program Policy dated October 2022 documented, Supervisors shall immediately inform the Administrator or person designated to act in the Administrators absence of all reports of incidents, allegations, or suspicions of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the Administrator or designee shall initiate an incident investigation. This policy goes on to state, The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered.

Based on interview, observation, and record review the facility failed to dispose of expired medications. This has the potential to affect all 91 residents living in the facility. Findings include: The Long-Term Care Facility Application for Medicare & Medicaid (CMS 671) dated 6/9/25, documents there are 91 residents living in the facility. 1. R61's admission Record documents an admission date of 10/27/2022 with diagnoses including in part type 1 diabetes, heart failure, and chronic pain syndrome. R61's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 12 indicating moderately impaired cognition. R61's Order Summary Report documents Zofran Oral Tablet 4 MG (Ondansetron HCl) Give 1 tablet by mouth every 8 hours as needed for nausea with a start date of 12/26/2023. On 06/11/25 at 3:01 PM, there was an expired card of Ondansetron 4 mg for R61 found in the medication cart. Medication card had 26 pills left in it and the medication card documented an expiration date of 12/27/24, instructions on the card were take 1 tab PO (by mouth) Q8 hours (every 8 hours) as needed for nausea. Medication card was dispensed to the facility on [DATE]. On 06/11/25 at 3:15 PM, V5 (Registered Nurse) confirmed the medication was expired and stated the pharmacy frequently checks the medication carts for expired medication. V5 stated she usually checks expiration dates on medications before she gives the medication. R61's Medication Administration Record dated January 2025 documents Zofran oral tablet 4mg (Ondansetron HCl) Give 1 tablet by mouth every 8 hours as needed for nausea was given on 1/29/25. R61's Medication Administration Record dated April 2025 documents Zofran oral tablet 4mg (Ondansetron HCl) Give 1 tablet by mouth every 8 hours as needed for nausea was given on 4/11/25. 2. On 06/11/25 at 9:03 AM, there were two bottles of Aspirin 325 milligrams (mg) with a documented expiration date of September 2024. On 06/11/25 at 9:03 AM, V6 (Licensed Practical Nurse) confirmed the 2 bottles of Aspirin 325 mg expired in September of 2024. V6 stated pharmacy checks the medication storage rooms for expired medication. V6 stated it is the night shift nurse's responsibility to return expired medications to the pharmacy. V6 stated the Asprin bottles were stock meds and not resident specific. On 06/12/25 at 12:36 PM, V2 (Director of Nursing) stated the pharmacy checks the medication storage room and the medication carts monthly. On 06/12/25 at 02:06 PM, V1 (Administrator) stated the nursing staff should be checking expiration dates for medications in the medication storage room and medication cart. V1 stated the pharmacy does not provide any documentation stating they checked for expired medications, and she just found out they only spot check the medication cart and medication storage room for expired medications. A facility policy dated 10/27/2014, titled Consultant Pharmacist Services Provider Requirements documents under Procedures, F. Specific activities that the consultant pharmacist performs includes, but is not limited to: 4) Ensure that the medication storage areas are examined monthly, and the medication carts quarterly for proper storage and labeling of medications, cleanliness, and removal of expired medications.

Based on observation and interview the facility failed to ensure proper hand hygiene was performed before assisting dependent residents with eating and while serving residents glasses for 4 of 8 residents (R10, R58, R72, and R88) observed for dining in a sample of 51. Findings include: On 06/10/25 at 12:30PM, V7 (Certified Nurse Assistant/CNA) was noted to be assisting R88 with eating. V7 used her right hand and would pick up R88's spoon and give him a few bites. V7 then put down R88's spoon she then touched her face then both of her hands and then she picked up R58's spoon with her right hand and started to give R58 a couple of bites of her food. V7 then put down R58's spoon and then picked up R88's spoon and started assisting R88 with several bites. No hand hygiene was observed at anytime during this observation. 1. R88's admission record dated 06/12/25, documents an admission date of 04/01/25 with diagnoses in part of critical illness myopathy, chronic motor or vocal disorder, gastro-esophageal reflux disease without esophagitis, age-related physical debility, personal history of traumatic brain injury, unspecified abnormal involuntary movements, and lack of coordination. R88's MDS (Minimum Data Set) dated 04/07/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 14 which indicates cognitively intact. Section GG documents eating as dependent. R88's Care Plan with a revision date of 04/22/25 documents a focus of R88 has a ADL (Activities of Daily Living) self-care performance deficit r/t (related to) a traumatic brain injury. This focus area includes a intervention of: Eating R88 is dependent on staff for eating during meals. On 06/12/25 at 1:00PM, R88 stated that the CNA's (Certified Nurse Assistant's) must assist him for all meals. R88 stated that the CNA' s will usually assist him with eating along with another resident at the same time. R88 stated that he has never seen a CNA perform hand hygiene of any kind such as washing hands or using a hand sanitizer after they assist the other resident with a bite and then switch over to give him a bite. 2. R58's admission record dated 06/12/25, documents an admission date of 05/02/25 with diagnoses in part of zoster without complications, paroxysmal atrial fibrillation, dysphagia, need for assistance with personal hygiene, and anorexia. R58's MDS dated [DATE] documents in Section C a BIMS score of 01 which indicates R58 is cognitively impaired. Section GG documents supervision or touching assist with eating. R58's Care plan with a revised date of 04/21/25 documents a focus area of, R58 has a ADL self-care performance deficit activity intolerance fatigue. This focus has an intervention of: Eating R58 is able to eat with supervision/cues. On 06/10/25 at 12:50PM, V7 (CNA) stated that she did not perform hand hygiene at anytime when she was assisting R88 and R58. V7 said that anytime you touch anything or switch from assisting one resident to the other that you should perform hand hygiene such as washing hands or using a hand sanitizer. V7 said she forgot to bring her hand sanitizer and that she was more worried about assisting R88 and R58 with their meals and she forgot all about hand hygiene. On 06/10/25 at 12:29pm, R72 and R10 were being assisted by V4 (Restorative CNA). V4 was continuously observed from 12:29pm to 12:38pm, no hand hygiene was observed being performed by V4. V4 was alternating between assisting R72 and R10 with eating. V4 was also grabbing their glasses by the rim and continue to assist them with eating and did not perform hand hygiene. V4 was observed touching the table and touching the residents during this observation. 3. R10's admission record documents an admission date of 01/22/2020, with the following diagnoses: senile degeneration of the brain, Parkinson's disease, and unspecified dementia. R10's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 3, indicating R10 is severely cognitively impaired. Section GG-Functional Abilities documents that R10 requires substantial/Maximum assistance for eating. R10's current care plan documents, requires assist with all adls (activities of daily living) r/t (related to) cerebral vascular accident, Parkinson's and dementia. 4. R72's admission record documents an admission date of 09/18/2024 with the following diagnoses: unspecified dementia and lack of coordination. R72's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 2, indicating R72 is severely cognitively impaired. Section GG-Functional Abilities documents that R72 requires supervision or touching assistance for eating. R72's current care plan documents, The resident has an ADL self-care performance deficit r/t (related to) activity intolerance, confusion, dementia, fatigue. With an intervention of, .requires supervision from staff for eating during mealtimes. On 06/11/25 at 12:37pm, V4 (Restorative CNA) stated she did not recall whether she sanitized in between residents while assisting with lunch. On 06/12/25 at 11:23am, V15 (Dietary Manager) stated staff should not grab cups by the top where residents drink from. On 06/12/25 at 03:13pm, V2 (DON/Director of Nursing) stated her expectation would be for staff to perform hand hygiene in-between direct contact with residents. Facility policy titled, Handwashing/Hand hygiene with a revision date of August 2008 documents in general guidelines, use of an alcohol-based hand rub for all of the following situations: . before direct contact with residents .

Based on observation, interview, and record review the facility failed to provide safe transfers with mechanical lifts, implement interventions for falls, and follow facility policy to complete assessments and investigations post resident fall for 4 (R1, R2, R3, and R6) of 6 residents reviewed for accidents int the sample of 6. Findings include: 1. R1's Admission Record documented an admitted [DATE] with diagnoses that included: muscle weakness, chronic pain syndrome, morbid obesity, osteoarthritis of left and right knees. R1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/20/24 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. R1's MDS also documented R1 was dependent on staff for transferring. On 1/15/25 at 9:48 AM, R1 said he had fallen out of the sit to stand mechanical lift twice. R1 said the first fall happened when a Certified Nursing Assistant (CNA) was transporting R1 to the shower room from R1's room. R1 said he told the CNA prior to being transported R1 did not think his knees could hold him up long enough to transport him to the shower room. R1 said when he was almost to the door in his room he told the CNA his knees were going to give out and his knees buckled and R1 fell out of the sit to stand mechanical lift. R1 said the second fall out of the sit to stand mechanical lift was during a transfer from the bedside commode to his wheelchair. R1 said he did not recall how the second fall happened. R1 said once they had lifted R1 off the bedside commode the next thing he knew he was in the floor lying on top of a CNA. R1 said he had not sustained any injuries from either of his falls. On 1/16/25 at 2:46 PM, V18 (CNA) stated that on 12/2/24, she was caring for R1. V18 said she was transporting R1 from his room to the shower room on the sit to stand mechanical lift. V18 said she was comfortable transporting R1 to the shower room in the mechanical lift because a few days prior to 12/2/24 she had used the sit to stand mechanical lift to transport R1 from his room to the shower room. V18 said after getting R1 on the sit to stand mechanical lift she transported R1 to the door of his room and when she turned around to open the door, she heard R1 scream, turned to see R1 throw his arms into the air, slide out of the lift's sling falling onto the floor on his buttocks then rolling to his side. V18 said she yelled for help and V19 (CNA) and V20 (Licensed Practical Nurse/LPN) came into R1's room. V18 said V20 assessed R1 and told V19 and V18 it was safe to get R1 up. V18 said she and V19 used the sit to stand mechanical lift to lift R1 out of the floor and transfer R1 to his wheelchair. V18 said after R1 was back in his wheelchair she went to the front office and informed V1 (Administrator) and V2 (Director of Nursing/DON) of R1's fall from the sit to stand mechanical lift. V18 said V1 and V2 told V18 residents were not supposed to be transported around the facility in the sit to stand mechanical lift. V18 said she had worked previously as a CNA and was familiar with the sit to stand mechanical lift but had not received any training on how to use the sit to stand lift in the facility. V18 said she was hired in the facility to work in the activities department but had transitioned to working in the nursing department. R1's Electronic Medical Record (EMR) did not document any progress notes, post fall assessments, or updates to R1's care plan for R1's 12/2/24 fall from the sit to stand mechanical lift. R1's 12/2/24 Occupational Therapy Treatment Encounter Note(s) documented in part . (V2/DON) entered therapy room asking if patient could be 2 assist transfer with walker as (R1) is requesting this. (V2) states (R1) had fall off of sit to stand lift earlier this date . went to room to train CNAs with transfer training during toileting, when entering (R1's) room he is sitting edge of bed, (R1) visibly upset, due to being upset (R1) is not listening to safety education . (R1) stated throughout that the fall off of the sit to stand happened due to the CNAs attempting to transfer him too far instead of just putting him back into the wheelchair they attempted to bring him into the hallway to bring him to the shower and he took himself out of the sit to stand sling due to his knees unable to hold him up anymore and lowered himself to the floor, (V2) is aware of this and has provide education to CNAs that this is unsafe to do . On 1/16/25 at 11:39 AM, V20 (LPN) said she was the nurse caring for R1 on 12/2/24. V20 said she did not recall R1 falling out of the sit to stand mechanical lift. V20 said she did not recall any CNAs reporting to her any residents falling off the sit to stand mechanical lift. On 1/16/25 at 12:34 PM, V2 (DON) said a post fall assessment and a fall risk assessment should have been completed by V20. V2 said R1 should have had a fall risk care plan and a new intervention should have been put in place after the 12/2/24 fall. V2 said she was not sure why a post fall assessment, fall risk assessment, or fall risk care plan with fall interventions was not completed for R1's 12/2/24 fall. V2 said the facility did not have an investigation for the root cause of R1's 12/2/24 fall or interventions. V2 said due to V18 (CNA) being hired in the activities department and transitioning to the nursing department V18 had not received training on the sit to stand mechanical lift because this training was supposed to be completed on hire. V2 said all staff should receive training on all the mechanical lifts in the facility prior to the staff using the lift. The facility's mechanical lift training log documented V18 did not receive any training on mechanical lifts until 12/18/24. R1's Care Plan includes a focus area with a date initiated of 12/13/24 that documented (R1) has, had an actual fall with no injury during sit to stand transfer due to poor communication/comprehension and unsteady gait. R1's Care Plan also documented a Created on date of 1/15/25 for this focus area. Corresponding interventions included to Monitor/document/report PRN (as needed) x (times) 72h (hours) to MD (medical doctor) for s/sx (signs/symptoms): Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, with a date initiated of 12/13/24; Nursing to monitor and report any behaviors of not following proper transfer technique. Report to nursing supervisor and or MD as needed, with date initiated of 12/15/24; PT (physical therapy) consult for strength and mobility, with date initiated of 12/13/24; and Resident and staff educated on proper transfer technique, with a date initiated of 1/15/25. Although the initiation date of the focus area and 3 of the 4 interventions were all listed as being initiated in December 2024, the Created on dates of the focus area and interventions were all listed with a date of 1/15/25. On 1/16/25 at 1:20 PM, V1 (Administrator) said R1 did not have a baseline care plan completed on R1's admission and did not have a care plan for fall prevention or safe transferring until she created one on 1/15/25. V1 said R1 should have had a baseline care plan completed on admission for fall prevention and transfer. V1 said R1 should have also had a revised resident centered care plan for fall prevention and for transfer safety. On 1/16/25 at 11:33 AM, V8 (CNA) said she was caring for R1 on 12/13/24 with V7 (CNA). V8 said on 12/13/24, V7 and V8 were transferring R1 from the bed side commode to his wheelchair when R1 started to slide out of the sit to stand mechanical lift. V8 said V7 tried to keep R1 in the mechanical lift but was not strong enough to hold R1 up. V8 said R1 let go of the mechanical lift and slid out of the sling and landed on top of V7. The facility produced a typed and signed statement by V7 dated 12/13/24 that documented in part . Around 2:30 PM (V8) and I (V7) went to get (R1) off the bedside commode . After using soap and water to clean him, while drying his bottom off, he started to stop standing as well, so we were hurrying to get him to the wheelchair and I used my legs to brace him from behind, just to get to the chair and right before we could turn into the chair he let go of the (sit to stand mechanical lift), so I lowered him to the floor with my body underneath his . R1's Post Fall Evaluation dated 12/13/24 documented R1 had a staff witnessed fall in his room while using the sit to stand mechanical lift and did not sustain any injuries and was not transferred to the hospital. R1's Post Fall Evaluation for 12/13/24 was not completed with the following areas left blank: Provider notified, contributing factors, medication changes, vital signs, skin, physical findings, MDS, care planning, clinical suggestions. R1's fall investigation incident description dated 12/13/24 documented Resident was being transferred from BSC (bed side commode) to w/c (wheelchair) by sit to stand, with 2 staff present. He became weak and raised his arms causing the sling to raise and he started sliding down, when CNA got behind him and supported to to (sic) the floor, He denied injury, ROM WNL (range of motion within normal limits). The report further documents Summary of events: Res (resident) was using sit to stand with 2 staff members who were transferring him from the bedside commode back to his chair when he got upset and let himself fall. Root cause: resident raised his arms up and slid out of the sit to stand. Resident was aware that this would happen. New intervention: Educated resident on sit to stand directions. The facility's sit to stand mechanical lift's undated Owner's Operator and Maintenance Manual documented in part / . Section 1 - General Guidelines . The (company name) patient lift is NOT a transportation device. It is intended to transfer an individual from one resting surface to another (such as a bed or wheelchair). Moving a person suspended in a sling over ANY distance in NOT recommended . The facility's revised August 2008 Safe Lifting and Movement of Residents policy documented in part . 2. Staff responsible for direct resident care will be trained in the use of mechanical lifting devices. The manufacturer of purchased equipment shall provide initial staff training on the use of mechanical lifts, as well as on the routine checks and long-term maintenance of equipment. Subsequent trainings and retraining of staff on the use of mechanical lifting devices shall be conducted by designated team leaders. 3. Staff competency and the use of mechanical lift shall be assessed at least annually . 7. The transferring needs of residents shall be assessed on an ongoing basis. Resident transferring and lifting needs shall be documented in the care plan. Assessment of the residents transferring needs shall include: a. Mobility of the resident . b. Size of the resident c. Weight-bearing ability d. Cognitive status . 2. R6's Admission Record documented an admitted [DATE] with diagnoses including: metabolic encephalopathy, muscle weakness, morbid obesity, Alzheimer's Disease, dementia, and psychosis. R6's MDS assessment with ARD date of 11/18/24 documented a BIMS score of 9, indicating R6 was moderately cognitively impaired. The MDS Section J Health Conditions indicated R6 had a history of falls prior to admission. R6's 12/1/24 fall investigation documented in part . Root Cause: Resident attempted to stand up and (wheelchair) rolled out from under him . Intervention: Anti-Roll backs to w/c (wheelchair) . R6's Fall Risk assessment dated [DATE] documented R6 was at high risk for falls. R6's Care Plan includes a focus area initiated on 11/21/24 that documented (R6) has a history of falls and has had an actual fall here since admission, no injuries sustained. Other risk factors includes impaired mobility, incontinence, antipsychotic use, (diabetes mellitus), Alzheimer dementia. One of the corresponding interventions listed for this focus area documents 12/1/24: Anti-Roll backs to w/c (wheelchair) with a date initiated of 12/18/24. On 1/17/25 at 11:40 AM, R6 was sitting in the dining room in a wheelchair that did not have anti-roll backs present. On 1/17/25 at 11:45 AM, V4 (Nursing Supervisor/LPN) stated she was not sure if R6 was supposed to have anti-roll backs on his wheelchair. V4 said she would have to look at R6's Care Plan to know if R6 was supposed to have anti-roll backs on his wheelchair. Upon checking, V4 said R6's Care Plan did document R6 was supposed to have anti-roll backs on his wheelchair and she was not sure why it didn't. V4 said she would put in a work order to have anti-roll backs on R6's wheelchair. 49664 3. R3's Admission Record documents an admitted [DATE] including diagnoses of Type 2 Diabetes Mellitus, Dementia, Parkinson's Disease, Polyneuropathy, Chronic Obstructive Pulmonary Disease, and Hypertension. R3's MDS with Assessment Reference Date (ARD) of 10/11/24 includes a BIMS score of 00, indicating severe cognition impairment. R3's MDS Section J, Health Conditions documents R3 has had falls resulting in injury since admission/entry or prior assessment. R3's Care Plan includes a Focus Area of R3 is at risk for falls related to: Confusion, Gait/balance problems, poor safety awareness, constantly removes 1 shoe and sock. Corresponding interventions included (but not limited to): 11/17/24 Anti-Roll backs to w/c (initiated 11/25/24) and 5/28/24 Maintenance to place anti slip floor strips to exit side of bed (initiated 6/5/24). On 1/16/2025 at 12:40 PM, R3 was propelling self in wheelchair up and down the hall. There were no anti-roll backs noted to be on R3's wheelchair at this time. On 1/17/2025 at 10:40 AM, R3's room was observed to have no anti slip floor strips beside exit side of bed. On 1/17/2024 at 10:42 AM, V15 (CNA) stated she cares for R3 most of the time. V15 stated I have never seen anti-skid strips placed by R3's bed. V15 stated sometimes R3 lays down after meals, R3 will usually lay down if we ask him to. V15 stated R3 wanders all over the facility in his wheelchair and stated she was not aware of the intervention of anti-roll backs on R3's wheelchair. On 1/17/2025 at 10:46 AM, V16 (Registered Nurse/RN) stated she was caring for R3 today. V16 stated she was not aware that R3 needed nonskid strips beside his bed. V16 stated that is probably an old intervention and the care plan needs updated. V16 stated she is notified of new interventions when she is told about them and after the meetings of the department heads who make the interventions. V16 stated after a resident falls the nurses are supposed to do a fall risk assessment in risk management. V16 stated this must be done after every single fall. On 1/17/2025 at 11:00 AM, R3 was propelling self in wheelchair down the hallway and there were again no anti-tippers noted to be on R3's wheelchair. A facility document titled Incidents lists R3's falls occurring on 10/25/2024, 11/17/2024 (2 occurrences on this date), 12/6/2024, 12/7/2024, and 12/11/2024. The only Fall Risk Assessment provided by the facility for R3 was dated 12/7/2024. The facility was unable to provide fall assessments completed for R3's other falls listed above. On 1/17/2025 at 12:10 PM, V1 (Administrator) verified there were no other fall risk assessments completed for R3's fall occurrences on 10/25/2024, the two falls on 11/17/2024, 12/6/2024, and 12/11/2024. R3's Care Plan did not include any new interventions for the falls that occurred on 10/25/24 and 12/6/24. 4. R2's Admission Record documents an admitted [DATE]. R2's MDS with ARD of 11/30/24 documents a BIMS score of 7, indicating severe cognitive impairment. Section GG documents R2 requires supervision with sit to stand and chair to chair transfer, and is substantial/maximal assistance with toileting/bathing, and walking 10 feet, 50 feet, and 150 feet. Section J, Health conditions documents R2 has had two or more falls with no injury since the prior assessment. A facility document titled Incident by incident documents R2 had falls on 11/15/2024, 11/25/2024, and 1/3/2025, 1/6/2025, and 1/12/2025. Electronic fall assessments dated 11/15/24 and 11/25/24 were found, however there were no fall assessments completed for the falls that occurred on 1/3/2025, 1/6/2025, and 1/12/25. R2's incident report dated 1/3/25 documents an immediate intervention of keep wheelchair at bedside with leg pedals off. R2's Care plan includes a Focus Area initiated on 6/13/24 of (R2) is at risk for falls related to confusion, psychoactive drug use, unsteadiness. Corresponding Interventions to the fall dates listed above included 1/6/2025: Tag alarm to be in place when (R2) is in bed as well as when in chair (date initiated 1/8/2025), 11/15/24: med review with family and provider, specifically her Haldol (date initiated 11/25/2024), and 11/25/2024: Assess for readiness to get up for meals (date initiated 12/18/2024). No interventions were added to the care plan regarding the falls that occurred on 1/3/24 or 1/12/24. On 1/17/2024 at 10:00AM V1 stated I cannot find any other fall assessments that were completed post falls for this resident. The facility's revised May 2024 Falls - Clinical Protocol policy documented in part, Under the heading Assessment and Recognition . 2. Fall Risk Assessment shall be completed . after a fall, and as clinically indicated . 6. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. a. falls should be categorized as a) those that occur while trying to rise from a seated or lying to an upright position, b) those that occur while upright and attempting to ambulate, c) other circumstances, such as sliding out of the chair or rolling from a low bed to the floor. They should be identified as witnessed or unwitnessed events. Under the heading Cause Identification . 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. a) Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke. b) Often, multiple factors in varying degrees contribute to a falling problem. C) After a first fall, the staff (And physician, if possible) Should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, further evaluation may not be needed. If the individual has difficulty or is unsteady in performing the test, additional evaluation should occur. 2. If the cause of a fall is unclear, if the fall may have a significant medical cause, such as a stroke or an adverse drug reaction (ARD), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes. a. After more than one fall, the physician should review the resident's gate, balance, and current medications that may be associated with dizziness or falling . 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Under the heading Monitoring and Follow-Up . 4. If the individual continues to fall, the staff and physician will reevaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions .

Deficiencies at this level require more than one deficient practice statement. A. Based on interview and record review, the facility failed to ensure residents assessed as being at risk for elopement were supervised and interventions were implemented to prevent elopement for 2 of 3 (R96 and R162) residents reviewed for accidents and supervision in the sample of 51. This failure resulted in R96, who had a history of elopement, and was assessed as being at risk of elopement, exiting the facility when a visitor entered, without staff knowledge, walking half the length of the facility and re-entering through the kitchen door that is located at the end of the facility, and R162 exiting the facility through a window, crossing a busy highway, and walking approximately 1.3 miles without staff knowledge. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 8/3/24 when R96 exited the facility without staff knowledge. On 8/3/24 when a visitor entered the facility through the front door, R96 exited the facility without staff knowledge. R96 walked half the length of the facility and re-entered through the kitchen door. On 8/9/24, R162 left the facility through a window, without staff knowledge. The local police notified the facility R162 was at a local business located across a busy highway and approximately 1.3 miles from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 08/20/2024 at 1:18 PM. The surveyors confirmed by observations, interview, and record review, the Immediate Jeopardy was removed on 08/12/2024, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training. Findings Include: 1. R96's Admission Record, with a print date of 8/16/24, documents R96 was admitted to the facility on [DATE], with diagnoses that include dementia, anxiety disorder, weakness, cognitive communication deficit, conduct disorder, delirium, major depressive disorder, and insomnia. R96's MDS (Minimum Data Set), dated 7/12/24, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive deficit. R96's current Care Plan documents a Focus area of, Is an elopement risk/wanderer related to: Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness. Date Initiated: 07/01/2024. This Focus area documents the following interventions: (electronic monitoring device) (wandering ) management system at all times. Date Initiated: 07/01/2024 .Resident to be seen by Geri-psych (geriatric psychiatry). Date Initiated: 07/31/2024. Psych NP (Psychiatric Nurse Practitioner) to do med review (medication review) and medication adjustment one on one care till (until) able to rest and sleep. Date Initiated: 07/15/2024.Initiate monitoring of change of behaviors after family visits. Date Initiated: 07/18/2024. Implement one to one observation anytime resident begins wandering hallways, displaying anxiety after family visits and attempts exit seeking. Date Initiated 07/16/24. Front door to remain locked, and sign posted for visitors to ring doorbell and visitors can now only enter with staff assistance. Date Initiated: 08/08/24. Sign to be posted at front and back entrance for all staff and visitors to look behind them before opening door and re-direct (R96) away from doorway before entering or exiting. Date Initiated: 08/08/2024.Check (electronic monitoring device) battery function weekly and PRN (as needed). Date Initiated: 07/01/2024.Check (electronic monitoring device) placement every shift and PRN (as needed). Date Initiated: 07/01/2024. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 07/01/2024.Monitor for fatigue and weight loss. Date Initiated: 07/01/2024.Offer a warmed blanket. Date Initiated: 07/01/2024.Offer reassurance appropriate to the concern. Dated Initiated: 07/01/2024. Offer to take to a scheduled or planned activity. Date Initiated: 07/01/2024.Offer to take to the toilet or assist with continence care. Date Initiated: 07/01/2024. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date Initiated: 07/01/2024 .Redirect resident when wandering or exit seeking. Date Initiated: 07/01/2024. Resident is to be one on one anytime the resident starts to wander, and exit seek. Resident is to remain one on one until behavior resolves. One on One is to be implemented every time this behavior occurs. Date Initiated: 8/15/2024. Return to bed for additional rest or comfort. Date Initiated: 07/01/2024. Scan (electronic monitoring device) every shift for battery percentage, ensure placement and skin integrity. Location: LLE (left lower extremity). Date Initiated 08/05/2024. Use distraction to change thought pattern. Date Initiated: 07/01/2024. R96's Elopement Evaluation, dated 7/10/24, documents a score of 04, indicating R96 is at risk of elopement. R96's Elopement Evaluation, dated 8/6/24, documents a score of 08, which indicates R96 is at risk of elopement. R96's Elopement Evaluation, dated 8/14/24, documents a score of 09, which indicates R96 is at risk of elopement. R96's Progress Notes, dated 8/3/24, documents, (V21, LPN/Licensed Practical Nurse) advises resident had left the building and no alarm sounded. Found the (electronic monitoring device) was malfunctioning r/t (related to) placement and extra socks. Contacted ADON (Assistant Director of Nurses - V2 RN/Registered Nurse) and reported resident leaving the building. Awaiting further direction at this time. POA (Power of Attorney) aware. One on one direct supervision with resident directly after occurrence until confirmed wanderguard placement and activation. A Facility Incident Report regarding R96, dated 8/3/24, documents, IDT (Interdisciplinary Team) met and reviewed incident. Complete head count was conducted. NP (Nurse Practitioner) and POA (Power of Attorney) notified. Investigations immediately conducted. Staff, resident and visitor interviews conducted. (R96) was seen ambulating the long-term care hallways on video camera. Then (R96) was seen at (name) nursing station with (V32, CNA/Certified Nursing Assistant). At 3:15 pm a visitor was entering front entrance facility when (R96) exited the facility. Visitor told (R96) she is not supposed to be outside. (R96) told visitor 'well I am going outside'. Visitor proceeded down to his father's room and did not inform the facility staff that a resident had exited the facility. (R96) walked out the front entrance and immediately re-entered the facility through the dietary door. The dietary staff took the resident to the (name) nurse station and informed the nurse that (R96) came into the dietary exit door from outside the facility. When the staff started checking (R96) (electronic monitoring device) the visitor stated I forgot to tell you that she went outside when I was coming in. (R96) (electronic monitoring device) transmitter was checked, and the red light was blinking. Blinking light indicates transmitter is active. When the transmitter was checked with the transmitter tester it indicated the transmitter was active. All resident (electronic monitoring device) transmitters were checked for the red blinking light, checked with transmitter tester and at each exit door and all alarms sounded. All staff was in-serviced with elopement policy, checking transmitters for red blinking light and checking with transmitter tester. Visitors inserviced upon entering facility not to let residents out and to immediately notify staff if it occurs. Medication review was completed, NP (Nurse Practitioner) and POA (Power of Attorney) updated, Care Plan Updated. Front door was locked, and sign posted for visitors to ring doorbell and visitors can not only enter with staff assistance. 15 minute safety checks were initiated. NP and POA updated. Care Plan updated. On 8/14/24 at 10:01 AM, V21 (Licensed Practical Nurse/LPN) stated she didn't recall what happened on 8/3/24 when R96 left the facility without staff knowledge. R96's progress note, dated 8/3/24, was reviewed with V21 and she stated, No., when asked if she could recall the events. On 8/14/24 at 10:03 AM, V31 (CNA/Certified Nursing Assistant) stated she was in with another resident, and when she came out, a nurse (V21) was walking with R96, and stated the kitchen staff just let R96 in the back door. V31 stated she never heard the alarm sound. V31 stated they kept R96 with them after that, because they do 15-minute checks when R96 has elopement behaviors. V31 stated she was walking with a visitor to let them out the front door, when the visitor said R96 got out the door when they came in. V31 stated the visitor tried to stop R96, but she said she was going. V31 stated that is when they started locking the front door. When asked if the door alarm should sound even if it was opened by a visitor, V31 stated it should, and they had checked R96's (electronic monitoring device) and it was on, and the battery level was working. V31 stated she didn't know why the alarm didn't sound. V31 stated they have a little box they hold up to the bracelet, and it will say if it is on and check the battery level. V31 stated there is also a blinking light on the bracelet, and if it is blinking, it means the bracelet is working. When asked if there was a way to see if the alarm would sound, V31 stated they took R96 to the door to see if would sound. V31 stated she wasn't there when it was checked. V31 stated they check the bracelet daily, and have always checked placement, and if the light on the bracelet was blinking. V31 stated she had forgotten they could check the battery level with the box. V31 stated they were shown how to check it after R96 eloped on 8/3/24. V31 stated R96's wanderguard was working, and they have no idea what happened. On 08/14/24 at 12:28 PM, V33 (Dietary Aid/Cook) stated she was working on 8/3/24 between 3:00 and 3:30 PM, when R96 came into the kitchen. V33 stated they thought it was V30 (Dietary Manager) coming in the door, but when it opened it was R96. V33 stated the door she entered is down by the dumpsters, near the stop sign on the south side of the facility. V33 stated she took R96 to the unit, and she was unable to locate the nurse. V33 stated once she found V21 (LPN), she (V21) got an attitude and then came back into the kitchen and told them to mind their own business; she had gotten R96 another (electronic monitoring device). V33 stated she never heard an alarm sound. On 8/14/24 at 10:05 PM, V35 (Anonymous) stated she was down the hall doing treatments, when V21 stated to her the kitchen staff said R96 was outside, and knocked on the Dietary door. V35 stated V21 walked R96 up to the front door to see if the door would alarm, and it didn't. V35 stated R96 was then placed on one to one, and V21 left the floor. V35 stated she thought V21 was calling to report the elopement to management, but she didn't. V35 stated she called V2 (Assistant Director of Nursing/ADON) to report it. V35 stated she later found out, R96 pushed past a visitor that was entering the facility and was let outside. V35 stated R96 was placed on one to one after the incident. V35 stated she didn't go with V21 when she walked R96 to the front door to see if the alarm would sound. When asked why it wouldn't alarm, V35 stated it may be an equipment malfunction. V35 stated they had training after the incident on how to check the battery and how to check for placement. V35 stated they placed a new (electronic monitoring device) bracelet on R96 after the incident, and they verified everyone else's (electronic monitoring device)were working. V35 stated she knows now how to check the bracelets. V35 stated they have a device that checks the battery. V35 stated she didn't have any idea how to use it before the incident, but now she does. When asked if she was aware they could check the battery's prior to this incident, V35 stated, No, not a clue. V35 stated prior to this incident where they documented the checks, it said to check placement. V35 stated so they were checking placement, not to make sure it was working properly. On 8/14/24 at 1:56 PM, V34 (Plant Operations Manager) stated they check the (electronic monitoring device) weekly, and staff check each day. V34 stated maintenance checks all the door alarms, but doesn't check the individual bracelets. V34 stated the nurses check the individual bracelets. V34 stated the nurses have a tester on the med cart, and it reads the warranty date, serial number, and tells if the battery is good. V34 stated if the battery is not good, it says it is zero, and to replace it. V34 stated they should be tested daily. V34 stated he is sure it is a manufacturer recommendation. V34 stated they are getting ready to enhance the system they have. When asked why the alarm didn't sound, V34 stated they called him and he in-serviced everyone, but R96's alarm was functioning properly. V34 stated they figured out staff had put the code in for another resident, and there is a 30 second delay on the door alarm, and before that 30 seconds was up the visitor let R96 out. The (electronic monitoring device) manufacturer recommendations were provided by V34, and they document the following, Testing Tags Accutech Tags operate by internal battery. Over the course of normal operations, Tags (wanderguards) eventually lose battery power and the Tags will need to be replaced. The Tag battery is not replaceable. For maximum protection of residents or assets, Accutech recommends that tags be tested on a weekly basis. There are many ways that you can test Tags: Enter a monitored zone, With an S-TAD, the Keypad's Auxiliary LED (Yellow) will light when a Tag is detected (Optional: additional wire required). Check Visual Pulse LED if present. On 8/14/24 at 4:40 PM, V1 (Administrator) stated on 8/3/24, she got a call at home telling her R96 eloped, and they didn't know how she got out. V1 stated R96 left out the front door and came in the Dietary door. V1 stated she came to the facility and when she got there, they went through the entire building because the staff were all questioning the alarm system. V1 stated apparently a visitor came in, and R96 was trying to leave. V1 stated the visitor told R96 he didn't think she was supposed to leave, and she did anyway. V1 stated the visitor said he forgot to tell anyone she left, until he heard staff talking about it. V1 stated she checked the cameras, and R96 was seen wandering the hallway by the time clock around 3:00 PM. V1 stated R96 was with V32 (CNA) at the nurse's station and then the visitor was coming in around 3:15 PM. V1 stated based on when kitchen staff take their lunch breaks, R96 entered the kitchen right before 3:30 PM. V1 stated they took R96 to the nurse and she was assessed. V1 stated no one remembers hearing an alarm. V1 stated the facility staff checked R96's (electronic monitoring device) and told her it was working, and then took R96 to the door, and no alarm sounded. V1 stated they first checked the alarm by the blinking light that indicates it was working, then they checked it against the door once, and it didn't work and then again, and it did work. V1 stated they got a different (electronic monitoring device) bracelet for R96, and it alarmed as it should. V1 stated they checked every resident's bracelet against all three doors, and they all alarmed as they should. V1 stated she decided they needed to lock the doors because they can't have visitors letting people outside and staff not know they are gone. V1 stated it may have been a delay on the alarm after the code was put in for someone else, but they can't say for sure that is what happened. V1 stated before this incident, staff were checking placement and to ensure the red light was blinking on the bracelet. V1 stated after this incident, the staff were educated to use the tester to make sure the battery was full. V1 stated they didn't use the tester on R96's bracelet until she came into the facility, and when she checked it with the tester, it was working as it should. V1 stated she had R96 assessed by the psychiatric nurse, and they did medication adjustments. V1 stated she was diagnosed with a urinary tract infection, but it wasn't a bad one. V1 stated after the elopement on 8/3/24, R96 was placed on one to one. R96's Resident Safety Checks reviewed, and do not document safety checks were being done on 8/3/24. 2. R162's Admission Record, with a print date of 8/16/24, documents R162 was admitted to the facility on [DATE], with diagnoses that include unspecified dementia, altered mental status, anxiety disorder, cognitive communication deficit, weakness, insomnia, and suicidal ideations. R162's MDS, dated [DATE], documents a BIMS score of 09, which indicates a moderate cognitive impairment. R162's Elopement Evaluation, dated 7/31/24, documents a risk for wandering/elopement was identified. R162's Elopement Evaluation, dated 8/9/24, documents a score of 07, which indicates R162 is at risk for elopement. R162's current Care Plan documents a Focus area of, Is an elopement risk/wanderer related to: Impaired safety awareness, dementia with mood disturbance. Date Initiated: 08/01/2024. The interventions documented for this Focus area are Check (electronic monitoring device) battery function weekly and PRN (as needed). Date Initiated: 08/01/2024. Check (electronic monitoring device) placement every shift and PRN. Date Initiated: 08/01/2024 .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers watching television and being able to go out to smoke every couple of hours. Date Initiated: 08/01/2024 .Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicated the need for more exercise: Intervene as appropriate. (R162) wanders purposefully looking for her family and wandering (sic) why she is here. Date Initiated: 08/01/2024. Offer a warmed blanket. Date Initiated 08/01/2024. Offer food or snacks. Date Initiated: 08/01/2024. Offer to take to a scheduled or planned activity. Date Initiated: 08/01/2024. Redirect resident when wandering or exit seeking. Date Initiated: 08/01/2024. Resident is to be one on one due to elopement out of the window. Date Initiated: 08/16/2024. Resident to be one to one at all times due to exit seeking behaviors. Date Initiated 08/16/2024. Use distraction to change thought pattern. Date Initiated: 08/01/2024. (electronic monitoring device) to be applied at all times. Date Initiated: 08/01/2024. R162's Facility Incident Report Form, dated 8/9/24, documents, Investigation conducted. IDT met and reviewed incident. Resident and staff interviews conducted. A visitor came to visit (R162) when it was discovered that (R162) could not be located. A full facility head count was conducted and determined (R162) was not in the building. All other residents were accounted for. Facility and facility grounds searched with no findings of (R162). While search was in process a staff member was notified by phone from the (local) Police department that (R162) was at the (name of business) on (name of road). Staff members then got into vehicle and went to collect (R162). (R162) was found safe with no injuries or any signs of distress. MD (physician) and Family member notified of resident elopement and safe entry back into the facility. Nurse completed full body assessment and vital signs upon reentry to facility with no abnormal findings. Safety checks initiated and (R162) was placed 1:1 at this time. (R162) admitted to kicking out the window screen and jumping out the window during interview which resulted in the alarm not sounding. Staff then assisted to check windows or any other possible site of exit. It was found on a closed Memory unit that a window was open with screen bent and had been kicked out. Upon these findings immediate interventions placed with placing a sign on the closed memory unit and placing an alarm on the closed doors that will sound anytime the doors are opened. Upon further investigation and interview with (R162) it is noted that (R162) was complaining of bilateral knee pain. Call placed to NP (Nurse Practitioner) (V5) with new orders for bilateral knee X-ray and UA (urinalysis) with culture if indicated. All labs and Xray results with negative findings. Staff continues to monitor resident for any changes in mood, status, or behavior. No changes noted. MD and family member updated on findings of investigation. Care plan updated. On 8/15/24 at 1:00 PM, V10 (Certified Nursing Assistant/CNA) stated she was working when R162 eloped. V10 stated R162 had called the police earlier that day. V10 stated she was working in the dining room, and everyone had been fed. V10 stated R162's family member came into the facility around 12:45 or 1:00 PM looking for R162 and they couldn't find her. V10 stated they searched each room and down the unit R162 lived on. V10 stated she didn't see R162 had opened a window. V10 stated V38 (MDS Coordinator) said the local police had pinged R162's phone and got her location. V10 stated they went to get her, and she was inside a place of business drinking water. V10 stated R162 was disoriented and confused. V10 stated she offered R162 a cigarette and told her they would call her family. V10 stated prior to his incident, R162 had never succeeded in eloping. V10 stated the window R162 went out was on the closed memory unit, and all the staff but one person was in the dining room, and that one person was passing meal trays. On 8/15/24 at 2:32 PM, V36 (CNA) stated she noticed right after lunch R162 was gone. V36 stated they looked through the whole building and outside, and there was a window on the closed memory unit that was open, and the screen was bent. V36 stated they assumed R162 went out the window because she was wearing a (electronic monitoring device) and no alarm went off. V36 stated they looked for approximately 20 minutes and was not able to locate R162. V36 stated R162 had been calling 911 all day that day. V36 stated V38 (MDS Coordinator) told her and V10 that R162 was on a nearby road. V36 stated then they got a call R162 was at a local business. V36 stated once they got to R162, she told them she went out a window. V36 stated R162 was very emotional, not angry or combative, just really sad. V36 stated they did a skin check when they got back to the facility. V36 stated she wasn't aware of R162 exiting the facility prior to this incident. V36 stated R162 had a (electronic monitoring device) on, and the light was blinking indicating that it was working. On 8/15/24 at 2:56 PM, V21 (Licensed Practical Nurse/LPN) stated she was working on the day R162 eloped, but she had no information related to it. V21 stated she knows nothing. On 08/15/24 at 4:05 PM, V3 (Infection Preventionist/Licensed Practical Nurse/LPN) stated she was working in the conference room, and sometime around 2:00 PM, she heard a page overhead that they needed a facility head count. V3 stated unknown staff told her R162 was missing. V3 stated they completed the head count and did not locate R162. V3 stated they had people searching outside the building and down the road. V3 stated they found an open window on the closed memory unit, with the screen bent, where it had been kicked out. V3 stated she thought V38 got a phone call stating they had R162 at a local business. V3 stated staff offered to go pick R162 up and bring her back to the facility. V3 stated R162 is a newer admission, they did an elopement risk assessment on her, and she was assessed as being at risk for elopement. V3 stated she wasn't aware of that risk prior to admission she thought she just had behavior/psychiatric issues. V3 stated when R162 got back to the facility they did an assessment, checked her vital signs, and called their corporate team, who had them place her on one to one observation. V3 stated she took R162's statement, and she was confused and didn't remember leaving. V3 stated she spoke with her later on and she said her knee was hurting. V3 stated when she asked her what she did to her knee, R162 stated it was probably when she kicked that thing out so she could escape. V3 stated they also placed an alarm on the closed memory units door so they would know if anyone entered the unit. When asked if she knew how long R162 had been gone, V3 stated she had been seen 30 minutes prior to them realizing she was missing. On 08/15/24 at 4:41 PM, V37 (CNA) stated around 11:30 AM, right before lunch, R162 came out of the activity room and handed her phone to her. V37 stated it was the local police, and R162 had called them and asked for help. V37 stated she explained to the police R162 was a confused resident. V37 stated R162 was sitting in the activities room. V37 stated she left and went to the dining room. V37 stated about 20 or 30 minutes later, after lunch the announcement went out for a head count. V37 stated she went out the back door with another CNA to look for R162. V37 stated she was checking windows, but didn't think to look on the closed memory unit. V37 stated her boyfriend, who also works at the facility, came to pick her up, so it was probably closer to 2:00 PM when they were looking for R162. V37 stated then the police called and said they had located R162. On 8/16/24 at 11:51 AM, V38 (MDS Coordinator) stated she was making rounds when V37 (CNA) came up to her and said R162 hadn't been seen for 15 minutes. V38 stated she paged for a head count and directed two CNA's to go out the back door to look, and her and the Business Office Manager started out the front door. V38 stated on her way out the door, the local police called and said they had one of the residents at a local place of business. V38 stated V10 and V36 (CNA's) went to pick her up. V38 stated R162 was sitting on a couch with a few workers, was in no distress, and had no injuries. V38 stated R162 said she had escaped V38 stated they placed R162 on one to one when they got her back to the facility, and moved her to a different room where the window goes out to the courtyard instead of outside. V38 stated R162's (electronic monitoring device) was in place and working when they got her, but because she went out a window, it didn't alarm. V38 stated R162 was leaving in two days because family had someone in place to provide 24-hour care at home. On 8/16/24 at 2:43 PM, V39 (LPN) stated she was working on the day R162 eloped. V39 stated R162 was agitated earlier in the day. V39 stated she was in the dining room when an unknown CNA came in and said R162 had called 911, and they heard her tell them we were holding her hostage. V39 stated about 20 minutes later, R162's family member brought her clothes, and they weren't able to find her. V39 stated she had checked R162's (electronic monitoring device) earlier in the day, and it was working and in place. V39 stated the police found her at the (place of business) a little over a mile from the facility. V39 stated R162 said she had jumped out of the window. V39 stated R162 complained of knee pain after she returned to the facility, and they x-rayed it with no findings. On 8/19/24 at 9:29 AM, V44 (Family Member) stated R162 went on a walkabout and when she got back to the facility, they placed her on one to one. V44 stated prior to admission to the facility, R162 had a history of wandering away. V44 stated when she left the facility, R162 made it to the gas station on the main corner in town. V44 stated someone from the nursing home called the police and they found her. On 8/19/24 at 12:55 PM, V1 (Administrator) stated on the day R162 eloped, she was out of state, and wasn't involved in the incident. V1 stated the facility did notify her R162 had left the facility. V1 stated she was told R162 kicked out a window and was gone 10-15 minutes. V1 stated once R162 was back in the facility, she said she hurt her leg kicking out the window. According to Google Maps, it would take the average person approximately 27 minutes to walk from the facility to the place of business she was located at. According to the website https://www.wunderground.com/history/daily/us/il/[NAME]/KMWA/date/2024-8-9., the temperature between 12:45 PM and 2:45 PM was 79 degrees Fahrenheit. The facility Elopement and Search (Code Amber) Policy, dated 1/2023, documents, Policy: To establish methods for protecting residents who are at risk for elopement and for conducting an organized search for a resident who cannot be located. Policy Specifications: 1. All nursing personnel are responsible for: a. Knowing the whereabouts of residents for which they are assigned. b. Department Supervisors are responsible for conducting resident rounds. C. Staff are responsible for keeping the nurse informed of a resident's whereabouts .5. Residents who have been identified as cognitively impaired and who have been assessed as an elopement risk will be provided with an elopement prevention device (arm or ankle bracelet) or be placed in an area of the facility that has a door alarm device with audible sound, or on a secured/locked unit. 6. Bracelets will be observed for placement and checked for function daily. Facility exit door alarms are checked daily for function. All personnel are responsible for promptly reporting/replacing malfunctioning elopement prevention devices. Maintenance is responsible for fixing/replacing any exit doors that do not alarm. 7. All personnel are responsible for promptly going to the location and determining the cause of the activated audible door alarm. 8. When a resident makes repeated/continuous attempts to leave the building, the resident will be visibly observed every fifteen (15) until the behavior is resolved. In the event the resident continues to attempt to leave the building, a staff member will be assigned to provide one/one supervision and the physician notified. The resident will remain on one/one supervision until the behavior resolves or alternative interventions are initiated (i.e. elopement prevention device, secured/locked unit, or placed in an area of the facility that has a door alarm device). 9. In the event a resident cannot be located the following procedure is to be implemented: a. The charge nurse of the missing resident will announce CODE AMBER (name of the floor/unit of the missing resident) over the paging system. b. The Administrator and the Director of Nursing will immediately be notified. c. All available staff will immediately report to the nursing floor/unit of the CODE AMBER to be informed of the identity of the missing resident. The nurse should provide staff a description of what they look like, what they are wearing, etc.). d. The charge nurse will assign available staff to search each of the following areas including: i. Each floor/nursing unit/hallway. The resident rooms should be searched including the bathrooms and closets. ii. Gathering areas such as lounges, dining rooms, therapy rooms, shower rooms. iii. Offices, equipment rooms, utility rooms. Even rooms that are locked should be unlocked and searched. iv. Outside building grounds including the parking lot, storage sheds, ponds, wooded areas, patio, etc. v. Some staff members should also be immediately assigned to start searching off facility premises such as streets, surrounding areas containing woods, ponds, railroad tracks within close proximity of the facility, etc. vi. Notify the police department to assist in the search if resident is not promptly found. (Authorities should be called early enough to avoid police canines loss of tracking ability, if needed). vii. Notify additional off-duty personnel for search assistance as needed. viii. Notify the attending physician and authorized legal representative. ix. Assign one individual to gather and have available for reference: information to identify the resident, such as general description, picture, clothing being worn, etc 10. When the resident is found a licensed nurse will: a. Announce CODE AMBER ALL CLEAR over the paging system. b. Perform a clinical assessment of the resident's skin and functional status and dete[TRUNCATED]

Based on interview and record review, the facility failed to ensure residents were free from verbal/mental and physical abuse for 1 of 2 (R45) residents reviewed for abuse in the sample of 51. This failure would cause a reasonable person to experience feelings of fear, anxiety, and insecurity while living in their home. Findings Include: R45's Admission Record, with a print date of 8/20/24, documents R45 was admitted to the facility on [DATE], with diagnoses that include diabetes, dysphagia, osteoarthritis, brief psychotic disorder, delusional disorder, mild cognitive impairment, and depression. R45's MDS (Minimum Data Set), dated 8/20/24, documents R45 has a BIMS (Brief Interview for Mental Status) score of 10, which indicates a moderate cognitive impairment. R45's current Care Plan documents a Focus Area of, Resident is considered at risk for abuse/neglect (per assessment) due to anxiety, dependent on others, pain, displays behaviors, psychiatric hx (history). Date Initiated: 09/16/2021. The interventions documented for this Focus with an initiation date of 9/16/21 are, Address all complaints/concerns promptly with grievance policy and procedure . Advise resident of rights yearly and PRN (as needed) . Complete risk for abuse/neglect assessment quarterly Intervene if observing any resident-on-resident conflict to avoid potential abusive situation The interventions for this same Focus area, with an initiation date of 8/19/24 are, 8/16/2204 Daughter educated to inform administrator and/or DON (Director of Nurses) of any unusual comments made by (R45) so an investigation can be conducted to prevent any incidents of verbal or physical abuse by residents or staff R45's Facility Incident Report, dated 8/12/24, documents under Final, IDT (Interdisciplinary Team) met and reviewed incident. Staff and resident interviews conducted. Visitor reported witnessing a nurse striking (R45) in the face and or mouth area. (R45) denied any nurse or staff member striking her in the face or mouth area. (V49/RN-Registered Nurse) denied striking (R45) at any time. All staff and resident interviews also confirmed that (V49) has not been witnessed striking any resident. (Name of Local Police) was notified of incident. NP (Nurse Practitioner) and POA (Power of Attorney) updated. (R45) feels safe at the building. She has verbalized understanding of what to do if anyone makes her feel unsafe, uncomfortable or threatens her in any way. Her and her daughter will report any incident to staff, who, in turn, will notify the Abuse Prevention Coordinator for immediate investigation. There is insufficient evidence to substantiate abuse. Care Plan updated. R45's undated Abuse Investigation Summary documents, Resident Interviews: (R45) 8/13/2024: This writer (V1/Administrator) and (V38, MDS Coordinator) interviewed (R45) together. This writer asked (R45) if any resident or staff member hit her on the face or mouth. She stated no. This writer asked (R45) if she has been hit anywhere on her body. She stated yes on my head. Asked (R45) to point where on her head. She pointed to the back of the head. Asked (R45) who hit her on the back of the head she stated I don't know her name. Asked her if she works days or nights. She stated nights. Asked her if she knows the staff name. She stated no but she is not very nice. Asked her if her head hurts. She stated no I am ready for dinner now and took to the dinning (sic) room for supper. Employee interviews: (V6/LPN) (not dated): I have never seen a staff member hit a resident on my hall or anywhere in the building. I was not present when this incident was reported. I have seen the alleged staff member be mean or verbally aggressive with (R45). I have never seen her be verbally aggressive toward another resident. (R45) was trying to take other resident belongings and I heard (V49) tell her no do not do that you know better than that get over here and sit down and made her follow her from the start of med pass. Family Interviews if Applicable: (V57/Family Member/Visitor) 8/13/2024 reported to administrator that when she was in her (family members) room (V49) came in and gave meds to her (family members) roommate. When the resident that wanders the hallways with the walker and is constantly going in other resident rooms tried to come into my (family's) room, she heard (V49) tell her to go sit her ass down. Then about 30 minutes later she witnessed (V49) throw her hands up in the air and strike the same resident in the mouth or face area out in the hallway. She said she heard the resident state ouch you hit me. She said I was so shocked by what I saw I thought I would let you know. (V56/Family Member) 8/16/2024. I have never seen anyone mistreat my mom (R45) and she loves living there. She is happy there. (R45) did tell me about a month ago that someone hit her on the back of the head so I asked the CNA (Certified Nursing Assistant) about it, and nobody had ever seen anyone hit her so I started watching and talking to people, but I could never catch anyone, and nobody ever saw anyone hit her. I did not say anything to anyone in the front office or the DON (Director of Nurses) about it because I thought maybe (R45) was confused or telling stories but from now on if she says something strange or does not seem right, I will report it so you can investigate it. R45's Progress Notes document on 8/13/24 at 5:01 PM, Note Text: Visitor alleges, that RN was redirecting resident and told resident to 'sit her ass down.' Visitor also alleges that RN hit resident in the mouth. Resident then told RN 'You hit me' without crying and resident was not in pain. RN was suspended pending investigation. Investigation started. On 08/20/24 at 4:05 PM, V2 (Assistant Director of Nurses) stated a visitor (V57), whose family member had since passed away, said she saw a nurse (V49) hit R45 and told her to 'sit her ass down'. V2 stated this was reported to V1 (Administrator) and the nurse (V49) acted surprised, and said she didn't do it. V2 stated R45 said it happened all the time and described the nurse (V49). V2 stated the nurse had been suspended since the allegation was reported. On 8/21/24 at 9:58 AM, V57 (Visitor) stated she spent every day at the facility with her family member. V57 stated she was in her family's room one evening with the curtain partially pulled, sitting facing the window. V57 stated it was dark outside, so she could see the reflections of what was happening in the room, in the window. V57 stated a nurse (V49) was giving the roommate her medications, and a confused resident with dementia (R45) walked into the room. V57 stated she was talking with her son on the phone, and she wasn't really paying attention to what the nurse was saying, until the nurse said to the confused resident (R45) who had wandered into the room get your ass out of here. V57 stated then she saw the nurse take the back of her hand and pop the resident in the face. V57 stated it was nighttime, and she told V1 (Administrator) about it the next morning. V57 stated she had never witnessed anything like that before. V57 stated when it occurred the confused resident (R45) stated, you hit me. V57 stated R45 then just left the area. On 08/20/24 at 4:52 PM, V49 (Registered Nurse/RN) stated she had no answers. When asked if she had ever cursed at a resident, specifically R45, V49 stated, No ma'am. I don't curse. I have before, a time or two, but I make it a practice not to. When asked if she had ever hit a resident, V49 stated, One hundred percent absolutely not. I don't even know where or how this could come about. On 08/21/24 at 8:59 AM, V56 (Family Member) stated R45 was currently in the hospital with a diagnosis of a urinary tract infection. When asked if she was aware of an allegation of abuse, V56 stated, It wasn't an allegation, it happened. V56 stated a while back (date unknown), R45 reported to her someone had been hitting her in the head. V56 stated she talked with unknown staff, and they didn't know who she was asking about, from R45's description of the person who she reported had hit her. V56 stated since she couldn't find the person R45 described, she kept watching, and V56 stated after the visitor reported R45 had been hit by V49, R45 told V1 (Administrator) it was the same nurse who hit her before. V56 stated from now on, if R45 tells her someone is hitting her, she will assume that it is happening. V56 stated V1 assured her V49 wouldn't be back to work. V56 stated there was no physical injury, but R45 was distraught when she was telling her about it. V56 stated, Who wants to get hit in the head? V56 stated she felt bad because a part of her didn't believe R45 when she first reported it. V56 stated R45 had to go through it, and no one was doing anything about it. V56 stated it was upsetting for R45 because she was getting hit in the head. V56 stated she was not notified of the incident until the next day, and when she asked the unknown male nurse why they waited to notify her, she was told they had to do whatever they had to do before they called. On 8/21/24 at 9:15 AM, V6 (LPN/Licensed Practical Nurse) stated she didn't work with V49, and the only thing she witnessed was one day when V49 was coming in to relieve her, R45 was walking by. V6 stated V49 raised her voice and said, No don't walk that way. V6 stated she didn't like the way V49 talked to R45, but she didn't think it was abusive. V6 stated after the allegation was made and V49 was suspended, she found out that Certified Nursing Assistants said V49 made R45 follow her around during medication pass, and made R45 sit with her at the nurses station. On 8/22/24 at 1:30 PM, V8 (CNA/Certified Nursing Assistant) stated V49 was rough and hateful, but she didn't think it was abuse. On 8/24/24 at 11:25 PM, V59 (CNA) stated V49 was stern, but she was good with the residents, and she had never witnessed abuse. V59 stated if she had, she would notify V1 immediately. On 8/24/24 at 11:37 PM, V60 (CNA) stated she had worked with V49, and she was a little rude or pushy when R45 was non-compliant, going in and out of other resident rooms. V60 stated V49 would reprimand R45 and was a little loud with it, but didn't yell. V60 stated R45 had never reported abuse, but awhile back V56 (Family Member) said something to her about someone being rude to R45, but they didn't think anything of it. On 8/21/24 at 10:43 AM, when asked why the allegation wasn't substantiated, V1 (Administrator) stated she talked to multiple staff, R45, and V57 (Visitor), who told V1 she witnessed V49 smacking R45 in the face/mouth area and heard R45 say Ow you hit me. V1 stated when she interviewed V49, other staff, and R45, they all denied it. V1 stated R45 denied being hit in the face, but did say she had been hit in the back of the head before. V1 stated V56 (Family Member) stated at some time, maybe a month ago, R45 told V56 someone hit her in the back of the head, and they suspect it was V49. V1 stated V56 couldn't substantiate it had occurred, and thought R45 was confused. When asked how she was not substantiating the allegation of abuse when there was someone who witnessed the abuse, V1 stated an employee who works here is related to V57 (Visitor), and said V57 makes false allegations. V1 stated, So even though (V57) said she witnessed it, since (R45) stated she was hit in the back of the head instead of in the face, I can't substantiate it. V1 stated R45 did confirm being hit in the head at some point by V49, so they are still terminating the nurse and reporting it to the Department of Professional Regulation. The facility Abuse Policy, dated 10/2022, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility 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 abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.

Based on interview, observation, and record review, the facility failed to provide medications and treatments as ordered by a physician, failed to document reassessments, and evaluate residents for advanced treatment needs for 3 (R63, R68, R100 ) of 3 residents reviewed for quality of care in a sample of 51. This failure resulted in R63 missing medication for approximately 30 days, suffering shortness of breath, and being admitted to the hospital for three days. Findings include: 1. R63's Face sheet documents an admitted [DATE], with diagnoses including: chronic obstructive pulmonary disease (COPD), non-st elevation myocardial infarction, essential hypertension, dementia, anxiety disorder, atrial fibrillation, and type 2 diabetes mellitus. R63's current Care plan includes a focus area of: R63 has COPD r/t (related to) smoking: with an intervention dated: 07/01/24 of: give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. R63's Order summery sheet, dated 06/06/24, documents medications were discontinued with a line drawn through them; Lasix oral tablet 40 MG (Furosemide), give 1 tablet by mouth in the morning for edema, does not have a line drawn through it. This indicates the Lasix should have been continued. R63's Medication Administration Record (MAR), dated June 2024, documents: Lasix oral tablet 40 MG (Furosemide) give 1 tablet by mouth in the morning for edema, with a start date of 03/08/2024 at 8:00 AM, and a D/C (discontinued) dated of 06/06/2024 at 3:05 PM. The MAR, dated June 2024, documents the Lasix was not administered after 06/06/24. The facility document titled, eINTERACT Change in Condition Evaluation, dated 06/30/24 at 2:29 PM, documents: A. Signs & Symptoms Identified .abnormal vital signs and shortness of breath checked. 2. This started on: 06/30/24 3. What time of day did this start? with afternoon marked . blood pressure: 122/68 .pulse: 88 (bpm) (beats per minute) date: 06/30/2024 14:32 (2:32 PM) pulse type: irregular - chronic . 7. Most recent O2 (oxygen) sats (saturations): 96% date: 06/30/2024 14:31 (2:31 PM) method: oxygen via nasal cannula List any medication changes made in the past week: d/c (discontinued) from hospice and Lasix . 2a. describe respiratory changes; shortness of breath is marked, 2a1a. describe shortness of breath; with abrupt onset of SOB (shortness of breath) with pain, fever, or respiratory distress .3a. describe cardiovascular changes: with edema marked . describe cardiovascular signs/symptoms: increased swelling of bilateral lower extremities Since the change in condition occurred have the symptoms or signs gotten: with 'better' marked, 1b. things that make the condition or symptoms better are: with 'applied oxygen' written in, 2. This condition, symptom or sign has occurred before: with 'yes' marked, 2a. treatment for the last episode: with 'duoneb and rescue inhaler' written in, 4. Summarize your observations, evaluation and recommendations: with 'contacted on call provider and received VO (verbal order) for duoneb q (quaque (every) 6' written in . Were the change in condition and notifications reported to primary care clinician: with 'yes' marked, 2. Date and time of clinician notification: with '06/30/2024 at 14:31 (2:31 PM) noted, 3. Recommendation of primary clinician: with 'follow up with primary provider tomorrow, call if condition becomes worse or does not improve, 5. Interventions: with 'new or change in medications' and 'oxygen' marked. R63's progress note, dated 06/30/24 at 2:31 PM, documents a pulse oximetry of 96%, method: oxygen via nasal cannula. R63's Physician order sheet documents an ordered date of 06/30/24 for ipratropium-albuterol 0.5 - 2.5 (3) MG/3ML solution with a status of 'on hand' documented with a start date of 07/08/2024, with no documentation of any administration of this medication. R63's order audit report documents an order for ipramtropium-albuterol 0.5 - 2.5 (3) mg/3ml, with the box next to 'confirmed' checked with a date of 06/30/24 at 2:28 PM noted. R63's oxygen saturation (SPO2) percentages are documented from 04/01/24 - 05/09/24 to be 96% or greater on room air. On 05/10/24 the SPO2 at 8:25 AM is documented to be 94% with oxygen via nasal cannula. On 05/27/24, 06/03/24+, 06/10/24, 06/17/24, and 06/24/24 have SPO2 of 96% or greater on room air documented. On 06/30/24 at 2:31 PM a SPO2 of 96% on oxygen via nasal cannula is documented. On 07/01/2024 at 11:15 PM a SPO2 of 96% on room air was documented. On 07/08/24 at 4:41 PM a SPO2 of 96% on oxygen via nasal cannula and 07/08/2024 at 8:52 PM a SPO2 of 96% on oxygen via nasal cannula is documented On 07/15/24 at 8:11 PM a SPO2 of 96% with oxygen via nasal cannula is documented. There are no SPO2s documented for 07/02, 07/03, 07/04, or 07/05/2024. A facility document for R63, dated 6/30/24, documents under problem/request, resident (R63) feet swollen family and resident request examination. This document is addressed to V5 (Nurse Practitioner/NP) with the response of: CBC (complete blood count), CMP (comprehensive metabolic panel), mag (magnesium), and Hgba1c (hemoglobin A 1 C) and Lasix 20 mg PO (per os (by mouth)) from V5, with the date of 07/01/24 noted. A facility document for R63, dated 07/03/24, documents: patient: (R63) date: 07/03/24, problem/request: SOB (short of breath) feeling bad. She (R63) was wearing 3L O2 (oxygen) & sating (saturating) @ 71%. Bumped her (R63) up to 5L but still not feeling well, with a response from V5 of chest x-ray and UA (urinary analysis) noted on the page. At the bottom of the page there is a not written in parentheses: Pt (patient) family took her to (local town) ER (emergency room ) and was admitted . R63's progress note, dated 07/03/24 at 2:04 PM, documents: (local hospital lab) called, Res (R63) CO2 (carbon dioxide) is 42. V5 notified. No new orders at this time. R65's hospital records, dated 07/05/24 at 2:44 PM, document: Physical exam: constitutional: general: she (R63) is not in acute distress; appearance: she is not ill-appearing; Pulmonary: breath sounds: rales present, no wheezing; Abdominal: general: there is no distension. Review of Systems: Respiratory: positive for shortness of breath, negative for cough. Cardiovascular: positive for leg swelling, negative for chest pain and palpitations. Medical Decision Making: 64 y.o. (year old) female presents to the ER as described. Admit for COPD exacerbation and volume overload. Clinical Impression: as of 07/05/24 at 7:50 PM: pneumonia of lower lobe due to infectious organism, unspecified laterality, COPD exacerbation, and acute pulmonary edema. Chief complaint patient presents with: shortness of breath. R65 is a [AGE] year old female with pmh of COPD on 4 L O2, memory loss nursing home resident presented in ED (emergency department) for worsening sob, weight gain, leg swelling for last weeks. Recently she was admitted for cardiac arrest, was discharged to nursing home with hospice care, however patient/family declined hospice two weeks ago. Was not on Lasix for two weeks, however started on Monday. At 6:47 PM Review of Systems: No intake/output data recorded. I/O (input/output) this shift: In 300 (IV piggyback:300) out: -. Physical exam: Pulmonary: breath sounds: wheezing present. Abdominal: general: there is distension, musculoskeletal: right lower leg: edema present. Left lower leg: edema present. Laboratory results: collection time: 07/05/24 at 3:16 PM Carbon dioxide 45 (HH) reference range: 21-31 mmol/L (millimoles/liter), blood urea nitrogen 28 (H) reference range: 7 - 25 mg/dl (milligrams/deciliter), creatinine 1.50 (H) reference range 0.60 - 1.30 mg/dl, X-ray chest 1 view result date 07/05/24: impression: Bibasilar atelectasis or pneumonia. Intake/output summary (last 24 hours) at 07/06/2024 at 11:45 AM: gross per 24 hour: intake 700 ml output 600 ml net 100 ml. Physical exam: Respiratory: Lungs are diminished to auscultation bilaterally. Respiratory effort is normal. No accessory muscle use. Results from last 7 days: BNP B ( B-type natriuretic peptide) 07/05/24 at 3:16 PM - 375 pg/ml (picogram/milliliters) and 07/05/24 at 10:24 PM 281 pg/ml. Current facility administered medications: arformoterol-budesonide 15mcg - 0.5 mg combo (combination) neb (nebulizer) BID ( bis in die (twice a day)) on 07/06/24 at 7:35 AM, carvedilol tablet 3.125mg BID 07/06/24 at 9:43 AM. Furosemide (Lasix) injection 80 mg BID 07/06/24 at 9:59 AM prednisone tablet 50mg daily on 07/06/24 at 9:43 AM, and spironolactone tablet 25 mg daily at 07/06/24 at 9:43 AM. On 07/06/24 at 6:13 PM patient presents with: shortness of breath; subjective : sob better, objective: hypervolemic. I/O this shift: in 241 out: 1200. Physical exam: Pulmonary: breath sounds: wheezing present. Abdominal: general: there is distension, musculoskeletal: right lower leg: edema present. Left lower leg: edema present. Intake/output summary (last 24 hours) at 07/07/2024 at 10:44 AM gross per 24 hour: intake 799.43 ml, output 3100ml net -2300.57 ml. Physical exam: Neck: supple, mild but improved JVD (jugular vein distention) is present, Respiratory: lungs are diminished to auscultation bilaterally, respiratory effort s normal. There is no accessory muscle use. On 07/07/24 at 9:40 PM I/O last 3 completed shifts: in: 1479.4 out 4375. Intake/output summary (last 24 hours) at 07/08/2024 at 11:32 AM, gross per 24 hour: intake 1388 ml, output 1975 ml net -587ml. On 07/08/24 at 11:31 AM progress notes document: assessment: principle problem: pneumonia of lower lobe due to infectious organism, unspecified laterality. Assessment & plan: 1. Acute on chronic heart failure with preserved ejection fraction-appears well compensated on exam. Will decrease Lasix to 20 mg daily which should be continued at discharge, continue spironolactone 25 mg daily, low sodium diet and daily weights. 2. Acute on chronic hypoxic hypoxic respiratory failure secondary to COPD. 3. AKI (acute kidney injury) is improving, creatinine is 1.6 today. R65's hospital discharge summary dated 07/08/24 at 12:09 PM documents: primary discharge diagnosis: pneumonia of lower lobe due to infectious organism, unspecified laterality and heart failure exacerbation (probably right heart). On 08/14/24 at 2:15 PM, V6 (LPN) stated if she had a resident that had a 71% SPO2, she would get a hold of V5 (Nurse Practitioner/NP) after she bumped up the oxygen, and see if she wanted the resident sent out. When R63 had the SPO2 of 71%, she contacted V5, and she gave an order for an in house x-ray on 07/03/24. The company that does the in-house x-ray is supposed to be same day, but now they are taking 2 to 3 days to get to the facility. (V5) is aware of the x-rays taking that long to be done. Usually, (R63's) oxygen will come back up. All the SPO2 levels are documented on the MAR. On 08/15/24 at 10:18 AM, V24 (family) stated she took R63 out to the ER (emergency room ) on 07/05/24. V24 stated she came to visit and R63 was struggling to breathe; she had more shortness of breath than usual, she was a grayish color, and her feet were so swollen they would not fit into her shoes, and she has loose fitting sandals. A CNA (Certified Nurse Assistant) asked if she wanted R63 to see V5 because she was in the building, but she stated, no, she thought she needed to go to the hospital. V5 had not done anything yet, and R63 was having problems. V24 stated R63 came to the facility after being in the hospital with pneumonia and edema. It was the hospital that she was in prior to this facility that identified the heart concerns and gave her Lasix. She does not understand why they discontinued her Lasix. Then when they prescribed the Lasix again around the beginning of July, it was at half the dose she was on. On 08/15/24 at 12:58 PM, V6 (Licensed Practical Nurse/LPN) stated when V5 (Nurse Practitioner) gave the new orders after R63 was discontinued from hospice, she believes that could be when the Lasix was discontinued. She would not have been given a reason why it was discontinued. She is not sure how to look for the old orders, so that would just be her guess. On 08/19/24 at 2:12 PM, V47 (LPN) stated she can see where the order for Ipramtropium-albuterol was put in on 06/30/24, but it is not on the MAR for June, and she does not see where she received any in July, but the start date was 07/08/24. On 08/19/24 at 2:13 PM, V6 stated she has Ipramtropium-albuterol on the cart. She does not remember ever giving R63 the medication. V6 stated she can see the order from 06/30/24, but it is not on the June MAR. She does see the order on the July MAR, and the start date is 07/08/24. She believes it has a start date that is different than expected because the order was not confirmed; the order will not show up on the MAR until the order is confirmed. On 08/15/24 at 4:15 PM, V1 (Administrator) stated, From looking at (R63's) order sheet from when her hospice medications were discontinued, it appears the medications that were discontinued have a line through them. The Lasix order does not have a line through it, so following the pattern I see, I do not know why the Lasix order was discontinued; it does not appear it should have been. On 08/19/24 at 1:22 PM, V8 (CNA) stated she kind of remembers R63 in that timeframe before she went out to the hospital; she remembers her looking grayish. On 08/19/24 at 2:16 PM, V1 (Administrator) stated, If we had a resident that had a low oxygen saturation rate and her oxygen was increased and she was still feeling bad, especially at 71%, I would expect they would be sent out. V1 stated she would expect if an order for a chest x-ray was put in, stat, it would be done in 4 to 6 hours; a standard x-ray would be a day or two, so it would depend on the way the x-ray was ordered. V1 stated she does not know why the start date for the duoneb is not 06/30 for R63. On 08/20/24 at 3:35 PM, V5, Nurse Practitioner, stated she does not know anything about R63's Lasix being discontinued, or why it would be. She did not discontinue R63's medications after she was discontinued from hospice care, that would be V48 (Physician). V5 stated she did not get notified of R63 having a SPO2 of 71%; they could have notified the Nurse Practitioner on call. V5 stated she did not give the order for ipratropium-albuterol; it must have been one of the Nurse Practitioners on call. On 08/21/24 at 10:10 AM, V35 (Licensed Practical Nurse/LPN) stated she worked on 06/30/24. She stated someone came and got her from the dining room and told her, it's an emergency. She assessed R63, who was a gray blue color. V35 stated she took her SPO2 (oxygen level) and it was 88% with no oxygen. (R63) has COPD (Chronic Obstructive Pulmonary Disease); she has oxygen and a nebulizer in her room. V35 had an order for the duoneb (nebulizer treatment) before, so I called (V5) to get an order for the medication and gave it to her. If her SPO2 did not come up right away, I would have sent her out. On 08/21/24 at 1:26 PM, V48 (Physician) stated he does not have any notes from the end of May to July. Nothing in his notes is indicating that he discontinued the Lasix after R63 came off of hospice care. V48 stated, I am looking at her hospital notes and her creatinine was up a bit, but not bad, her CO2 runs in the high 30s typically with her history of smoking and COPD, so a CO2 of 42 would not be that alarming. (R63) does not have great kidney function, so we have to watch how much Lasix (R63) is given. I did not realize in house x-rays took that long, most of my facilities can get an x-ray on the same day, or at the latest the next morning. If I was only given the information of: a resident's oxygen saturation was 71% with 3 L of oxygen and it was raised to 5 L and the resident was still feeling bad, I would say they should have been sent out, without having any follow up oxygen saturations or information on status. On 08/21/24 at 1:40 PM, V2 (Assistant Director of Nursing/ADON) stated he would expect if the nurses had a resident that had a low oxygen saturation to apply oxygen or increase oxygen, and contact the Nurse Practitioner. V2 stated if the condition persists, he would expect the nurse to call 911. He would expect if the Nurse Practitioner was contacted, staff would document that they were contacted and what the response was. In the situation with R63, he would expect that a Nurse Practitioner would have been contacted, but he would not know that for sure without a progress note. On 08/21/24 at 3:25PM, V6 stated she did notify V5 via text message on 07/03/24 of R63's oxygen level. V6 stated V5 did respond back later to her, and ordered a chest x-ray. V6 stated V5 never ordered for a recheck of R63 oxygen saturation. V6 stated she was working two halls on that day and didn't have a lot of time. V6 stated she did check on R63, but didn't chart it, because she didn't have time, was short of staff, and was working two halls. V6 stated she put a late entry in today regarding R63 on 07/03/24. V6 stated she didn't have proof on her phone of the text message. V6 stated she erases all her messages daily. 49907 2. R68's face sheet documents R68 was admitted to the facility on [DATE], with diagnoses that include: unilateral primary osteoarthritis, left knee, pain in right knee, unspecified injury of right lower leg, sequela, polyneuropathy, morbid (severe) obesity due to excess calories, and unspecified abnormalities of gait and mobility. R68's MDS (Minimum Data Set), dated 5/01/2024, documents a BIMS (Brief interview for Mental Status) score of 15, indicating R68 is cognitively intact. Section GG-Functional Abilities and Goals documents V68 is dependent on staff for toileting hygiene, showering, and bathing. V68 is listed as partial/moderate assist for personal hygiene. R68's current Care Plan documents Care Areas of: R68 has skin impairment with risk for pressure injury development related to: Immobility. R68's interventions include: Administer treatments as ordered, monitor for effectiveness. Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Monitor for infection. Report improvements and declines to the MD. Needs assistance to turn/reposition approximately every 2 hours, more often as needed or requested. A document in R68's medical record, dated 07/18/2024, titled Specialty Physician Wound Evaluation & Management Summary, documents a skin tear to the right thigh and a rash to the right thigh. The wound to the right thigh was described as a skin tear, a surgical excisional debridement procedure was performed, and the following dressing treatment plan was ordered: Primary Dressing(s)-Alginate calcium apply once daily for 30 days; Collagen powder apply once daily for 30 days; Silver sulfadiazine, apply once daily for 30 days. Secondary Dressing(s)-Gauze Island with boarder apply once daily for 30 days. The rash to the right leg was diagnoses as Candidiasis rash of the right leg. The following treatment plan was ordered. Fluconazole 150mg orally. Repeat dose in 7 days, clotrimazole 1% as directed. A document in R68's medical record, dated 07/25/2024, titled Specialty Physician Wound Evaluation & Management Summary, documents a follow up for wound to the right thigh. It further documents the wound is resolved. There is no mention anywhere on this document about the rash to the right leg. R68's July Medication Administration Record (MAR) and the Physician's Order Sheet reveals the order for Fluconazole 150mg orally. Repeat dose in 7 days was not started or administered to R68. R68's July Treatment Administration Record (TAR) and Physician's Order Sheet reveals the order for the treatment to the skin tear to the right thigh and rash was not started or administered to R68. R68's shower sheets document she received a shower on 07/18/24, when areas of skin alteration were noted. R68 received a shower or bed bath on 07/22, 07/25, 08/01 and 08/12, and no areas of skin alteration were noted. On 08/13/2024 at 12:45 PM, V3 (LPN/Infection Prevention Nurse) stated V2 (Assistant Director of Nursing/ADON) takes care of wound rounds. V3 stated R68 last treatment orders that ended on 06/13/2024; her only current order was for Nystatin powder. V3 stated it would be her expectation the staff that receives these orders to put them in and start them. V3 stated she would immediately assess V68's skin today, and contact the doctor if there were any concerns. On 08/14/24 at 12:00 PM, V37 (Certified Nurse's Assistant/CNA) was providing incontinence care for R68. An area was observed on R69's right hip that was scabbed over with brown/red eschar; no signs of infection noted on surrounding tissue. R68 stated she wasn't sure how it got there, and then said she thought she got it from her wheelchair. R68 asked V37 to please wipe the area on her leg because some people forget to clean it when they provide care, and it burns. V37 lifted R68's right leg into the air and used a wipe to wipe what appeared to be a macerated/abrased area on upper inner thigh area. R68 stated staff aren't doing any current treatments to the area on her right leg, it has been there 3-4 weeks and the nurses were putting some kind of cream and a band aid on it at one time. R68 was not sure what the actual treatment was or exact dates of the treatment. On 08/20/2024 at 1:42 PM, V1 (Administrator) stated it is the responsibility of the DON (Director of Nursing) or ADON (Assistant Director of Nursing) in the DON'S absence to follow up on wound rounds and orders. V2 stated it is also the responsibility of all the nurses; the wound doctor informs the floor nurses of what the plan of care is. 48356 3. R100's Face Sheet documents an admitted [DATE], with diagnoses of UTI (Urinary Tract infection), Enterocolitis due to clostridium difficile, type 2 diabetes mellitus, and neuromuscular dysfunction of the bladder. R100's Minimum Data Set (MDS), dated [DATE], documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R100 is cognitively intact. R100's MDS also documents substantial/maximal assist with toileting, showers, and dressing. R100's Care Plan, dated 06/19/24, documents a Focus area of a foley catheter related to: urinary retention, neurogenic bladder. Interventions include in part, monitor/record/report to MD (Medical Doctor) for s/sx (signs and symptoms): pain, burning blood tinge urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating pattern. There is no care plan related to history or risk of Urinary Tract Infections. R100's local hospital discharge summary documents an admitted [DATE], and a discharge date of [DATE], which documented in part under Active Issues requiring Follow-up Jardiance stopped due to fungal UTI (Urinary Tract Infection)/chronic foley. Hospital course documented R100 also had leukocytosis, Candida UTI, foley catheter exchange following admission. Home Jardiance discontinued. Treat with oral fluconazole. Under Discharge Medications the following is new medications are documented: Fluconazole 200 mg (milligrams), oral, daily, for Candida UTI: Quantity 11 tablets and Vancomycin 125 mg capsules 1 capsule two times a day orally, every 6 hours scheduled: Quantity 28 capsules. Stopped medications: Jardiance 25mg tablets. R100's current Physician Orders documents no fluconazole order. On 08/10/24, a new order was documented for Jardiance oral tablet 25mg give 1 tablet by mouth in the morning for DM (Diabetes Mellitus). On 08/14/24 at 12:10 PM, V4 (Licensed Practical Nurse/LPN) stated R100 was not on fluconazole and he was never started on it when he came back from the hospital on 08/07/24. V4 said the Jardiance was stopped on return from the hospital, but was restarted on 08/10/24. V4 said there was no note in the progress notes to say why the Jardiance was restarted. On 08/14/24 at 12:43PM, V3 (Infection Preventionist) stated since she looked at the discharge summary today, she noticed R100 did have an order for fluconazole, and an order to stop the Jardiance. V3 said V4 (Licensed Practical Nurse/LPN) told her R100 had orders that didn't get transferred over when he returned on 08/07/24. V3 stated R100 should have been started on fluconazole for his UTI. V3 said it does say to stop the Jardiance related to the UTI. V3 stated it was stopped on 08/07/24, but was restarted on 08/10/24. V3 stated she does not know why the Jardiance was restarted. V3 said there is no progress notes stating why the Jardiance was restarted. V3 said she would have expected a progress note stating why the Jardiance was restarted. V3 stated R100 was in the hospital for a UTI from 08/02/24, until returning on 08/07/24. V3 stated she doesn't know why they missed the other orders because they did start the vancomycin that was ordered on the discharge summary. V3 stated because they did not start the fluconazole for R100, which was ordered for his urinary tract infection, it could have caused problems or even harm to R100, because he did not get the treatment for his UTI as ordered. V3 stated she was going to call V5 (Nurse Practitioner) to see what she wanted the facility to do, since they missed the new order from the hospital for fluconazole for R100's UTI. R100's Progress notes, dated 08/14/24 at 1:34 PM, documented, New order per V5. UA (Urinalysis) with culture if indicated. R100 agrees with new orders. R100's Urinalysis with Culture collected on 08/15/24. The Final Report, completed on 08/18/24, documented urine culture with Mixed Urogenital Flora. V5 (Nurse Practitioner) signed off on Urinalysis with culture on 08/19/24 with no new orders. On 08/20/24 at 1:40 PM, V48 (Medical Doctor) said, (R100) is in pretty bad shape. I was not aware that the facility did not follow the discharge instructions to start fluconazole for (R100's) UTI and to discontinue Jardiance. (R100) should have been started on the fluconazole when he returned from the hospital. I don't know why (R100) did not start the fluconazole. The medication would have been beneficial to treat (R100's) Urinary Tract Infection. I did see that the facility did a Urinalysis with culture for (R100) on 08/15/24. The final culture of the urinalysis and the results showed Mixed urogenital flora. V48 said he does agree no treatment is needed at this time related to the current urine culture. V48 said he saw on the hospital discharge they wanted to stop the medication Jardiance. V48 said he understands why the hospital would have wanted that medication stopped, because it removes the glucose from your body in your urine. V48 said the Jardiance should have been stopped until the urinary tract infection was resolved, then re-started, because Jardiance has a lot of other benefits such as cardiac benefits. V48 said he is glad R100 was restarted back on Jardiance, but it should have been at a later time. V48 said he agrees with the Nurse Practitioner starting him back on Jardiance. V48 said the vancomycin would not have altered the culture results of the urinalysis. On 08/20/24 at 3:52PM, V5 (Nurse Practitioner) said she was made aware of the order for fluconazole on 08/15/24, when one of the nurses told her the order got missed from the 08/07/24 discharge summary. V5 said she ordered a urinalysis to be done on 08/15/24 to see if R100 still had a UTI, and if he still needed the fluconazole or another medication. V5 stated the fluconazole should have been given as ordered from the hospital, but the nursing staff missed it. V5 said R100 needed the fluconazole for his UTI. V5 said when she found out R100 didn't get the fluconazole, they did a repeat UA with Culture, if indicated. V5 said they did get the urine back with the final culture and it showed Mixed urogenital flora. V5 said she did not order for R100 to have any new medication. V5 said the UTI did clear up. V5 said she did restart the Jardiance on 08/10/24. V5 said she wasn't made aware the reason the Jardiance was stopped, but she believes he needed the Jardiance for its other benefits. V5 said she wasn't given the full (hospital) discharge summary when R100 got back to the facility to know they stopped the Jardiance related to his Urinary Tract Infection. V5 said since R100's UTI is cleared, she would prefer that R100 continue the Jardiance. The facility policy titled Admissions to the Facility, revised 12/2006, documents the following under Physician Admission Orders: Prior to or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least, B. Medication orders, including (as necessary) a medical condition or problem with each medication. 4. R100's Care Plan, dated 06/19/24, with a Focus area of, (R100) has altered skin integrity and/or risk for pressure injury development related to disease process impaired mobility, weakness. Interventions for this focus area include in part: Weekly skin check. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, or discoloration noted during bathing or daily care. R100's Progress notes document on 08/05/24 at 6:38AM, R100 is currently in the hospital. Progress note, dated 08/07/24 at 7:15PM, documents R100 returned from hospital. No skin assessment was noted on readmission from the hospital in R100's progress notes. R100's Specialty Physician Wound Evaluation and Management Summary, dated 08/08/24, documents under History chief complaint, (R100) has wounds on his sacrum, right groin, left foot, right elbow, left hand, right dorsal hand, right foot. At the request of the referring provider. A thorough wound care assessment and evaluation was performed today. On 08/15/24 at 11:30 AM, V21(Licensed Practical Nurse/LPN) and V41(LPN) were performing treatments to R100, when V21 stated all treatments were completed. Three dressings were noted to R100's left upper mid back that appeared older with exudate on them. V21 stated she was not aware of any treatment to R100's left upper mid back. V21 removed all three dressings, which had exudate on the dressings. All three dressings were dated 08/06/24, with no initials. V21 said she was not aware of any open areas to left mid upper back. V21 stated R100 does not have any treatment to those areas. R100's Physician Orders documents a order on 06/18/24 Skin checks every day shift every Mon (Monday), Thu (Thursday). An order, dated 06/18/24, skin assessment on shower days every day shift every Mon, Thu. No treatment order for upper left back was noted in Physician orders. R100's Bath and Skin Report Sheet for August 2024 documents on 08/08/24, a bed bath was given, with no new skin areas documented. 08/15/24 Bed bath documented with no new skin areas documented. On 08/20/24 at 1:06 PM, V21 stated after she discovered the three areas to R100's left upper mid back, she did call the wound doctor. V21 stated the wound doctor said he would come in and look at the new areas and decide what treatment is needed, if any. V21 said the wound doctor is aware R100 has a diagnosis of bullous pemphigoid. V21 said R100 gets blisters often. V21 said the wound care doctor did come in and evaluate the three areas to R100's left upper mid back, and did not want treatment started at this time, because the areas were drying up. The facility policy titled Pressure Ulcers/Skin Breakdown, dated 8/2008, documents the nurse shall assess and document/report the following: Full assessment of skin condition including but not limited to location, stage or partial/full thickness, length, width, and depth, presence of exudates or necrotic tissue.

Based on observation, interview, and record review, the facility failed to provide nutritional supplements, monitor weights, and implement interventions for 2 (R53 and R100) of 8 residents reviewed for nutrition in a sample of 51. This failure resulted in R53, who only weighed 76 pounds and had a recent 23% weight loss in 6 months, not receiving the ordered nutritional supplements to be able to maintain a healthy weight. Findings include: 1. R53's Face Sheet documents R53 is a female resident with diagnoses including: unspecified dementia unspecified severity with mood disturbance, anemia, chronic embolism and thrombosis of unspecified axillary vein, essential hypertension, underweight, tremor, cognitive communication deficit, acute embolism and thrombosis of unspecified deep veins of left lower extremity, acute embolism and thrombosis of right subclavian vein, and portal vein thrombosis. R53's Minimum Data Sheet (MDS), dated ,d+[DATE], documents no BIMS (Brief Interview for Mental Status) was conducted due to resident is rarely/never understood. R53's MDS documents R53 is dependent for eating. R53's Order summary report documents a dietary order of regular diet with pureed texture, nectary consistency, offer fortified foods at all meals. Super cereal at breakfast, double eggs at breakfast, and offer thickened nutritional shakes TID (three times a day) use a straw with all drinks for nutrition, with an order date of 03/19/2024, and a start date of 03/19/2024, with no end date documented. R53's care plan documents a focus area, dated 09/06/24, of: R53 has potential nutritional problem (weight loss) related to: poor intake, underweight, dementia and interventions listed as: monitor wts (weights) as ordered dated 06/30/23, monitor/document/report to MD (Medical Doctor) PRN (as needed) for s/sx (signs/symptoms) of dysphagia: pocketing, chocking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appears concerned during meals dated 05/31/23, monitor/record/report to MD PRN s/sx of malnutrition: emaciation (cachexia), muscle wasting, significant weigh loss: >5% in 1 month, >7.5% in 3 months, > 10% in 6 months with a date initiated of 05/31/23, provide and serve diet as ordered. Monitor intake and record q (every) meal (03/19/24) pureed, nectar consistent fluids, fortified foods all meals, super cereal with breakfast double eggs at breakfast, ice cream @ (at) supper, use straws with all drinks dated 03/20/2024, provide and serve supplements as ordered with an initiated date of 06/05/23, and RD to evaluate and make diet change recommendations PRN, with a date initiated of 05/31/23. R53's progress note: dietary note, dated 07/16/24 at 10:40 AM, documents: RD (Registered Dietician) WT (weight)/wound note. (R53) has 23% weight loss for 6 months. (R53's) ht (height) is 67 inches and has a wt (weight) of 76 # (pounds) on July 2nd with a BMI (body mass index): of 12%. On June 11 (R53's) wt was 79 #, in April 82 pounds, and in January 99 #. (R53) has variable meal intakes as reported. (R53) is fed/assisted at meals. (R53) has severe dementia. She has treatments to wound on lt (left) buttock and skin tear lt sacrum. She is receiving MVI (multivitamin), Vit (vitamin) C, Zinc, (liquid protein medical food) and (arginine supplement drink) BID (twice a day) to help with healing. Continue pureed-NTL (nectar thick liquids) diet, fortified foods, SC (super cereal) at B (breakfast), double eggs at B (breakfast), thickened health shakes TID/(with) meals. Noted Res (resident) has been medically declining. Offering additional cals (calories)/pro (protein). Encourage intakes. Include extra [NAME] (margarine)/butter all meals. Monitor skin, WTs (weights) and further needs. R53's progress note: dietary note, dated 06/16/24 at 9:47 PM, documents: note text: RD WT/wound note. Res (R53) with 25% wt loss/6 months. Ht: 67 inches, June 11 wt:79# BMI: 12, March wt: 83#, Dec (December) wt: 106#. Variable meal intakes as reported. Res (R53) fed/assisted at meals. Has severe dementia. Tx: wound (lt) lat buttock/chronic ulcer and ABTX - cellulitis (Rt) elbow. receiving MVI, Vit C, Zn, (liquid protein medical food) and (arginine supplement drink) BID to help with healing. Continue pureed-NTL diet, fortified foods, SC at B, double eggs at B, thickened health shakes TID/meals. Noted Res (R53) has been medically declining. Offering additional cals/pro. Encourage intakes. Offer snacks between meals. Monitor skin, Wts, further needs. R53's progress note by V5 (Nurse Practitioner), dated 07/22/24, documents a visit date of 07/11/24, and a diagnosis of failure to thrive in adult, dated 07/22/24. On 08/12/24 at 12:16 PM, R53 did not receive a health shake with her lunch; she only had a glass with thickened water. R53 was being assisted by a staff member. On 08/13/24 at 12:14 PM, R53 did not receive a health shake with her lunch; she had one glass of an opaque thickened liquid in front of her. On 08/13/24 at 12:42 PM, V11 (Certified Nurse Aide/CNA) who was assisting R53 stated R53's drink was thickened water. On 08/14/24 at 8:04 AM, R53 did not receive a health shake with her breakfast; she had a thickened cranberry juice. She did not receive a double portion of eggs. There were no eggs observed on R53's meal tray. On 08/14/24 at 12:18 PM, R53 did not receive a health shake with her lunch. On 08/14/24 at 12:18 PM, V11, who was assisting R53, stated R53's only drink was thickened water. V11 stated, (R53) can eat good some days, and sometimes she will turn her head. On 08/15/24 at 8:01 AM, R53 did not receive a health shake with her breakfast or a double portion of eggs; she had one glass of thickened cranberry juice. On 08/15/24 at 8:07 AM, V9 (CNA) who was assisting R53, stated, (R53) had the hot cereal with the extra butter and sugar and stuff put in it, pureed sausage, and pureed pancakes, with thickened cranberry juice. On 08/15/24 at 12:11 PM, R53 did not receive a health shake with her lunch; she had one glass of thickened cranberry juice with lunch. On 08/15/24 at 1:16 PM, V9 (CNA) who was assisting R53 stated she has not seen R53 with a health shake, that would probably be a good thing for her because she drinks better than she eats. On 08/15/24 at 4:17 PM, V12 (Dietary manager) stated, If (R53) is ordered to have a health shake, she should have received a health shake, and she should have received it three times a day if that is what is ordered for her. The kitchen puts them in a pan to give out to the residents that are supposed to receive them. (R53) should have received the double eggs with every breakfast. They put thickener on the carts for every dining room, so the CNA's can thicken the drinks that need to be thickened. The fortified foods are made with powered milk, brown sugar, white sugar, or butter. On 08/19/24 at 2:44 PM, V30 (Registered Dietitian) stated R53 is about 77 pounds; she does not know if she has been over a 100 pounds; she would have to be able to see her chart. V30 stated she has ordered the health shakes three times a day for her to hope to maintain her weight; she does not know if she would gain weight. V30 stated she would expect her to be receiving all three health shakes a day and the double eggs for protein. She would expect all residents that she recommends health shakes or other supplements for to receive them. At this facility, the fortified foods are considered whole milk. On 08/20/24 at 3:35 PM, V5 (Nurse Practitioner) stated, (R53) should receive the supplements and diet as recommended by (V30). 48356 2. R100's Face Sheet, dated 08/15/24, documents an admitted [DATE], with diagnoses of acquired absence of other toes, Enterocolitis due to clostridium difficile, type 2 diabetes mellitus, urinary tract infection, heart failure, iron deficiency anemia, gastrointestinal hemorrhage, and dysphagia. R100's Minimum Data Set (MDS), dated [DATE], documents in Section C a BIMS (Brief Interview for Mental Status) score of 15, which indicates R100 is cognitively intact. Section GG documents independent with eating and substantial/maximal assist with toileting, showers, R100's Progress note, dated 08/13/24 at 1:48PM from V30 (Registered Dietitian), documents, (R100) reported 20% WT (Weight loss)/1 mo. (Month). July 5 WT (Weight): 176# (Pounds) June WT: 221#. (R100)readmitted to facility with DX (Diagnosis) C-diff (clostridium difficile), UTI (Urinary Tract Infection), continue with previous recommendations. Monitor WT's closely. Refer prn (as needed). On 08/14/24 at 12:45 PM, R100's tray was sitting on his bedside table covered with aluminum foil along with thickened cranberry juice and thickened water; both were also covered with saran wrap. R100 was sitting in bed. R100 stated he wasn't hungry and didn't want to eat. On 08/15/24 at 10:40 AM, R100 stated he has had a significant weight loss. R100 said he doesn't like the food at the facility. R100 said they don't ever offer him an alternative, but he doesn't ask for one either. R100 said he does like the oatmeal at breakfast, but that usually is one of the main meals he eats. R100 said the food they usually serve him he doesn't eat. R100 said he believes this is why he has lost so much weight because he doesn't like a lot of the food they serve him. On 08/19/24 at 8:40 AM, R100 had his plate in front of him with oatmeal and toast. R100 said he feels like he ate better this weekend then he usually does. R100 said the food was a little better this weekend, and he did not ask for an alternative. On 08/18/24 at 8:50 AM, V40 (Speech Language Pathologist) stated she feels like R100 does good with his thickened liquids and mechanical soft diet. V40 stated R100 is not coming out of his room into the dining room to be monitored right now because he is on contact isolation related to c-diff. V40 said R100 really didn't come out much when he wasn't on contact isolation, but he did come out on occasion. V40 said R100 said he doesn't like a lot of the things they serve at the facility. On 08/18/24 at 1:00 PM, R100's room tray had sauerkraut with polish sausage and vegetables, and one glass of cranberry juice thickened to honey constituency. R100 consumed his glass of cranberry juice and maybe 25% of his meal. R100 stated he fed himself a little bit, but didn't eat much. On 08/18/24 at 3:00 PM, V30 (Registered Dietitian) stated R100 could not have super cereal related to him being a diabetic. V30 said she knows R100 is on a supplement for wound healing. V30 stated she is not done reviewing charts for weight changes yet this month. V30 said next week she will look at R100's weight changes. V30 said she does remember charting on R100 on 08/13/24, and she said she knows R100 did have c-diff from his recent hospital stay. V30 said she didn't realize R100's weight loss was the month prior to him having c-diff. V30 said next week, she will look at adding double eggs and whole milk to R100's diet. V30 was not aware =R100 had the 20% weight loss from June to July until R100 notified her of the weight loss. V30 said nobody notified her of significant weight changes all the time. V30 said its hit and miss; usually when they do notify her, it's about a resident on a tube feeding or resident on dialysis. V30 said no one notified her of R100 having any weight loss. V30 said if they would have notified her sooner, it would of had an impact on the weight loss. V30 would have been able to start interventions earlier. V30 said with that much of a weight loss, he should have been added to daily weights, not monthly. V30 said she does have focus groups she works on; she runs a report when she comes in to see what all residents have had weight losses. V30 said when she notices a significant weight change, she sends a note to the Director of Nursing with recommendations she would recommend to help with the weight loss. V30 said the 20% weight loss on R100 should have been sent to her immediately. V30 said she does know ]R100 is on a supplement for his pressure ulcers. V30 said ]they did add a nutritional supplement with a vitamin supplement for his wounds. V30 said ]if they would have notified her sooner, she could have done more to help prevent further decline in weight and would have created a fax of recommendations to send to the medical director and director of nursing. On 08/21/24 at 12:03 PM, V12 (Dietary Manager) stated she was not aware of R100 having over a 20% weight loss in one month. V12 said she used to get a weight log monthly, or every other week, about who lost or gained weight. V12 said she hasn't got a weight log for resident who lost or gain in a long time. V12 doesn't even know who gained or lost anymore. V12 said V30 is usually pretty good about finding out who has gained or lost weight and will let her know. V12 said she thinks now maybe V30 did tell her recently about R100 saying he had a weight loss, but that she forgot about it. V12 said all residents should be offered alternatives, but that most of the time the CNA's (Certified Nurse Assistants) say no resident wants the alternative. V12 said she needs to go down and talk to R100 to see what is going on,and why he is losing weight. V12 said if she knew R100 had lost weight earlier,she might be able to prevent him from losing any more weight. V12 said she was not aware R100 had pressure ulcers or wounds,either. V12 said they should have given her a list of residents who have wounds as well, but they don't do that either. V12 said anyone with wounds need extra protein and more nutritional needs for wound healing. V12 said she thinks all the staff does not communicate as much as they used to about all areas of care. On 08/20/24 at 1:40 PM, V48 (Medical Doctor) stated he was not aware of R100 having over a 20% weight loss in one month. V48 said that R100 is in pretty bad shape. On 08/20/24 at 3:52 PM, V5 (Nurse Practitioner) said she wasn't aware of R100 having more than a 20% weight loss in one month. V5 said R100 did tell her he doesn't like the food at the facility much. V5 said she thinks this was about a week ago, so she recommended for him to have a nutritional supplement, because he needed the extra nutrients related to him having pressure ulcers and wounds. V5 said she did see him on 08/13/24. V5 said she knows his diet got changed to mechanical soft diet with honey thickened liquids. V5 stated she recommended for R100 to get the nutritional supplement three times a day. The facility policy,dated 08/2008, titled, Nutrition (Impaired)/Unplanned Weight loss - Clinical Protocol documents: 1. Monitor and document the weight and nutritional status of residents in a format which permits readily available month-to-month comparisons. Assess the individual's current nutritional status and identify individuals with anorexia, recent weight loss, and significant risk for subsequently impaired nutrition: for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever, and infection, or those taking medications that may be causing or increasing the risk of anorexia or weight loss. 2. The physician will help identify conditions (cancer, renal disease, depression, dental problems, etc.) and medications that may be causing weight loss or increasing weight loss risk.

Failures at this level require more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to ensure a resident was free from neglect when they failed to accurately assess, treat, and prevent a significant decline in condition for 1 (R1) of 3 residents reviewed for neglect in the sample of 24. This failure resulted in R1, who has a history of confusion with infections, experiencing altered mental status and refusing overall care after being diagnosed with a urinary tract infection. R1's refusals of care additionally led to R1 developing a Stage 3 pressure ulcer, an unstageable pressure ulcer with sepsis secondary to skin and soft tissue infection, subsequently requiring an 11-day hospitalization for IV antibiotic therapy. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 6/19/2024 when R1 was readmitted to the facility from a hospitalization . R1 was on a physician ordered treatment for urinary tract infection, yet the facility failed to implement interventions to prevent worsening of infection. R1 endured confusion with delusions related to infection, which led to refusal of medications and refusal of care with activities of daily living. R1's refusal of care included care with incontinence and repositioning, which led to development of pressure ulcers. R1's facility acquired pressure ulcers were not treated, and led to hospitalization on [DATE] for sepsis related to infection of skin and soft tissue in relation to the stage 3 pressure ulcer and unstageable pressure ulcer. V1 (Administrator) was notified of the Immediate Jeopardy on 7/11/2024 at 2:12 PM. The surveyors confirmed by observations, interview, and record review the Immediate Jeopardy was removed on 7/17/2024, but the noncompliance remains at a Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: R1's Admission Record documents R1 was admitted to the facility on [DATE]. R1's POS (Physician order sheet), dated 7/2024, list diagnoses that include angina pectoris, heart failure, GERD (Gastroesophageal Reflux Disease), unspecified dementia, unspecified severity with other behavioral disturbances, atrial fibrillation, type 2 diabetes mellitus, paranoid schizophrenia, chronic kidney disease stage 4, hypothyroidism, chronic peripheral disease, gout, and COPD (Chronic Obstructive Pulmonary Disease). R1's MDS (Minimum Data Set), dated 4/10/2024, documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. The same MDS section GG documents R1 requires substantial/maximal assistance with toileting/hygiene and with shower/bathing, and R1 requires assistance for sit to lying, sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfers. R1's care plan, dated 4/12/2024, documents R1 has risk for skin impairment and risk for pressure injury related to impaired mobility/use of assistive device, chronic kidney disease, and cardiac issues. Documented interventions include: minimize exposure to moistures and keep skin clean and dry especially fecal contaminant, assist with turning and positioning approximately every 2 hours and more often if needed or requested, and notify nurse immediately of any new areas of skin breakdown. R1's care plan also dated 4/12/2024 documents R1 is considered at risk for abuse/neglect (per assessment) due to depression, being dependent on others, Schizophrenia. Documented goals include R1 will be free from harm secondary to abuse/neglect through the review period with interventions including Report any suspected of abuse/neglect to Administrator immediately. R1's Progress Note, dated 6/19/2024 at 7:45 PM, documents, (R1) was returned to the facility via ambulance from local hospital with orders for Augmentin 875-125 mg (milligrams) twice daily for 10 days to treat urinary tract infection with ESBL (extended spectrum be-lactamase) in the urine. The same note documents R1 was alert and oriented to person, place, and time, refused a skin evaluation and was refusing to take medications as ordered. R1's Nursing Notes documents on 6/21/2024 at 5:11 PM, referral information faxed to a behavioral hospital for possible placement related to (R1's) delusions, refusal of care, and verbal behaviors. R1's Progress Note dated 6/21/2024 at 3:08 PM, documents, Resident refused to get up out of bed. He is mumbling to himself unable to understand what he is saying. He refused to take all meds. He would not allow writer to take his vitals. He did allow (blood glucose monitoring) to be done in thumb only but refused sliding scale coverage. He did eat about half of his breakfast and lunch. R1's Progress Note, dated 6/23/2024 at 5:27, PM documents, Resident has been in room talking to people that are not there all day he was heard telling people to get out of his room and mumbling under his breath. He refused to get up this shift has refused all meds. He did allow (blood glucose monitoring) but not insulin. R1's Progress Note, dated 6/24/2024 at 2:28 PM, documents, Res (resident) refusing to take meds and insulins. Refusing to get out of the bed as well as get dressed. Res educated on the importance of taking meds. Res became verbally aggressive and argumentative. Res non-compliant. (V26, Physician) notified. R1's Progress Note, dated 6/27/2024 at 4:13 AM, documents, refused meds and meals for past 1-2 weeks. R1's Progress Note, dated 6/28/2024 at 3:26 PM, documents, CNA (Certified Nursing Assistant) states that resident has been incontinent of stool and is lying in his bed with genitals exposed and refusing to be changed. V23 (Nurse Practitioner/NP) present for conversation and aware of continued behaviors. R1's Progress Notes, dated 6/28/2024 at 3:44 PM by V2, documents, this writer spoke with (V23), NP (Nurse Practitioner) regarding (R1's) continued behaviors, (V23) reports that she spoke with (V26, Physician) about (R1) and stated they both feel that IM (Intramuscular) medication is needed but they are fearful for the safety of staff if they were to attempt to administer an IM medication to resident and therefore feel that a placement in a behavioral health facility is the best option at this time. On 7/1/2024 an order was given by (V18, Psychiatric Nurse Practitioner) gave an order for Haldol solution three times a day with meals. R1's Progress Notes, dated 7/1/2024 at 2:55 AM, documents, All shift resident has refused to let staff change him. Resident's bed is saturated in urine and dripping into the floor. Resident has a puddle of urine under his bed and was trailing to the door. Resident let staff clean the urine from his bed to the door but refused to let staff change him or clean under the bed. When cleaning under the bed was mentioned, the resident started yelling 'no' at the staff. Resident has been pleasant since that interaction and calling for needs. R1's Progress Note, dated 7/2/2024, signed by V2 (DON/Director of Nursing) documents, spoke with (V23) about resident's altercation with (R9) and CNA. (V23) immediately called (V26) and reported to (V26) (R1's) aggressive behavior. (V26) and (V23) agree that (R1) must be sent to ER for evaluation. (V26) advises to send resident to ER and to call local police if needed to assist EMS (Emergency Medical Services) with the transfer. (V26) states At this point you have to get (R1) out of there. What he has done tonight is assault and it is not safe for (R1) or other residents for him to remain in the building. Floor nurse (V7 Licensed Practical Nurse) notified of order to send to ER and transfer process begun at this time. R1's Progress Notes, dated 7/2/2024 at 6:45 PM, documents, (R1) was transported out by way of local ambulance service to local hospital after an altercation with (R9). Noted local police contacted and sent an officer in case assistance was needed due to acts of violence. R1's Shower Sheets, dated June 2024, documents R1 refused showers on 6/24/24 and 6/25/2024. The last documented shower R1 received was on 6/11/2024. There were no other showers documented indicating R1 did not receive a shower for 22 days. R1's Medication Administration Record (MAR), dated June 2024, documents Augmentin 875-125 mg one tab every 12 hours for bacterial infection for 10 days, start date of 6/19/2024. This same MAR documents from the dates of 6/19/2024 through 6/29/2024, R1 refused Augmentin 875-125 mg, 16 out of 20 offered dosages. The same document contains a physician order for another antibiotic of Levaquin 500mg, give one tablet by mouth one time a day for urinary tract infection for 7 days with start date of 6/20/2024, the same MAR documents R1 refused Levaquin 500mg 5 out of 7 offered doses. R1's Treatment Administration Record (TAR), dated 6/1/2024-6/30/2024, documents a physician's order for skin checks scheduled every Monday and Thursday with a start date of 9/17/2020. The TAR documents R1 refused the skin checks on 6/20/2024, 6/24/2024, and 6/27/2024. The same TAR documents a physician order for antifungal powder under bilateral breast folds, bilateral abdominal folds and groin every bedtime, start date of 11/22/2023. The TAR documents R1 refused treatment from 6/19/2024 to 6/30/2024. R1's local hospital ER (emergency room ) record, dated 7/2/2024, documents R1 reports he is here to have his wounds on his bottom addressed. This is the only area of pain that he has. No other complaints. Calm and cooperative at this time in ER. The ER's Impression and Disposition notes under clinical impression documents the following: 1. Sepsis due to unspecified organism, unspecified whether acute organ dysfunction present. 2. Altered mental status, unspecified altered mental status type. 3. Cystitis. Differential Diagnosis includes but not limited to, UTI (urinary tract infection), Electrolyte abnormality, medication induced psychiatric illness. Hospital Progress Notes on 7/3/2024 at 1:36 AM documents Sepsis secondary to skin and soft tissue infection. Hospital Wound Care Notes on 7/3/2024 at 10:00 AM documents, wound care consult completed at this time. Patient noted to have ITD (Intertriginous Dermatitis) to bilateral axilla's, bilateral chest folds, bilateral abdominal flanks, bilateral groin, and inner thighs and to scrotum and coccyx. Patient noted to have evolving DTPI (Deep Tissue Pressure Injury) to right buttocks and Stage 3 pressure injury to left buttocks. Left buttocks, stage 3 wound measuring 4 cm (centimeters) length, 2.5 cm width, 0.3 cm depth and wound surface area 10 cm. Right buttocks DTPI measuring 3 cm length, 2cm width, 0.3cm depth and 6 cm wound surface area. The hospital records from theER on [DATE] at 1:36 AM, indicates R1 was given IV (Intravenous) antibiotics of Vancomycin 2 gm (grams) and Levofloxin 750 mg (milligrams) after blood cultures were obtained. On 7/10/2024 at 11:17 AM, V9 (Certified Nurse Assistant/CNA) stated she sometimes takes care of R1. V9 stated, I had noticed for the last 2 weeks or more (R1) had not been acting himself. He has been refusing care and having bad behaviors. (R1) did get sent to the hospital and he is still there. On 7/10/2024 at 11:25 AM, V6 (Licensed Practical Nurse/LPN) stated she had taken care of R1, as he is on her hall. V6 stated, I noticed a change with (R1) the last 2 weeks. (R1) had been more violent and was refusing care. (R1) was supposed to be taking antibiotics for a urinary tract infection, but he was refusing his medications. V6 stated the floor nurses do treatments on the residents except for Thursdays because that is the day that the wound doctor comes to the facility. V6 stated she was not aware of any wounds on R1, and he was not getting any treatments. V6 stated she heard of his behaviors when he tried to pull another resident out of the bed. On 7/10/2024 at 11:20 AM, V5 (CNA) stated she always works 6am to 2pm shift. V5 states she normally takes care of R1. V5 stated, (R1) was always fine until the last few weeks, and he started refusing care. V5 stated, I did not know of any wounds on (R1). We tried to provide care to him, but he would get upset. On 7/10/2024 at 12:00PM, V7 (Licensed Practical Nurse/LPN) stated she works all halls here, and she is familiar with R1, as she takes care of him when she works his hall. V7 stated the floor nurses do the treatments on the residents. V7 stated, I was here when (R1) tried to pull (R9) out of bed. (R1) had tried to go into (R9's) room several times on that day and we had to keep redirecting him. I moved my medication cart down the hall closer to (R9's) room so that I could keep an eye on the situation. (R1) went into (R9 's) room and started yelling that (R9) was causing electrical shock to his beard and something about black stuff, then (R1) grabbed (R9's) foot and tried to drag him out of bed. When the CNA tried to separate them, (R1) hit (V14, Certified Nurse Assistant) in the abdomen, and (R1) had earlier grabbed (R9's) over bed table and threw it. I witnessed (R1) trying to grab (R9) out of bed. V7 was asked if she felt this was considered abuse to R9, she replied, No because (R1) did not do that intentionally because he did not know what he was doing. V7 stated, Prior to 2 weeks or so ago, (R1) was so sweet and real easy going. I was unaware of any wounds on (R1) until right before I sent him out to the hospital the last time on 7/2/2024. (V12, CNA) was helping try to get (R1) ready to be transported to the hospital and she noted a large wound to (R1's) buttocks, (V12) reported it to me immediately, but when I went into the room to assess the wound (R1) refused, so I did not get to even look at it. V7 was asked how often they did skin checks on R1, and V7 stated weekly. V7 stated they document those on the (MAR) Medication Administration Record. On 7/10/2024 at 3:55 PM, V12, CNA, stated she works the hall where R1 resides. V12 stated, I had taken care of (R1) for a long while. (R1) was always nice up until the last month to month and a half. V12 stated, (R1) was refusing all care as of lately. One day we went in his room, and (R1) was drenched in urine, the floor had urine everywhere, and the mattress was leaking urine on the floor and under the bed. It was bad. (R1) allowed us to clean the urine off the floor, but would not let them clean under the bed, clean him up or change the mattress out. V12 stated, We offered care for days before (R1) went to the hospital, but he just refused. When V12 was asked about any skin issues with R1 she stated, I would apply powder to his groin area prior to his refusal of care because it was gaulded, but on the day we were getting ready to send him out to the hospital, I noticed a big circular area on (R1's) bottom and it was bleeding pretty good. I then went to (V7, LPN) and told her, but (R1) refused to let (V7) look at it and then the ambulance came. I was not aware the big area on (R1's) bottom was there until that day. V12 stated R1 is wheelchair bound, but R1 can walk a few steps. On 7/11/2024 at 2:59 PM, V18 (Psychiatric Nurse Practitioner) stated she started seeing R1 about 2 years ago. V18 stated R1 told her he first started having issues like delusions/hallucination when he got a UTI. V18 stated, I was asked to stop the Zyprexa a couple of years ago because he didn't have the proper diagnosis to support giving it. (R1) was a very pleasant and very knowledgeable man that was always alert and oriented x 4. V18 stated she was not aware of any psychiatric problems over the past 2 years until recently. V18 stated she had gotten a couple of calls from the facility about R1's behaviors lately and R1 refusing care. V18 stated she had talked with V23 (Nurse Practitioner/NP) and the staff about giving some medication IM (intramuscular) so they could get him better, and hopefully R1 would start taking his regular medications, antibiotics, and especially his insulin. V18 stated, The nurses would not give the medications IM due to it being unsafe for the nurses and I was told they could not hold him down to administer it. V18 stated she expressed concerns with him not getting his insulin, and she even offered to come to the facility and give the IM injections herself. V18 stated, The facility declined my offer because they stated he would refuse. V18 stated at this point, he was harmful to himself and others. V18 was asked if she felt the UTI could have caused the hallucinations/delusions, she replied, Due to the infection effects, it possibly started when (R1) refusing medications then refusing care and has had a definite effect on his well-being. V18 stated she feels R1 is misdiagnosed , and she feels he does not have Schizophrenia. V18 stated, First, Schizophrenia is a mental illness that is continuous, and he has been off medications for 2 years with no issues. V18 then stated she feels like he has bipolar, and that is why he can go for a while without medications before any issues come up. V18 stated, Sometimes any type of infection can cause confusion and that leads to other issues in people that are normally not confused. On 7/12/2024 at 8:01 AM, V27 (Healthcare Power of Attorney for R1) stated, I was not sure where (R1) was at this time. Before coming to the nursing home, (R1) was at another hospital because he wasn't taking his medications and got violent. This all started with a urinary tract infection. Once he got over the infection, he went back to his normal self and did good. (R1) has been a preacher for several years. (R1) never had his own church, but helped churches and filled in when a pastor was not available. I didn't know he was back in the hospital. V27 was asked if she was aware an Involuntary Discharge had been issued to the resident from the nursing home, and she stated, No, I didn't know. V28 (family member) was present on the phone call and stated, His behaviors are always triggered by infections. V27 was asked if she was aware of any skin issues like wounds and she stated, No, I didn't know anything about this either. On 7/12/2024 at 8:40 AM, R1 was visited at the local hospital. R1 was sitting up in bed watching television. R1 was alert and oriented x 4. R1 stated he is feeling much better. R1 stated his bottom is not hurting like it was so he thought his wounds were healing. R1 stated he got the wounds while at the facility. R1 stated, When I get any kind of infection it goes to my brain for some reason, and I am not right when I do get an infection. R1 stated he wants to go back to the facility. R1 was asked if he was aware of possibly not being able to return to the facility and he said, No, I don't know anything about that. R1 stated he is taking his medication and he is taking his insulin when he needs it. R1 stated he must take medications for his Neuropathy; he stated it is Gabapentin and it does help me. R1 also stated he has hypothyroidism, and he takes Levothyroxine for that as well. R1 stated he was tired and was going to take a nap at this time. R1 then stated, I miss my friends at the facility, and I teach Bible study classes there as well. On 7/12/2024 at 8:25AM, V29 (Case Manager at local hospital) stated (R1) is doing much better now that the infection is better. V29 stated, Facility said if he was seen by Psych (inpatient) that he could come back, but the behavioral hospital denied him after review of his hospital course, and said it was a medical issue. V29 stated R1 is taking his medications and his wounds are healing. V29 stated he is showing signs of sundown syndrome, as he tries to refuse medications at night, but is fine throughout the day. On 7/12/2024 at 11:07 AM, V3 (LPN/Licensed Practical Nurse/Infection Preventionist) was asked to describe R1 prior to 6/19/2024. V3 stated R1 was alert and oriented x4, he led Bible Study at the facility. V3 stated she noticed his behaviors when they moved a roommate in with R1. V3 stated, The resident we moved in was on Enhanced Barrier Precautions, and this set (R1) off. (R1) became withdrawn and was going to the dining room, but was observed talking back to himself, but it escalated. He was saying things about his family coming through the backdoor and threw stuff on him causing skin issues. This was definitely a change in condition. We know when (R1) starts acting off, he is afraid of an infection. I believe he was freaked out about the roommate that we had moved in, but we didn't leave that roommate in there very long at all. (R1) will come and ask us to do a urinalysis when he thinks he is getting a UTI because he is scared to get any kind of infection. We had received orders for urinalysis, but (R1) was refusing to give us a urinalysis for several days. He finally went to the ER because of his groin pain and cellulitis. V3 explained what happened once he returned from that hospitalization . V3 stated, Well, the hospital stated he was taking his medications, but we found out later that he did not take medications there either, and he had ripped out his IV's. V3 stated R1 returned 6/19/2024, with antibiotic orders for UTI. He was still having delusions and was refusing medications, and he was refusing care. When V3 was asked if the Healthcare Power of Attorney was called, she stated, I believe she was, but every time we talk to her, she is always saying (R1) wants attention, and he knows I am busy with my son who has cancer. V3 stated The hospital can do more than we can, he is a bigger guy. V3 was asked, since she was the Infection Control Preventionist Nurse, was she looking at R1 from an infection standpoint, V3 replied, I was focused on the behaviors more, but he wouldn't let me screen him about infections, and I believe half of his problems were stemming from infections. V3 was asked if she was aware of his wounds and she stated, No, I do not do skin checks or deal with wounds. V3 stated she was with V2 when they went to the hospital to give IVD (Involuntary Discharge) papers. V3 stated, (R1) was alert, but I questioned if he understood what all we were reading and telling him, about the appeal process. V3 was asked about the lack of care, especially from 6/19/2024 through 7/2/2024. She stated, We tried to do more for (R1), and we felt if we sent him to the hospital that they would just send him right back. When (R1) tried to pull another resident out of bed, this was an isolated incident besides hitting the CNA in the stomach. Again, we looked more at the psych and behaviors even though we knew he did this with infections. V3 stated, I am going to review the updates, but I did see the pictures of his wounds that were taken at the hospital, and they didn't look good, but I did not know he had those. On 7/12/2024 at 9:40 AM, V2 (Director of Nursing/DON) was asked to explain issues with R1, from the time of readmission from the hospital on 6/19/2024. V2 stated, (R1) had been having unusual behaviors like, refusing medications, he would say that he didn't need his medications, and he was refusing care up until he went back to the hospital on 7/2/2024. (R1) was sent out to the ER at his request on 6/16/2024 because he was having pain in his groin area. He was admitted for cellulitis of the groin area then noted to have a urinary tract infection (UTI). (R1) was being seen by the wound doctor for the yeast on his groin area, but had refused to allow the wound doctor to see him the last couple of times. (R1) came back on 6/19/2024, was refusing medications including antibiotics for UTI. We were trying to get him into a behavioral facility because of his Psych (psychiatric) issues. I was aware (R1) was refusing all care most of the time. V2 stated she received a call one night from the facility that (R1) had so much urine everywhere in his room, his mattress was saturated and leaking on the floor, the urine was even running out into the hallway. (R1) would only let the staff mop the hallway and barely in his room. V2 was asked if care was provided at that time to clean up R1 and change out the mattress, V2 stated, (R1) would not let the staff clean anything else. I was looking more at the Psych issues than I was the medical issues. During interview, V2 reviewed the shower sheet documentation for R1 from the time of readmission 6/19/2024 until R1 went back out to the hospital on 7/2/2024, and there were no showers given due to refusals. V2 stated, I was not aware of any wounds on (R1), and nobody reported wounds to me, and I do all the wounds in the facility and round with the wound doctor on Thursdays. V2 stated, We did call the EMS (Emergency Medical Services) on 6/10/2024 and for (R1) to go out to the ER, but EMS would not take him because he refused, and he was able to answer all their questions appropriately. V2 was asked how they got him to go to the hospital on 7/2/2024, she stated, He didn't have a choice; he tried to harm another resident. V2 was asked if she was aware there was documentation of talk between V23 (NP) and V26 (physician) about giving medications IM to help get R1 care, but there was concern with the safety for the staff. V2 replied, Yes, I made that entry, and I was worried that staff would get hurt because (R1) is a big strong guy, and I didn't want any staff to get harmed. When V2 was asked if R1 received care from 6/19/2024 through 7/2/2024, she stated, No, not really, he was refusing all care. We were documenting to try to get enough documentation to get him out to a behavioral facility to help with his Psych issues. On 7/12/2024 at 9:10 AM, V1 (Administrator) stated she was out of town the week of 7/2/2024, when she got the call from V2 (DON/Director of Nursing). V1 stated V2 had a report of abuse with R1 and another male resident. V1 stated V2 reported R1 was sent out to the hospital. V1 stated she received another call a little later from V2, who stated Corporate contacted her and said they had to give an Involuntary Discharge (IVD) to R1. V1 stated she told V2 that many others had to be contacted before an IVD could be given, including the Ombudsman, and it was too late in the night for all those calls. V1 stated someone called V2 and said R1 qualified for IVD because he was harmful to himself and others. V1 said on 7/3/2024, V2 and V3 (LPN/Licensed Practical Nurse/Infection Control Nurse) took IVD papers to R1 at the local hospital. V1 stated she was pretty sure V27 (Healthcare Power of Attorney for R1) was called about the IVD. V1 stated, I think it was an emergency discharge. We want (R1) back if he gets his infections taken care of because he goes over the deep end when he gets an infection. It's a cycle he has done before. (R1) is normally our best resident, he is [NAME] President of Resident Council, he teaches Bible Study classes, and he is our facility Santa Claus every year, and he does so well with the kids that the employees bring in to see him as Santa. When V1 was asked if she knew R1 had pressure ulcers that he acquired at the facility she stated, No, I did not know that. I get updates from the hospital, but I only look at Case Manager notes. V1 stated she hates that, but he was refusing all care for a while. V1 stated she was going to go see R1 at the hospital as she really wants to get him back to the facility. V1 stated, We all love (R1), and we want him here. On 7/12/2024 at 1:57 PM, V23 (Nurse Practitioner) stated, I have known and cared for (R1) for a long time. V23 stated normally R1 is a pleasant guy that is alert and oriented x4. V23 stated, I feel (R1) needs inpatient psych to get his meds regulated. V23 stated she had worked closely with V18 (Psych NP) regarding R1. V23 stated V18 ordered Haldol liquid and they tried giving it to R1 in a drink, and R1 wouldn't drink it. V23 stated, I was afraid someone would get hurt if they tried to give him an IM injection. V23 stated, That would only help for a little bit though. V23 stated, (R1) was urinating everywhere and was pouring urine all over himself, was laying in urine and feces, and refused care for long periods of time. V23 was asked if she was aware of the wounds on R1's buttocks and she stated, I didn't know anything about wounds, but have seen the pictures taken at the hospital. V23 stated, (R1) was always cautious about getting a UTI and (R1) would come and tell me that he needs a UA (urinalysis) because he may be getting a UTI. V23 stated, I ordered a UA when the staff told her that he was talking to himself, but (R1) refused it. V23 stated she would stop by and check on him and he would say, I am doing ok, then I would walk past the doorway and he would be talking to the television. V23 stated, I was there the night (R1) went out the last time and I had them to call the police to come because I was afraid R1 would hurt someone because he is a big strong guy. V23 was asked if she felt the infection caused the confusion and delusions and she stated, It is hard to say which came first the psych issues or the infection. V23 stated, I was aware (R1) was refusing care including personal care and refusing medications with most concerning medications of antibiotics. On 7/12/2024 at 12:50 PM, V26 (Physician/Medical Director) stated he was aware of R1's behaviors. V26 stated he was aware R1 tried to harm another resident and R1 went out to the hospital. V26 was asked if he was aware R1 was refusing all care from the staff, he stated, I was aware he was refusing medications, but was not aware of how long he was refusing. V26 was asked if he was aware R1 refused all care from 6/19/2024 through 7/2/2024 and he stated, (V18 Psych NP) has been dealing with him mostly, but I wasn't aware that he refused care for that many days. V26 was asked if he talked with V18 at one point about possibly giving medications IM so R1 would allow care or be sent to the ER, V26 stated, Yes, but I was told they were afraid someone would get hurt as he is a big guy, but I have been hit myself and I am sure you have too. V26 stated, My biggest concern was that (R1) was going to hurt himself or other residents. V26 stated, I am sure they tried to care for him, and I know (V18) was trying, sometimes it is just difficult. The tipping point is why they sent him out, when he tried to pull the other guy out of the bed. V26 was asked if he felt like R1 was harming himself by refusing care and medications, V26 replied, Of course he was. V26 stated, I know (V23) had gone to see him including the day they sent him out. V26 was asked if he knew about the wounds R1 had once he got to the ER, and he stated, No, nobody has told me about that. V26 was asked if he felt the infection could have caused the behaviors which led to the lack of care, which in turn caused the wounds and he stated, Well lack of care can cause wounds and infection of any kind can cause worsening of confusion. Infections are rough on some folks. V26 was asked if he felt R1 was causing harm to himself by refusing his medications including Insulin and antibiotics and refusal of care and he replied, Yes, he was not helping his situation. V26 stated R1 has been at the facility a long time and is usually very pleasant and active in different activities there. R1's Progress Note, dated 7/13/24 at 3:40 PM, documents R1 returned to the facility and is alert and oriented x 3, has no complaints, and is cooperative. The facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol (revision date August 2008) documents under section Assessment and Recognition: 1. Document an individual's significant risk factors for developing pressure sores, for example immobility, recent weight loss, and a history of pressure ulcers. In addition, the nurse shall assess and document/report the following: a. Full assessment of skin condition including but not limited to location, stage or partial/full thickness, length, width, depth, presence of exudates or necrotic tissue. B. Pain assessment, c. Resident's mobility status, d. current treatments, including support surfaces, e. all active diagnosis. Under the section titled Cause Identification it documents 1. Identify factors contributing or predisposing residents to skin break [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents assessed as being at risk for elopement were supervised, interventions to prevent elopement were implemented, and incidents of elopement were thoroughly investigated for 1 of 3 (R16) residents reviewed for accidents and supervision in the sample of 24. This failure resulted in R16, who had a history of elopement and was assessed as being at risk of elopement, exiting the facility and walking approximately two tenths of a mile down a busy road without staff supervision. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 6/13/24 when R16 was identified to be at risk for elopement and the facility did not implement interventions to prevent elopements. On 6/16/24, R16 attempted to exit the facility and while facility staff were looking for an elopement bracelet to put on R16, R16 left the facility and was located approximately 25 yards from the facility. R16 again exited the facility on 7/10/24. R16 walked approximately two tenths of a mile down the busy street before being joined by staff and approximately eight tenths of a mile down the same street before staff were able to convince R16 to return to the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 7/11/24 at 2:12 PM. The surveyors confirmed by observations, interview, and record review the Immediate Jeopardy was removed on 07/17/24, but the noncompliance remains at a Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: R16's Admission Record, with a print date of 7/15/24, documents R16 was admitted to the facility on [DATE], with diagnoses that include unspecified dementia, cognitive communication deficit, altered mental status, and delirium. R16's Minimum Data Set, dated dated [DATE], documents a Brief Interview for Mental Status score of 03, which indicates a severe cognitive deficit. R16's Elopement Evaluation, dated 6/13/24, documents a score of 01, which indicates R16 is at risk of elopement. This same assessment documents R16 has a history of attempted elopement and wandering aimlessly. They were no interventions addressed as part of this evaluation. R16's Progress Notes document the following: 6/13/24 Elopement Score 1.0, History of elopement while at home. Yes . 6/16/24 6:29 PM, Resident noted attempted exit through back staff entrance at 1720 (5:20 PM), also witnessed by (V13/CNA-Certified Nursing Assistant). Upon entry resident resistant to moving away from door and had to be corralled back towards unit. Once she was back on the unit this nurse (V21/RN-Registered Nurse) and (V30, CNA) went looking for a wanderguard transponder. We looked on (unit name) with no success. Then went down to (unit name). While in the med (medication) room looking, I texted (V2/Director of Nurses/DON) to ask if there was an extra in her office or another location and then heard the front door alarm go off. I immediately headed in that direction walking very briskly. As I came through the main dining room, CNA (V31) said that it was (R16). I ran towards the front door. At the door, (name of family member) was frantically trying to get into the door to alert us that she (R16) was out of the building. Once getting out of the door the resident was noted down the road about 25 yards north of the building. Upon reaching her she was verbally combative and physically evasive. CNA (V31 and V32) were able to calm resident and get her to agree to come back into the building. DON (Director of Nursing) immediately notified. DON in at 1740 (5:40 PM) to address .NP (Nurse Practitioner) notified at 1814 (6:14 PM). Attempt made to contact resident's husband .No answer. Message left for call back. The facility Abuse Investigation Summary, dated 6/16/24, documents under Initial Allegation, A visitor was entering the building when (R16) attempted to go out the open front door. As the visitor was telling (R16) that she needed to stay inside, (R16) became verbally aggressive and went out the door. Visitor immediately ran to get staff for help. Abuse coordinator notified. Wanderguard placed on resident. Facility head count conducted, and all residents accounted for. NP (Nurse Practitioner) and spouse notified. All exit doors wander guard alarms checked. Investigation begun Final Summary/conclusion: Investigation conducted. IDT (Interdisciplinary) met and reviewed incident. Resident and staff interviews conducted. A visitor was entering the building when (R16) attempted to go out the open front door. As the visitor was telling (R16) that she needed to say inside, (R16) became verbally aggressive and went out the door. Visitor immediately ran to get staff for help. Another resident with a wanderguard alarm in place was near the front door at time of elopement which set off the wanderguard alarm causing more staff to come to the front door to assist. Resident was assisted back inside the building by nurse and CNA's (certified nursing assistants). Resident continued to be physically evasive and stated, I've got to go get my husband. Please my house is just right down the road here and I have to go get my husband! Abuse coordinator and DON notified. Wanderguard placed on resident. Facility head count conducted, and all residents accounted for. NP and spouse notified. All exit doors wander guard alarms checked. Staff continues to monitor resident for changes in mood, status, or behavior. No changes noted. MD (physician) and POA (power of attorney) updated on findings of investigation. Care plan updated. R16's Elopement Evaluation, dated 6/21/24, documents a score of 03, which indicates R16 is at risk of elopement. This assessment documents R16 has a history of or attempted leaving the facility without informing staff, verbally expressed desire to go home, packed belongings, and/or stayed near an exit door, wanders, wandering behavior likely to affect the safety or well-being of self/others, and is a recent admission. R16's Progress Notes, dated 6/26/24 at 11:00 PM, document, Employee entrance door alarming at 1940 (7:40 PM), (V22, Licensed Practical Nurse/LPN), went to check door and check outside for residents. Resident was urinating behind employee entrance. Resident was redirected and assisted back inside. Resident reports she was looking for husband and trying to go home. Resident was brought back inside, toileted and pajamas placed on. Resident then was assisted to bed. Said nurse (V22) administered HS (hour of sleep) medications, medications taken whole without difficulty. (V2/DON) notified .husband notified, and on-call MD (physician) notified. Resident diagnosed with unspecified dementia with agitation, altered mental status, cognitive communication deficit. (R16) is ambulatory and wanders throughout facility, staff redirects resident and brings her back to assigned hall. Resident agitated with staff at present time redirection attempt. The facility Abuse Investigation Summary, dated 6/26/24, documents under Initial allegation: Wander-guard alarm system alerted staff to the back door. Staff immediately responded and discovered (R16) right outside the doorway and escorted her back inside . Final summary/conclusion: Wander guard alarm system alerted staff to the back door. Staff immediately responded and discovered (R16) right outside the employee entrance door at the back of the building. When found resident was directly behind the employee door urinating. Staff escorted her back inside and to her unit. Head to toe assessment preformed with no abnormalities noted. IDT met and reviewed incident. Resident and staff interviews conducted. Abuse coordinator and DON notified. Wander guard in place and functioning properly. Facility head count conducted, and all residents accounted for. NP and spouse notified. All exit doors wander guard alarms checked. (V18/Psychiatric NP) contacted to complete a med (medication) review. Staff continues to monitor resident for changes in mood, status, or behavior. No changes noted. MD and POA updated on findings of investigation. Care plan updated. R16's Order Summary Report active orders as of 7/15/24 includes the following physician orders; Monitor Wander Guard each shift for placement, start date 6/28/24. R16's current Care Plan documents the Focus area dated 7/1/24 of Is an elopement risk/wanderer related to: Disoriented to place, History of attempts to leave facility unattended, Impaired safety . This same Focus area documents the following interventions all initiated on 7/1/24, Check wanderguard battery function weekly and PRN (as needed) .Check wanderguard placement every shift and PRN Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book Monitor for fatigue and weight loss .Offer a warmed blanket Offer food or snacks .Offer reassurance appropriate to the concern .Offer to take to a scheduled or planned activity . Offer to take Thereto the toilet or assist with incontinence care .Provide structured activities: toileting, walking inside and outside, reorientation strategies including sings, pictures, and memory boxes .Redirect resident when wandering or exit seeking .Return to bed for additional rest or comfort .Use distraction to change thought pattern .Wanderguard applied at all times On 7/10/24 at 2:55 PM, R16 was sitting in the common area just outside the dining room. R16 appeared clean and well-groomed. R16 was alert, confused, but pleasant. R16 was saying she wanted to go home. R16 stated it is like being in jail because they won't let her leave. R16's Progress Note, dated 7/10/24 at 1650 (4:50 PM), documents, .This writer (V1/Adminstrator) heard wander guard alarm sound around 4:50 PM at front door. This writer watched (V17/RN) respond to alarm. At 1452 (V19/Corporate Chef) came into office and stated 'I think one of your residents went out the front door.' This writer out (sic) front door and witnessed (R16) walking across front parking lot and (V17) and the IDPH (Illinois Department of Public Health) surveyor (name of surveyor) walking behind her attempting to re-direct her. She became agitated with their attempts to re-direct and started running. She ran out into the road and started running north down the roadway. The IDPH surveyor (name of surveyor) and (V17) could not catch up to (R16) and she kept telling them to get away from them that she was going home. This writer ran past (V17) and (name of surveyor) and was able to catch up to (R16) and began walking side by side with (R16). This writer attempted to re-direct her back to facility and she said no I am going home. I just live down the road here. I have to get back to my kids. (R16) continued to walk with this writer approximately 5 blocks down the road. This writer told (V17/RN) to call 911 and family during the unsuccessful attempts to re-direct (R16) back to facility. (V17) did go back to facility to get vehicle in the event (R16) would be able to be re-directed back to facility. This writer and V17 stayed with (R16) until (name of local police) and family responded. The (name of local police) were unsuccessful in their attempts to re-direct (R16) back to facility also. The son (V20) was able to get (R16) into his vehicle and bring her back to facility. (R16) was taken back to room to have assessment and vital taken. This writer also notified (V18/Psychiatric Nurse Practitioner) for a medication review. (V18) reviewed medication list. New orders were reported to nurse and orders processed. The IDPH surveyor (as described above) reported to this surveyor on 7/10/2024 at 4:52PM the following occurred: The IDPH surveyor walked out the front door of the facility. When the IDPH surveyor approached the front door there was an elderly couple coming through the second set of double doors. The lady was in front and using a walker, the IDPH surveyor approached to help her with the door. As the lady was coming through the door, suddenly another female resident (R16) went through the lady in front of the gentleman that was coming in the door. The other female resident (R16) exited the facility and went through the second set of doors. The door alarm sounded. The IDPH surveyor went out the doors to the front parking lot of the facility and approached R16 and attempted to get her to go back into the facility. The IDPH surveyor was aware R16 was not supposed to be out of the facility since she had observed R16 being redirected earlier in the day. R16 stated, No I am going home. V19 (Regional Chef) pulled up close to the facility and stated he had come back to the facility to return a charger he took. The IDPH surveyor explained to V19 she had tried to get R16 back into the facility and she wouldn't go back in with her. V19 asked the resident to go in with him and she wouldn't go. When asked if he had her V19 replied, I will go in and get the administrator. R16 then started walking to the north end of the parking lot. The IDPH surveyor stayed with R16 attempting to redirect her back to the facility. R16 told the IDPH surveyor she was pregnant and needed to go home then went onto the main road heading north. The IDPH surveyor stayed with the resident, and she began running down the side of the road. V17 (RN) came and then stated she couldn't run. Then V1 came running up the road yelling at R16 to stop running but R16 kept running. Once V1 caught up to the resident the IDPH surveyor returned to the facility. The IDPH surveyor (as described above) reported to this surveyor on 7/10/24 at 5:27 PM R16, V20 (Family Member), and V1 (Administrator) came back into the facility. At that time, V1 stated they had to call the local police and V20 to get R16 to come back to the facility. V1 stated R16 got all the way to the end of the road. R16's hair was wet with sweat and V20 stated, I have to take her to the nurse and get her vital signs, she is hot. On 7/11/24 at 11:10 AM, V13 (CNA) stated R16 tried to get out of the facility a lot, about ten times a day. V13 stated R16 is always going to the back door and knows to hold the door for 15 seconds to get it to stop alarming because she used to work at the facility. V13 stated R16 left not more than a week ago but stopped herself. V13 stated there was four staff with her and they followed R16. When asked what interventions were in place to prevent R16 from eloping, V13 stated R16 didn't reside on the hall she typically worked on, but when R16 was with her, she would have her help fold laundry. V13 stated R16 will sit and talk to residents and likes to read magazines to them. V13 stated they just keep R16 busy. On 7/11/24 at 11:31 AM, V11 (CNA) stated R16 was fairly new to the facility. V11 stated she had met her and R16 was a busy body. V11 stated R16 didn't reside on the hall she typically worked on. V11 stated she wasn't familiar with R16's interventions, but today she combed R16's hair, took her out on the enclosed patio, and sometimes R16 goes into laundry and folds towels. V11 stated it is hard to keep R16 busy. When asked if she had any concerns with residents who wander, V11 stated she didn't think there was enough entertainment for them. V11 stated there is not enough staff to keep the residents who wander busy. On 7/12/2024 at 12:33 PM, V17 (RN) stated she responded to the door alarm on 7/10/24 and saw a female resident and her husband standing at the front window. V17 stated there was a male resident (R4) standing close to the doors, and he wears an elopement alert bracelet. V17 stated she thought R4's elopement alert bracelet set off the alarm due to him standing close to the doors. V17 stated R4 tends to go out the door, so she was trying to get him away from the door and she turned the alarm off. V17 stated, I suspected he (R4) was the one that set off the alarm. V17 stated she didn't go outside to see if another resident had exited. V17 stated, (V19/Corporate Chef) came in and told us that (R16) was outside, so I responded by going outside to get her. V17 stated when she looked out the window, she saw the state surveyor and R16 at the end of the parking lot and by the time she got there R16 was down the road. V17 stated she caught up with them and told the state surveyor she couldn't run, then V1 caught up with them. V17 stated, I was concerned because people fly down that road, I know because I live down that road and there are no sidewalks on either side of that road. V17 stated that once the Administrator was with the resident, she went back to get her car so she could turn on the flashers to slow down the cars so they wouldn't hit R16. V17 stated she also called the police and V20 (Family Member) to help get R16 safe and back to the facility. On 7/15/24 at 12:14 PM, V34 (Receptionist/Medical Records) stated R16 had been attempting to elope all day on 7/10/24. V34 stated when R16 would see someone come up to the door she would run up to it. V34 stated she was watching R16 and would keep her from going out. V34 stated she wasn't aware of R16 getting out of the facility prior to 7/10/24. V34 stated she didn't know what interventions were in place to keep R16 from eloping. On 7/15/24 at 3:37 PM, V2 (DON) stated she wasn't at the facility on 7/10/24 when R16 eloped. This surveyor reviewed with V2 the incident and V17's interview that she didn't go outside when she heard the alarm. V2 stated she believed it was the policy of the facility to look outside and call a full facility head count. On 7/16/24 at 8:28 AM, V21 (RN/Registered Nurse) stated R16 was not his resident, but he was called to her unit because she was attempting to exit the facility through the activity room door on 6/16/24. V21 stated her attempt to leave prompted him to look for an elopement alert bracelet. V21 stated while he was looking for the bracelet, he heard the alarm going off and went to the front door. V21 stated a family member was between the two sets of doors and said she had tried to stop her. V21 stated R16 was approximately 25 yards down the street when he got outside. V21 stated R16 was very resistant to coming back to the facility and became verbally combative. V21 stated they did eventually get R16 back to the building. V21 stated as far as he knew, it was the first time R16 had attempted to and/or eloped. V21 stated when he left R16 to look for the elopement alert bracelet, there were several staff members with R16, and he wasn't sure where R16 was while he was looking and/or how she got out of the facility without staff being aware. When asked if he could remember interventions that were in place to prevent elopement prior to 6/16/24, V21 stated there was no elopement alert bracelet in place, and he couldn't remember any specific interventions. When asked what current interventions were in place to prevent elopement, V21 stated he wasn't sure if they were care planned, but R16 liked to fold clothes and clean up after meals. V21 stated the facility setting makes R16 feel like she is working. V21 stated evening is worse, but R16 always wanders and is exit seeking. V21 stated they are short staffed, and he didn't feel like they had enough staff to meet the needs of the residents. V21 stated he felt like R16 needed to be 1:1. V21 stated 2 nurses and 2-3 CNA's are not enough eyes to keep an eye on her. V21 stated they don't have enough staff to implement person centered interventions to prevent behaviors. On 7/17/24 at 8:37 AM, V1 (Administrator) stated they did not have an elopement alert bracelet on R16 after she was assessed on 6/13/24 as being an elopement risk. V1 stated she talked with staff to determine who monitored R16 on 6/16/24 after she was exit seeking and before she eloped, and she was not able to find anyone who was responsible for ensuring R16 didn't elope while they were looking for the bracelet. V1 stated R1's Care Plan for elopement was not implemented until 7/1/24. According to this interview, there were no specific person-centered interventions implemented to prevent R16 from eloping from 6/13/24 when she was assessed as being at risk for elopement until 7/1/24 and there are no person-centered interventions currently in place. On 7/17/24 at 11:25 AM, V33 (LPN/Licensed Practical Nurse) stated she was working on 6/16/24. V33 stated R16 was attempting to leave, and she and V21 went to look for an elopement alert bracelet. V33 stated a staff member (unknown) stated R16 was on the parking lot by the front door. When asked if anything was put in place to keep R16 from eloping while they looked for the elopement alert bracelet, V33 stated, Not that I am aware of. On 7/17/24 at 2:35 PM, V30 (CNA) stated R16 does exit seek and she has exited the facility. V30 stated it gets worse in the evening, and she has learned that if she keeps R16 busy it is better. V30 stated she will find things for her to do such as talk to other residents, or help her with a task by walking with her when she is getting something. V30 stated she also calls R16's son to talk with her and that helps as well. On 7/18/24 at 12:54 PM, V32 (CNA) stated R16 has gotten out of the facility a couple of times. V32 stated there was one incident (6/16/24) when R16 got out and was walking down the road. V32 stated she, V31, and V21 were chasing R16, and they were able to redirect her back into the facility. R32 stated R16 didn't have an elopement alert bracelet on, and she believed the facility staff were looking for one to place when R16 exited the facility. When asked what happened between R16's attempt on 6/16/24 and R16 exiting the facility, V32 stated it was dinner time, they have family members come in through that time frame, and they told them R16 was outside. V32 stated she was not aware R16 was exit seeking before 6/16/24. V32 stated on some days they have enough staff and other days they don't. When asked if they had enough staff to monitor and implement interventions for residents who have exit seeking behaviors, V32 stated, No, I wouldn't say that. On 7/20/24 at 10:52 PM, V31 (CNA) stated she was working when R16 exited the facility on 6/16/24. V31 stated she is usually the one who responds to the door alarms when they go off. V31 stated R16 likes to slip through the doors when visitors come in. V31 stated R16 knows how to work the system and is very charming. V31 stated on 6/16/24 she responded to the front door alarm and V21 was right behind her. V31 stated the intervention in place on 6/16/24 was to respond to the door alarm and try to get her back in as quickly as possible. V31 stated they did not have interventions in place then like they do now. V31 stated she was not aware R16 was an elopement risk prior to her elopement on 6/16/24. On 7/22/24 at 1:18 PM, V22 (LPN) stated she was working on 6/26/24 when R16 exited the facility. V22 stated she heard the alarm and immediately went to check on it and she thought she saw R16 dart out the employee entrance door. V22 stated she followed her out and R16 was just outside the door, but not outside the building. V22 stated R16 had her pants down and was urinating. V22 stated she redirected R16 back into the facility. The facility Missing Resident and Elopement Policy and Procedure, dated 8/10/23, documents, It is the policy of this facility to provide a safe environment for all residents. We will properly assess residents and plan the care to prevent accidents related to wandering behavior or elopement. Procedure Assessment and Identification of Wandering Residents 1. History of behaviors, including wandering, will be obtained prior to admission. 2. A resident with Alzheimer's/Dementia that is ambulatory will be considered at risk for elopement and an appropriate care plan will be put in place Residents identified at risk of elopement: Residents whose assessment identified wandering behavior shall also be considered at risk for elopement. If a resident is identified at risk for elopement, the following steps will be taken.: 1. If clinically indicated, an alarm bracelet will be placed on the resident to audibly alert staff of attempts by the resident to exit, in facilities with this capability. 2. The residents care plan shall address behavior using resident specific goals and/or approaches as assessed by the interdisciplinary team .4. Facility staff will ensure that all exit alarms will be responded to immediately When a door alarm sounds: When any door alarm sounds, staff shall: 1. Check the alarm panel to determine which door has been opened. Do Not Assume someone else has already done this. 2. Check the exit door for any exiting resident by means of a visual check. Also perform search of building parameter (sic) for exited resident. 3. If a resident is discovered outside the facility inappropriately, staff will assist him/her back into the facility. Follow the confirmed elopement procedure. 4. Reset the door alarm after it is determined by visual check that no resident has exited the facility inappropriately or is returned to the facility. The Immediate Jeopardy that began on 6/13/24 was removed on 07/17/24 when the facility took the following actions to remove the immediacy: *R16 was safely brought back into building on 7/10/24, elopement evaluation completed on 7/10/24, medication review completed on 7/10/24, medications adjusted on 7/10/24. Initiated monitoring of change of behaviors after family visits on 7/11/24, on 7/15/24 monitored behavior after family visits and identified increased exit seeking behavior, care planned for increased safety checks during the evening hours after family visits until behavior resolves on 7/16/24. Also discussed with family potential activities for re-direction during increased anxiety periods on 7/17/24. *Residents who are wander risks are at potential risk to be affected by the same alleged deficit. An audit was completed by the administrator (V1) and (V36) MDS coordinator on 7/17/24 of all wandering residents and no issues were identified *The Administrator (V1) and Maintenance Director (V35) in-serviced staff on 7/16/24 and 7/17/24 on the facility Elopement and Search (Code Amber) policy. Inservice included the topics elopement assessment, placing wander guard alarm band immediately when identified at risk, physician orders and where to locate the wander guard bands. Inservice included location of wander guard exit doors, wander guard alarm panels. Inservice included topics who responds to alarms, search indoors and outdoor perimeter, announcing alarm and calling all clear when resident is returned safely to building. Inservice includes remaining with resident and completing safety checks until exit seeking behavior resolves. *All staff have been in serviced on the Elopement and search code amber policy and will be in serviced prior to their next scheduled shift. *In-services were initiated on 7/16/24 and 7/17/24 and will continue to be given by Administrator designee prior to the staff next scheduled shift until completed. *The administrator has ensured all residents who are at risk for elopement have been assessed and appropriate interventions have been implemented. *The Administrator (V1) has reviewed the policy and procedure Elopement and Search Code [NAME] Policy and no updates at this time. *Administrator (V1) and/or designee will complete one Elopement drill rotating shifts daily for 2 weeks. Any areas for improvement will be immediately addressed. *Director of Nursing/DON (V2) and or designee will audit all new admissions/re-admission 5 days a week for 4 weeks for Elopement evaluation, wander guard placement if applicable and interventions initiated, interventions on care plan. Any issues will be addressed immediately. *Administrator (V1) or designee will audit incidents of elopement 5 days a week for 4 weeks to ensure they were thoroughly investigated. *Results of all audits will be discussed at QAPI in meetings and any further recommendations of interdisciplinary team will be immediately implemented and audit until 100 percent compliance.

Based on observation, interview, and record review the facility failed to identify, treat, and prevent the development of pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 24. This failure resulted in R1 developing a Stage 3 wound and an Unstageable wound to bilateral buttocks. Findings include: R1's Admission Record documents R1 was admitted to the facility on [DATE]. R1's Physician's Order Sheet (POS), dated 7/2024, documents diagnoses including angina pectoris, heart failure, GERD (Gastroesophageal Reflux Disease), unspecified dementia, unspecified severity with other behavioral disturbances, atrial fibrillation, type 2 diabetes mellitus, paranoid schizophrenia, chronic kidney disease stage 4, hypothyroidism, chronic peripheral disease, gout, and COPD (Chronic Obstructive Pulmonary Disease). R1's MDS (Minimum Data Set), dated 4/10/2024, documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. The same MDS section GG documents R1 requires substantial/maximal assistance with toileting/hygiene and with shower/bathing, and R1 requires assistance for sit to lying, sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfers. Section M, Skin Conditions, of the same MDS does not document any unhealed pressure ulcers/ injuries, venous or arterial ulcers, or any other ulcers, wounds, or skin problems for R1. R1's Progress Note, dated 6/28/2024 at 3:26 PM, documents, CNA (Certified Nursing Assistant) states that resident has been incontinent of stool and is lying in his bed with genitals exposed and refusing to be changed. (V23, Nurse Practitioner) present for conversation and aware of continued behaviors. R1's Progress Note, dated 6/28/2024 at 3:44 PM, by V2 (Director of Nursing) documents, This writer spoke with (V23, Nurse Practitioner) regarding (R1's) continued behaviors. (V23) reports that she spoke with (V26, Physician) about (R1) and stated they both feel that IM (Intramuscular) medication is needed, but they are fearful for the safety of staff if they were to attempt to administer an IM medication to resident, and therefore feel that a placement in a behavioral health facility is the best option at this time. R1's Progress Note, dated 7/1/2024 at 2:55 AM, documents, All shift resident has refused to let staff change him. Resident's bed is saturated in urine and dripping into the floor. Resident has a puddle of urine under his bed and was trailing to the door. Resident let staff clean the urine from his bed to the door but refused to let staff change him or clean under the bed. When cleaning under the bed was mentioned, the resident started yelling 'no' at the staff. Resident has been pleasant since that interaction and calling for needs. R1's progress notes, dated 7/2/2024 at 6:45 PM, documents R1 was transported out by way of local ambulance service to local hospital after an altercation with R9. R1's local hospital ER (emergency room ) record, dated 7/2/2024, documents R1 reports, he is here to have his wounds on his bottom addressed. This is the only area of pain that he has. No other complaints. Calm and cooperative at this time in ER. The ER's Impression and Disposition notes under clinical impression documents the following: 1. Sepsis due to unspecified organism, unspecified whether acute organ dysfunction present. 2. Altered mental status, unspecified altered mental status type. 3. Cystitis. Differential Diagnosis includes but not limited to, UTI (Urinary Tract Infection), Electrolyte abnormality, medication induced psychiatric illness. Hospital Progress Notes on 7/3/2024 at 1:36 AM documents Sepsis secondary to skin and soft tissue infection. Hospital Wound Care Notes on 7/3/2024 at 10:00 AM documents, wound care consult completed at this time. Patient noted to have ITD (Intertriginous Dermatitis) to bilateral axilla's, bilateral chest folds, bilateral abdominal flanks, bilateral groin, and inner thighs and to scrotum and coccyx. Patient noted to have evolving DTPI (Deep Tissue Pressure Injury) to right buttocks and Stage 3 pressure injury to left buttocks. Left buttocks, stage 3 wound measuring 4 cm (centimeters) length, 2.5 cm width, 0.3 cm depth and wound surface area 10 cm. Right buttocks DTPI measuring 3 cm length, 2cm width, 0.3cm depth and 6 cm wound surface area. The hospital records from theER on [DATE] at 1:36 AM, indicates R1 was given IV (Intravenous) antibiotics of Vancomycin 2 gm (grams) and Levofloxin 750 mg (milligrams) after blood cultures were obtained. On 7/12/2024 at 8:40 AM, R1 was visited at the local hospital. R1 was sitting up in bed watching television. R1 was alert and oriented x 4. R1 stated he is feeling much better. R1 stated his bottom is not hurting like it was so he thought his wounds were healing. R1 stated he got the wounds while at the facility. R1 stated, When I get any kind of infection it goes to my brain for some reason, and I am not right when I do get an infection. On 7/10/2024 at 11:25 AM, V6 (Licensed Practical Nurse/LPN) stated she had taken care of R1, as he is on her hall. V6 stated, I noticed a change with (R1) the last 2 weeks. (R1) had been more violent and was refusing care. (R1) was supposed to be taking antibiotics for a urinary tract infection, but he was refusing his medications. V6 stated the floor nurses do treatments on the residents except for Thursdays, because that is the day that the wound doctor comes to the facility. V6 stated she was not aware of any wounds on R1, and he was not getting any treatments. V6 stated she heard of his behaviors when he tried to pull another resident out of the bed. On 7/10/2024 at 12:00PM, V7 (LPN) stated she works all halls here, and she is familiar with R1 as she takes care of him when she works his hall. V7 stated, Prior to 2 weeks or so ago, (R1) was so sweet and real easy going. I was unaware of any wounds on (R1) until right before I sent him out to the hospital the last time on 7/2/2024. V7 stated, (V12 Certified Nursing Assistant/CNA) was helping try to get (R1) ready to be transported to the hospital and she noted a large wound to (R1's) buttocks. (V12) reported it to me immediately, but when I went into the room to assess the wound, (R1) refused, so I did not get to even look at it. V7 was asked how often they did skin checks on R1, and V7 stated weekly. V7 stated they document those on the Medication Administration Record (MAR). On 7/10/2024 at 11:17 AM, V9 (CNA) stated she sometimes takes care of R1. V9 stated, I had noticed for the last 2 weeks or more (R1) had not been acting himself. He has been refusing care and having bad behaviors. (R1) did get sent to the hospital and he is still there. On 7/10/2024 at 11:20 AM, V5 (CNA) stated she always works 6am to 2pm shift. V5 states she normally takes care of R1. V5 stated, (R1) was always fine until the last few weeks, and he started refusing care. I did not know of any wounds on (R1). We tried to provide care to him, but he would get upset. On 7/10/2024 at 3:55 AM, V12 (CNA) stated she works the hall where R1 resides. V12 stated, I had taken care of (R1) for a long while. (R1) was always nice up until the last month to month and a half. When V12 was asked about any skin issues with R1 she stated, I would apply powder to his groin area prior to his refusal of care because it was gaulded, but on the day we were getting ready to send him out to the hospital, I noticed a big circular area on (R1's) bottom and it was bleeding pretty good. I then went to (V7, LPN) and told her, but (R1) refused to let (V7) look at it and then the ambulance came. I was not aware the big area on (R1's) bottom was there until that day. V12 stated R1 is wheelchair bound but R1 can walk a few steps. V12 stated R1's showers are scheduled for Tuesday and Saturdays on day shift. V12 stated she didn't ever give showers to him because she works evenings. On 7/12/2024 at 8:01 AM, V27 (Healthcare Power of Attorney for R1) was asked if she was aware of any skin issues like wounds and she stated, No, I didn't know anything about this either. On 7/12/2024 at 8:25AM, V29 (Case Manager at local hospital) stated, (R1) is doing much better now that the infection is better. V29 stated R1 is taking his medications and his wounds are healing. On 7/12/2024 at 9:10 AM, V1 (Administrator) was asked if she knew R1 had some wounds that he acquired at the facility, and V1 stated, No, I did not know that. I get updates from the hospital, but I only look at Case Manager's notes. On 7/12/2024 at 9:40 AM, V2 (Director of Nursing) was asked to explain issues with R1 from the time of readmission from the hospital on 6/19/2024. V2 stated R1 would say he didn't need his medications, and he was refusing care up until he went back to the hospital on 7/2/2024. V2 stated, (R1) was being seen by wound doctor for the yeast on his groin area, but had refused to allow the wound doctor to see him the last couple of times. I was not aware of any wounds on (R1), and nobody reported wounds to me, and I do all the wounds in the facility and rounds with the wound doctor on Thursdays. V2 stated she was aware R1 was refusing all care most of the time. V2 stated she received a call one night that R1 had so much urine everywhere in his room, his mattress was saturated and leaking on the floor, the urine was even running out into the hallway. V2 stated he would only let the staff mop the hallway and barely in his room. V2 stated he would not let the staff clean anything else. V2 stated, I was looking more at the Psych issues than I was the medical issues. On 7/12/2024 at 12:50 PM, V26 (Physician) was asked if he knew about the wounds R1 had when he got to the ER, and he stated No, nobody has told me about that. V26 was asked if he felt the infection could have caused the behaviors which led to the lack of care, which in turn caused these wounds, and he stated, Well lack of care can cause wounds and infection of any kind can cause worsening of confusion. Infections are rough on some folks. On 7/12/2024 at 1:57 PM, V23 (Nurse Practitioner) stated, I have known and cared for (R1) for a long time. Normally, (R1) is a pleasant guy that is alert and oriented x4. V23 was asked if she was aware of the wounds on R1's buttocks and she stated, I didn't know anything about wounds but have seen the pictures taken at the hospital. I was aware (R1) was refusing care including personal care and refusing medications with most concerning medications of antibiotics. V23 stated R1 was urinating everywhere and was pouring urine all over himself and was laying in urine and feces and refused care. R1's (TAR) Treatment Administration Record, dated 6/1/2024-6/30/2024, documents a physician order for skin checks scheduled every Monday and Thursda,y with a start date of 9/17/2020.The R1's TAR documents R1 refused the skin checks on 6/20/2024, 6/24/2024, and 6/27/2024. The same TAR document a physician order for antifungal powder under bilateral breast folds, bilateral abdominal folds and groin every bedtime, start date of 11/22/2023. The TAR documents R1 refused treatment from 6/19/2024 to 6/30/2024. R1's Medication Administration Record (MAR), dated June 2024, documents Augmentin 875-125 mg one tab every 12 hours for bacterial infection for 10 days, start date of 6/19/2024. This same MAR documents from the dates of 6/19/2024 through 6/29/2024, R1 refused Augmentin 875-125 mg, 16 out of 20 offered dosages. The same document contains a physician order for another antibiotic of Levaquin 500 mg, give one tablet by mouth one time a day for urinary tract infection for 7 days with start date of 6/20/2024, the same MAR documents R1 refused Levaquin 500mg 5 out of 7 offered doses. R1's Shower Sheets, dated June 2024, documents R1 refused showers on 6/24/24 and 6/25/2024. The last documented shower R1 received was on 6/11/2024. There were no other showers documented indicating R1 did not receive a shower for 22 days. The facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol (revision date August 2008) documents under section Assessment and Recognition 1. Document an individual's significant risk factors for developing pressure sores, for example immobility, recent weight loss, and a history of pressure ulcers. In addition, the nurse shall assess and document/report the following: A. Full assessment of skin condition including but not limited to location, stage or partial/full thickness, length, width, depth, presence of exudates or necrotic tissue. B. Pain assessment, C. Resident's mobility status, D. current treatments, including support surfaces, E. all active diagnosis. Under section titled Cause Identification documents, 1. Identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes, congestive heart failure, overall medical instability, cancer, or sepsis, causing catabolic state, and macerated or friable skin. 2. Document any signs/symptoms of infection, skin condition assessment, the impact of comorbid conditions on wound healing, etc.

Based on interview and record review, the facility failed to prevent an accident for 1 (R2) of 3 residents reviewed for accidents in the sample of 9. This failure resulted in R2 receiving a 2 cm (centieter) laceration to the right side of the forehead and being sent to the emergency room requiring 2 sutures. Findings Include: R2's Admission Record documents R2 was admitted to the facility on [DATE], and is [AGE] years old. R2's Admission Record documents diagnoses including but not limited to Diagnoses: Transient cerebral ischemic attack, unspecified, vascular dementia, unspecified severity, with other behavioral disturbance, other idiopathic peripheral autonomic neuropathy, chronic pain syndrome, unspecified glaucoma, unspecified macular degeneration, legal blindness, fibromyalgia, chronic pulmonary embolism, long term (current) use of anticoagulants, abnormal posture, weakness, and history of falling. R2's Minimum Data Set (MDS), with Assessment Reference date of 3/25/24, documents a Brief Interview for Mental Status (BIMS) score of 09, which indicates R2 has moderate cognitive impairment. R2's MDS for Functional Abilities and Goals documents R2 uses a manual wheelchair and was coded as dependent for the ability to wheel 50 feet with 2 turns or to wheel 150 feet in a small corridor or similar space. (Dependent is defined as the helper does all of the effort .resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity). R2's Care Plan includes a focus area documenting R2 is at risk for falls related to: Weakness/Recent Infections, Dementia, Hx (history) of falls at home, self transfers initiated on 11/15/19 and revised on 7/23/23. Interventions include 4/12/14 High Back w/c (wheelchair) initiated on 4/25/24 and 6/15/24 bilateral foot pedals to w/c initiated on 6/21/24. The State of Illinois - Illinois Department of Public Health Long Term Care Facility Serious Injury Incident Report submitted by the facility documented R2 sustained a fall with physical harm or injury on June 15, 2024 at 11:30 AM. The incident report documented the following under Detailed Incident Summary: Resident (R2) is alert with intermittent confusion. BIMS: 10 severe cognitive impact. Diagnosis: TIA (transient ischemic attack) vascular dementia, blindness, neuropathy. Resident transfers with assist x (times) 2, may use hoyer lift when weak. Requires assistance with long distance ambulation using high back wheelchair. On 6-15-2024 at approximately 11:30, CNA (Certified Nursing Assistant) was assisting resident with ambulation in w/c (wheelchair) when she unexpectedly put her feet down, causing her to become entangled and fall forward out of chair. Resident does not remember the incident so is unable to say why she put her feet down while being assisted in the wheelchair. Resident propels self short distances and has not required foot pedals until this incident. Previously, she was able to hold legs up without difficulty. A laceration was noted to right side of forehead. First aid applied. Resident neuro checks WNL (within normal limits), vital signs stable, resident unable to provide statement as to what happened. Neurochecks initiated, NP (Nurse Practitioner) and resident's daughter notified. Resident sent to ER (emergency room ) for evaluation via EMS (Emergency Medical Service). 6-15-2024 at 15:55 (3:55 PM) resident returned from ER to facility via EMS. All CT's (computed tomography) are negative, two stitches to right forehead. Bruising to right side of head. Resident can have extra strength Tylenol for pain and was put on Macrobid 100mg BID (twice daily) x 5 days for UTI (urinary tract infection). Interventions include Med (medication) review, ABX (antibiotic) therapy for UTI and bilateral foot pedals. IDT (interdisciplinary team) met, Physician, POA (Power of Attorney), and care plan updated. R2's local hospital records include an ED (Emergency Department) Provider Note, dated 6/15/24, and documented Pt (patient) brought by EMS from (name of nursing facility). EMS states the staff was pushing her in the wheel chair and she fell forward and hit her head. She has this circular puncture wound noted to the right side of his forehead. They said there was nothing there that could have caused it. The ED Provider Note further documents a Clinical Impression of: Fall, initial encounter, Laceration of forehead, initial encounter, and Acute cystitis without hematuria. An ED Procedure Note documents a Laceration Repair to R2's forehead, laceration lengh of 2 cm (centimeters), repair type was sutures and number of sutures was documented as 2. New Prescriptions given were Acetaminophen 500 mg (milligram) 1 tablet as needed every 6 hours for pain and Nitrofurantoin Macrocrystalmonohydrate (Macrobid) 100 mg by mouth two times a day for 5 days. On 6/25/24 at 2:00 PM, V7 (Certified Nurse Aide/CNA) stated he was pushing R2 to the dining room for lunch and she put her feet down and fell forward. V7 said he tried to grab her to keep her from falling, but that didn't work. V7 said he did not have any foot rests on the wheelchair when he was pushing R2. V7 said it happened so fast. V7 said R2 had been able to hold her feet up prior to the incident, but after the incident, a couple of other CNA's told him that she would put her feet down at times. V7 stated he felt really bad. On 6/27/24 at 3:00 PM, V2 (Director of Nurses/DON) stated she did the reportable incident on R2. V2 said R2 did self propel short distances and was good about keeping her feet up on longer distances, but that day she just put her feet down and fell forward. The facility's Fall Policy titled Falls - Clinical Protocol documents a section of Assessment and Recognition which includes the following: 4. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. a. Risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impainnent, weakness, environmental hazards, confusion, visual impainnent, and illnesses affecting the central nervous system and blood pressure. 5. The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications associated with increased falling risk) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant).

Based on interview and record review, the facility failed to ensure thorough assessments for changes in condition were provided and documented (R1 and R8), and failed to identify, assess and treat wounds (R1) for 2 of 3 residents reviewed for quality of care in a sample of 21. These failures resulted in both R1 and R8 experiencing discomfort due to a delay in treatment. R1 experienced prolonged respiratory distress resulting in R1's transport to the local hospital, and R8 required transport to the local hospital with subsequent hospital stay for altered mental status, Urinary Tract Infection with hematuria, and acute pulmonary edema. Findings Include: 1. R1's Facility Admission record documents an admitted [DATE], with diagnoses that include Chronic Obstructive Pulmonary Disease, unspecified cirrhosis of the liver, Heart failure, hypertension, Nonalcoholic steatohepatitis (NASH), chronic kidney disease, and Psoriasis. R1's MDS (Minimum Data Set), dated 05/06/2024, documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 was cognitively intact. R1's Weights and Vitals Summary, dated 05/14/2024, documents the following: On 05/04/2024 at 11:09pm, Blood Pressure (B/P) 126/84, pulse (P) 86, respirations (R) 16, temperature (T) 98.2. On 05/06/2024 at 05:49am B/P 126/84, P 88, R 16, T 97.7. There were no vital signs documented from 05/04/2024 at 11:09pm until 05/06/2024 at 05:49am. A review of R1's progress notes document R1 was administered a dose of her as needed pain relief medication at 01:29pm on 05/05/2024 for left lower quadrant pain. She was later administered a dose of her as needed anti-nausea medication at 8:44pm and 10:26pm on 05/05/2024. R1's progress notes do not document any assessments, including respiratory assessments or oxygen saturation, or notes from 05/05/2024 until 05/06/2024 at 10:33am when they document the following: Resident (R8) is being sent out to (local hospital) ER (emergency room ) due to significant changes in Respiratory and responsiveness. Resident did appear lethargic at the beginning of the shift and was breathing deeply but had no complaints of pain and did respond no she wasn't hurting and when asked how she felt resident stated fine and shrugged her shoulders. This nurse was alerted around 10am that the patient is now not responding verbally. Resident is conscious and alert. Respirations have increased and breathing appears to be labored. Resident's urine is also discolored, and patient's vitals are BP 92/58, T=97.0, P= 99, O2= 80% on 3L (Liters) via NC (nasal cannula). V14 (NP/Nurse Practitioner) notified, and order given to send resident to the hospital. Daughter called and asked that she go to (name of larger hospital in another town) but could also go to (name of local hospital) if necessary. EMT (emergency medical technician) stated they preferred to take resident to (name of local hospital) d/t (due to) possible aspiration. This nurse attempted to call the daughter back twice to inform her of where the resident would be getting taken and got no answer from on the phone. Resident was transported via (name of ambulance service) to (name of local hospital) Hospital ER (emergency room ). A review of a document titled Patient Care Record for R1 from (name of ambulance service), dated 05/06/2024, documents the following: dispatched immediate response to (facility name) in (town name) for a female who has an altered mental status. Upon arrival staff stated that this morning she did not want to take her medicine and that is not like her. They then stated that she ate breakfast and took her meds and when they came back to check on her, she was altered, and her oxygen saturation was 80% on her normal 3 liters via cannula. They stated that her normal baseline is alert and oriented x4. Currently the patient is awake but unresponsive to voice or pain. She is moderately cyanotic with use of accessory muscles.She has a hx (history) of diabetes and COPD. She was placed on a capnography cannula at 6lpm (liters per minute). Her oxygen saturation was 70%. Lung sounds assessed and there was a pleural rub noted on the right side with wheezing. Her airway was suctioned, and stomach contents were removed. Her oxygen began to rise after suctioning. Her breathing began to improve, and she was given an albuterol breathing treatment. Patient was transported to (local hospital) ER without incident. R1's hospital record ,dated 05/06/2024, documents, 71 yo (year old) wf (white female) is brought to ER (emergency room ) for medical eval. Patient was found unresponsive, blue in color, patient has low sat on 70% at 3 liters. As per EMS (emergency medical services), patient vomited last night. Patient got better after suctioning and breathing treatment. Under Vital Signs it documents the following: temperature 94.7, heart rate 91, respiratory rate 26, blood pressure 91/63. R1's hospital record documents, Clinical Impressions 1. Acute on chronic respiratory failure with hypoxia and hypercapnia (HCC), 2. Pneumonia of left lung due to infectious organism, unspecified part of lung, 3. Mucus plug in respiratory tract, 4. Renal failure, unspecified chronicity, 5. Respiratory acidosis 6. Metabolic acidosis. R1's ED (Emergency Department) Triage Note from the local hospital dated 5/6/23 at 10:53 am, documents Pt (patient/R1) unresponsive to painful stimuli. Doctor in room on arrival. Pt (R1) has foley which has turbulent appearance in drainage bag. The Patient Expiration Pronouncement from R1's local hospital records documents a date of death of [DATE] and time of death of 9:34pm. A review of an incident report from the local police department documents a statement from V27 (Medical Doctor/MD performing autopsy) on 05/10/2024. This document states V27 confirmed the NASH (Nonalcoholic steatohepatitis) diagnoses and stated that R1 had end stage liver disease. V27 noted that most of R1's internal organs appeared to have been failing. V27 attributed the amount of fluid R1's body was retaining due to R1's organs failing and her lack of mobility. V27 attributed R1's death to be as a result of the poor condition of her organs. On 05/14/2024 at 10:01 am, V9 (Licensed Practical Nurse/LPN) stated R1 had some discomfort in her left lower quadrant on 05/05/2024. V9 stated she believed R1's vital signs were within normal limits for her. V9 stated R1 takes quite a few pills in the evening and on 05/05/2024, R1 was really having difficulty getting them down. V9 reported R1 always struggles with them, but that it was worse that night. V9 denied R1 had any episodes of emesis but stated R1 felt nauseated. V9 reported she administered a dose of R1's anti-nausea medication that was ordered as needed. V9 stated R1's nausea was resolved within an hour. V9 stated R1 requested her bed to be reclined more because V9 had R1 sitting straight up in bed. V9 stated she checked on R1 multiple times throughout her shift and did not notice anything abnormal about her. V9 stated she reported to the day shift nurse about R1's condition because she had never had this experience with her, and V12 (day shift LPN) said that it was a common occurrence for R1 on day shift. V9 reported she took R1's vital signs, but was not sure if she documented them. V9 further elaborated R1's blood pressure and pulse were typically pretty low on her shift, but does not specifically recall what they were on the night of 05/05/2024 going into the morning of 05/06/2024. V9 stated she does not recall if she did any assessments on R1. V9 stated she did not document assessment or vitals because she was not required to. On 05/14/2024 at 2:04pm, V13 (Certified Nurse's Assistant/CNA) stated she was not very happy when she came in and saw the condition R1 was in on the morning of 05/06/2024 at the start of her shift at 06:00am. V13 stated she could see R1's chest was going up and down hard before even entering her room. V13 reported R1 was lying flat in bed, her head was not elevated at all, and no one had given her any report. V13 noted R1 had brown stuff on her shirt and vomit in the basin that was also dark brown in color. V13 stated she reported all of this to V12 (Licensed Practical Nurse/LPN), and V12 stated she would keep an eye on her. V13 stated she gets R1 up for breakfast often and she knows that her feet can lay flat on the ground, but that morning her feet were so stiff, they wouldn't move, which she reported to V12, and V12 she stated it was just foot drop. V13 stated she was not able to take R1's vital signs because equipment is kept on the nurse's cart so they can take it. V13 stated she sat in R1's room with her and fed her breakfast in bed at approximately 08:00am. V13 reported R1 was not a big eater, but only took a few bites that morning. V13 did note that morning the little dots on R1's fingers and she reported it to V12. V13 reported she did provide incontinence care for R1 that morning and the stuff in her catheter was not a good color. V13 stated she reported it to V12 as well. V13 stated she was very concerned, and she continued to report it to V12, and she felt that it took hours for someone to do something. V13 stated she did have concerns about being brushed off or heard by some nurse's when they report concerns with residents to them. V13 stated R1 was communicating with simple yes or no responses that morning until around the time she took her tray away. V13 stated at that point, she started to check on R1 constantly, in between caring for other residents, and continued to report her concerns to V12 who was passing medications at that time. V13 said as soon as V15 (Infection Control Nurse) saw her standing at R1's door, she went and looked at R1 and got her vital signs. On 05/14/2024 at 12:27pm, V12 (LPN) stated she was working on 05/06/2024, and sent R1 out to the emergency room . V12 stated it was reported to her R1 was not taking her medications, which was unlike her. V12 reported that V13 (CNA) told her that she did not look good and she was not herself, but her vital signs were fine, so V12 told V13 there was nothing she could do. V12 stated her shift started at 6:00 AM, she stated that it was probably around 7:00 AM, R1 was breathing deeply with no pain and lethargic. V12 noted at that point in time, (R1) was not in respiratory distress, but was breathing deep. Not rapid, just looked comfortable and lethargic. V12 stated that is when she took the vitals and checked on her. V12 reported R1 was responding verbally. V12 recalled vital signs were within normal range; R1's blood pressure was on the lower end of normal, but within the normal range. V12 stated R1's blood pressure was on the lower end of normal for parameters, maybe not for her individually. V12 reported she was only R1's nurse twice, so she couldn't really say what was normal for her. V12 stated around 10:00am, V15 (Infection Control Nurse) grabbed her and said there were people in R1's room and she needed to check her out. So V12 went in there and R1 was alert and conscious. V12 stated she wouldn't say R1 had an altered level of consciousness, because she was awake, but not responsive. V12 reported she took vital signs on R1 and decided to send her out. V12 stated she did obtain vital signs on R1 at the beginning of the shift, but she did not document them as she was busy with her medication pass. V12 denies any concerns with the care R1 was provided the previous shift. V12 stated the previous shift had told her R1 wasn't herself and hadn't taken her meds as normal and she was nauseous. V12 denied anyone had told her R1 had an emesis. V12 stated on 05/06/2024, she didn't have an opportunity to put in any assessments on R1 because she was doing her medication pass. V12 denied having suctioned R1 on 05/06/2024. V12 stated she gave R1 medication that morning, and she was taking them a few at a time. V12 stated R1 shook her head no the last time, tried a few more drinks of water, said they went down, but V12 noted they were on her tongue. V12 reported she removed them with a spoon. V12 reported she made the hospital aware, she recalled she thought there were four pills. V12 stated R1 was responding by shaking her head, but not verbally responding. On 05/14/2024 at 4:11pm, V15 (Infection Control Nurse) stated when leaving morning meeting on 05/06/2024, she noticed a few Certified Nursing Assistants standing outside of the room of R1 and she asked them what was going on. They said R1 didn't seem to be doing well. V15 said she asked if they told their nurse and they said yes, they told V12 (LPN). V15 asked V13 (CNA) if R1 had any changes over the weekend and she said no, but she noticed it when she came on shift that morning. V15 reported V13 was really concerned and pretty upset. V15 stated she went in to check on R1 and you could tell something was wrong. V15 stated when she went to speak to R1, her eyes were open, but she wasn't responding. V15 noticed R1's urine didn't look good. V15 reported she went to V12 and asked about vital signs, V12 said she had done them, and they were within normal limits. V15 called V14 (On-call Nurse Practitioner) at 10:06 AM. V15 denied knowing whether V12 obtained vital signs at that time or not. On 05/14/2024 at 3:35pm, V14 (On call Nurse Practitioner) stated V15 called her at some point that morning (5/6/24) and told her R1 was less responsive and not herself. V14 told V15 to send R1 to the emergency room . V14 stated if someone has a change in condition that isn't emergent, they leave notes in her book so she can see the patient when she is at the facility. V14 stated she would expect staff to check vital signs. V14 stated there isn't anything in writing as to how often they should be assessing a resident or their vital signs with a change in condition, but V14 would expect they should just be using nursing judgement. On 05/15/2024 at 10:08pm, V2 (Director of Nurse's/DON) state, after a quick review of the events of the night of 05/05/2024 into the morning of 05/06/2024, she would expect to see documentation of reassessment and vital signs after administration of as needed medication for nausea and R1's reported symptoms and change in condition. V2 stated it would be her expectation staff would document vital sign values and assessments on residents for each encounter with them, and not in just one note. V2 stated it is her expectation staff would continue to reassess a resident that was in the condition that R1 was in, especially if staff continued to voice concerns about them. V2 said she would expect staff to assess a resident whether an assessment was scheduled or not if there were concerns and contact the physician even if vital signs were within normal limits. V2 recalled V12 (LPN) stopping her the morning of 05/06/2024 and asking if V14 (Nurse Practitioner) would be in house that day. V12 was hoping to have V14 take a look at R1 because she had been nauseous the night before, had spit her meds out and was lethargic that morning. Then at around 10am, V13 (CNA) stopped V15 (Infection Control Nurse) and asked her to take a look at R1. V2 couldn't say for sure if waiting until V14 came into facility was appropriate or not for R1's change in condition. V2 denied knowing if there was a facility protocol or standing order about the management of respiratory distress while waiting for an ambulance. V2 noted V14 would have given an order if she wanted any changes in the amount of oxygen R1 was receiving. On 05/15/2024 at 09:05am, V16 (Paramedic) stated when they walked into R1's room, she was blue. V16 stated R1's eyes were open, but she was not alert or responsive; he was told by someone there her baseline was A&O (alert and oriented) x4. V16 believes R1 was slightly moaning, but was working extensively to breathe. V16 stated he believed there was a delay in care, and R1 had likely been in distress for several hours. V16 reports he was almost certain they would be working a cardiac arrest before they arrived at the emergency room . V16 reported they received the call through the Ambulance service private number, and the report they received was R1 had an altered level of consciousness. V16 stated the report they received in no way depicted an accurate report of the condition R1 was in. V16 stated R1 was lying pretty flat in bed, with her normal dose of three liters of oxygen being delivered via nasal cannula. On 05/15/2024 at 09:05am, V17 (Paramedic) stated the facility reported R1's oxygen saturation was 80%, when they arrived, it was 73%. V17 stated R1 was still receiving her normal dose of oxygen of three liters via nasal cannula. V17 stated she suctioned R1, and she sounded a little better, but they also gave her a breathing treatment because she was still kind of restricted. V17 stated she absolutely believed there was a delay in care. V17 recalled she was really concerned this call was about to turn into a cardiac arrest. V17 denied R1 was alert when they arrived; her eyes were open, but she was not there. On 05/16/2024 at 2:06pm, V13, Infection Control Nurse, stated she did not see V12 take R1's vital signs at any point during the morning of 05/06/2024. V13 denied having taken her concerns to anyone besides V15 later that morning. V13 stated administration always tells them it is important for them to follow their chain of command. V13 commented she did not have this issue with all nurses, just two in particular, V12 being one of them. On 05/16/2024 at 02:07pm, V26 (emergency room Physician) confirmed from his progress note that R1 presented to the emergency room unresponsive, hypothermic, and hypotensive. V26 reviewed his clinical impression and agreed with his diagnosis of R1. V26 stated it is possible for someone in R1's poor condition of health to have normal vital signs and to decline so much from 06:00am to 10:00am. V26 stated he could not confirm or deny if R1 would have had a different outcome had she arrived at the hospital earlier. V26 stated he did not think it would have changed R1's outcome, but that it is really hard and dangerous for a practitioner to say in this situation. V26 further commented when diseases become more advanced, the ability to call for help becomes less and less. V26 further stated it is also not known if R1's vital signs were truly normal at 06:00am, and he cannot base his assessment on everything being normal at 06:00am and abnormal at 10:00am. A review of a facility policy titled Notification of Resident Change in Condition documents it is the policy of this facility to promptly notify the resident, their legal representative(s) and attending physicians of changes in the resident's health condition. Under the section titled Standards it documents in part the following: The licensed nurse is to use professional judgment in determining changes in condition based on assessment and findings or signs and symptoms of change which could lead to deterioration if not treated. Following assessment, observing signs and symptoms, and obtaining vital signs, the attending physician, family/guardian will be promptly notified of significant findings. 32765 2. R8's Admission Record, with a print date of 5/20/24, documents R8 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia, Alzheimer's disease, diabetes, hypertension, chronic kidney disease, arthritis, and history of falls. R8's MDS (Minimum Data Set), dated 3/4/24, documents R8 has a BIMS (Brief Interview for Mental Status) score of 10, which indicates a moderate cognitive impairment. R8's current Care Plan documents a Care Area of (R8) requires assist with ADL's (activities of daily living) r/t (related to): Activity Intolerance, Pain, confusion, non-compliant with asking to help. The interventions for this Care Area document R8 requires assist of one for bathing and toileting, requires assist with bed mobility, dressing, eating, grooming, and hygiene. R8's Weights and Vitals Summary, dated 5/20/24, documents R8's vitals on 5/12/24 at 11:09 PM as blood pressure (B/P) 115/70, temperature (T) 98.3, pulse (P) 80, and respirations (R) 20. This same report documents R8's vital signs on 5/16/2024 at 1:49 PM as B/P 189/106- T- 97.4, P 95, R 16. There are no vital signs documented from 5/12/24 at 11:09 PM until 5/16/24 at 1:49 PM. R8's Progress Notes, dated 5/13/24, documents an assessment by V24 (Nurse Practitioner/NP) with no significant findings. R8's Progress Notes do not document any assessments or notes from 5/13/24 until 5/16/24 at 1:44 PM when V30 (LPN) documented the following. Res (R8) observed drooling from L (left) side of mouth. Res (resident) c/o (complains of) dizziness, lethargy, nausea/vomiting, some increased confusion, coughing, and congestion. Res (R8) B/P was taken twice. First time it was 175/108, second time it was 189/106. Pulse 95. This nurse notified (V14 Nurse Practitioner) who gave orders to send res to hosp (hospital). This nurse called (name of ambulance service) at 1315 (1:15 PM). Report was called to (name of local hospital) ER (emergency room ) and given to (name of hospital staff), (Name of POA/Power of Attorney) was notified at 1320 (1:20 PM). (Name of ambulance) arrived at 1330 (1:30 PM). R8's hospital record, dated 5/16/24, documents, Pt (patient) arrives via EMS (Emergency Medical Services) with c/o (complaints of) cough, congestion, and periods of increased altered mental status Under Impression and Disposition R8's hospital record documents, Clinical Impression: 1. Altered mental status, unspecified altered mental status type. 2. Urinary tract infection with hematuria, site unspecified. 3. Acute pulmonary edema . R8's facility Progress Notes, dated 5/19/24, document, Pt readmitted from (name of local hospital) discharge r/t UTI. Nurse reported medication addition of ABT (antibiotic) of Levaquin 250mg (milligrams) PO (by mouth) BID (twice daily) and Coreg 3.125mg PO BID for HTN (hypertension). Nurse from (name of hospital) reports pt has not been ambulating since admission to (name of hospital). Pt arrived via BLS (Basic Life Support) ambulance and stretcher. Pt vital signs as follows blood pressure of 140/86, pulse regular 106, respirations 18 and non-labored on room air, temp 97.4 temporal, and weight of 120.6 lbs (pounds). Pt able to make needs known. Alert to self and place. Pt denies any pain at this time. Pt voids with clear amber urine. Pulse, movement and sensation noted to all extremities. Pt skin intact. No redness or open area noted. Call light within reach. Orders processed per policy. Dietary advised of pt return and order given. Will monitor. MD (physician) and on-call management advised. On 5/20/24 at 1:30 PM, R8 was in bed, appeared clean and well-groomed with no obvious signs of distress. R8 stated she did go to the hospital recently, and when asked if the facility sent her to the hospital in a timely manner, R8 stated, so- so. R8 was not able to tell this surveyor how long she was sick before the facility sent her to the hospital. On 5/20/24 at 10:09 AM, V33 (Family Member) stated she didn't have concerns with the care R8 received at the facility. V33 stated the nurse at the hospital told her R8 had advanced fluid in her lungs like it had been going on for a while. V33 stated she spoke with the physician at the hospital, and the physician said there was a little fluid in R8's lungs, but the physician was more worried about R8's blood pressure and the bad urinary tract infection R8 had. On 5/20/24 at 9:31 AM, V30 (LPN) stated she administered medications to R8 on the morning of 5/16/24. V30 stated later that same day, V32 and V37 (CNA's) reported to V30, R8 had a change in condition. V30 stated R8 had increased weakness, altered mental status, and was drooling. V30 stated she assessed R8, called the Nurse Practitioner (NP), and called an ambulance to transfer R8 to the local hospital. V30 stated R8 was admitted to the local hospital with a diagnosis of hematuria, altered mental status, and acute pulmonary edema. V30 stated R8 did not have any respiratory symptoms when she administered medications in the morning but was congested and had a cough when the CNA's reported the change in condition to her later in the day. On 5/20/24 at 9:55 AM, V32 (CNA) stated she provided care to R8 on 5/16/24. V32 stated R8 refused her shower and didn't want to wake up to eat breakfast. V32 stated that was normal for R8. V32 stated R8 didn't exhibit any symptoms until right after lunch when she vomited. V32 stated she reported it to V30 who assessed R8 and sent her to the hospital. When asked if she had any concerns with the care R8 received at the facility, V32 stated later, on 5/16/24, she was told by V34 (CNA) he had reported to his nurse on the evening of 5/15/24 that R8's skin color was not right and R8 wasn't acting her normal self. On 5/20/24 at 10:22 AM, V34 (CNA) stated he worked on 5/15/24 and 5/16/24. V34 stated he provided care for R8 on 5/15/24. V34 stated he reported to an unknown nurse on 5/15/24 that R8 was not looking like her normal self. V34 stated the unknown nurse asked what was wrong with R8, and he told her R8 was pale. V34 stated then V36 and V38 (CNA's) stated they thought R8 was having a stroke. V34 stated R8 wasn't eating and wasn't putting words together. V34 stated they all went to V35 (LPN) and V35 didn't really say anything and more or less pushed it to the back burner. V34 stated V35 told them she would get to it and would monitor R8. V34 stated this occurred between 2:00 PM and 3:30 PM. When asked if he checked R8's vital signs, V34 stated V35 didn't tell him to. V34 stated he is still new to the facility and didn't know where they kept everything. On 5/20/24 at 12:57 PM, V36 (CNA) stated she worked on 5/15/24 and provided care for R8. V36 stated she remembered R8 laying in her bed, not doing much. V36 stated she took R8 her dinner and she didn't eat it. V36 stated she gave this information to V35 (LPN) because R8 just wasn't her normal self. V36 stated V35 went into R8's room with V36 present, and asked R8 if she was alright. V36 stated V35 didn't check R8's vital signs or perform an assessment on R8. V36 stated V35 just stood and talked to R8. On 5/20/24 at 4:08 PM, V38 (CNA) stated she was working on 5/15/24 and provided care for R8. V38 stated R8 didn't seem to be her normal self on that night. V38 stated R8 was more confused. V38 stated they reported it to V35 (LPN). V38 stated V35 went to R8's room and looked at her and said R8 was ok and to just keep an eye on her. V38 stated V35 didn't check R8's vital signs and didn't have them check them. V38 stated she didn't recall V35 doing a physical assessment on R8. When asked if she had any issues with nurses not following up or doing assessments when she reports concerns to them, V38 stated, Yes, V35 doesn't seem to follow up. On 5/20/24 at 12:23 PM, V35 (LPN) stated she didn't remember if she provided care to R8 on 5/15/24 or 5/16/24. V35 stated she hadn't had any CNA's report a change in R8's condition to her. V35 stated the last time she saw R8, she was ok. V35 stated she didn't remember working with V34, V36, or V38. On this same date at 12:48 PM, V35 came back to this surveyor and stated she spoke with V30 (LPN), and now she remembered providing care to R8 on 5/15/24. V35 stated she thought V36 reported to her R8 wasn't feeling good. V35 stated she checked on R8, and she was up in her room, wheeling about in her wheelchair. V35 stated R8 was not coughing, and she didn't notice any concerns. When asked if she checked R8's vital signs, V35 stated, Probably because I usually do. When asked where she charted them, V35 stated, If they were fine, I wouldn't have. V35 stated if R8 was in distress she would have documented the vital signs. On 5/20/24 at 12:07 PM, V37 (CNA) stated she worked on 5/15/24 and 5/16/24. V37 stated she was not R8's primary CNA on those days but did see her. V37 stated R8 appeared more tired than normal. When asked if she had any issues with nurses responding or following up when they report changes in condition to them, V37 stated, sometimes. V37 was not able to provide this surveyor with any specific situations that this has occurred. V37 stated they (CNA's) get vital signs when they are asked to. When asked if they had access to vital sign equipment, V37 stated, No. V37 stated if they (CNA's) have to get vital signs, they get the equipment from the nurses who keep them on the medication carts. V37 stated they aren't always on the carts though and then they have to go find them on another cart on a different hall. On 5/20/24 at 4:44 PM, V30 (LPN) stated she had CNA's report to her other nurses were not following up when they reported concerns related to a resident's condition to them. V30 stated CNA's will get V30 when they report a concern to V12 (LPN) and/or V35 (LPN) and they don't do anything about it. On 5/20/24 at 4:34 PM, V2 (DON) stated if a resident had a change in condition, she would expect the nurse to assess them, see if it was a valid change in condition, document the assessment, and if there was a finding notify the nurse practitioner. On 5/20/24 at 5:01 PM, V1 (Administrator) stated after she spoke with this surveyor she talked to some CNA's, and they told her V12 and V35 don't respond when they take concerns to them. On 5/21/24 at 8:44 AM, V1 stated if there is a change in condition she would expect the nurse to assess the resident, address the concern, do vital signs if necessary, and document their assessment of the resident including the vital signs. 3. R1's Facility Admission record documents an admitted [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), Unspecified Cirrhosis of the Liver, Heart failure, Hypertension, Nonalcoholic Steatohepatitis (NASH), Chronic Kidney Disease, Psoriasis. R1's MDS (Minimum Data Set), dated 05/06/2024, documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 was cognitively intact. R1's Care Plan with an initiation date of 04/22/2024 documents no care areas, goals or interventions related to R1's diagnoses of psoriasis that can lead to alterations in skin. R1's progress notes from R1's admitted [DATE] through 05/06/2024 documents no alterations in skin integrity, discoloration, bruising, redness, scratching, open areas, skin tears or pressure ulcers. R1's skin assessments and shower sheets from admitted [DATE] through 05/06/2024 document no areas of scratching, redness, discoloration, skin tears or open areas. R1's bowel movement and continence task responses from 04/19/2024 documents that R1 had frequent loose stools and was almost always incontinent of bowel. R1's Physician Order Sheet, dated 05/08/2024, documents an order for Hydroxyzine HCI 10mg tablet by mouth every four hours as needed for itching. There were no orders for treatments of any skin conditions noted on R1's May 2024 Medication Administration Record, Treatment Administration Record, or Order Summary Report dated 5/14/24. R1's hospital record, dated 05/06/2024, documents bruising, erythema, and rash (petechial rashes) present in V26's (emergency room Physician) assessment of R1's skin. The following areas are photographically documented in R1's hospital record, Discoloration to bilateral hands, feet and heels. Redness to R1's mid back, discoloration, and open areas to R1's sacrum and coccyx. Two small open areas to R1's left hip. A large area of discoloration to R1's left arm. On 05/08/2024 at 10:27 AM, V3 (emergency room Registered Nurse) stated R1's pressure ulcers were to her right hip, left heel, sacrum, and right foot. V3 stated she would say most of R1's wounds were at least a stage II except for the sacrum. V3 stated it was more like a stage III, although she stated that she was not a wound nurse and does not stage wounds. On 05/08/2024 at 10:29 AM, V4 (emergency room Registered Nurse) stated she would like to remark about something else noted on R1's skin. V4 stated R1 had a significant number of open areas to her skin, but had a condition called pustular Psoriasis. On 5/16/24 at 2:07 PM, V26 (emergency room Physician) denied being able to recall any pressure type areas on her body or

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from neglect by facility staff failing to provide assistance with incontinence care in a timely manner for 1 out of 5 residents (R1) reviewed for neglect in a sample of 34 residents. This failure resulted in R1 being left in a soiled urine soaked adult incontinent brief in a public area for approximately 5 hours and 52 minutes. This would cause a reasonable person to experience feelings of discomfort, shame, humiliation, and/or embarrassment. Findings include: 1. R1's face sheet documented an admitted [DATE], and diagnoses including: Alzheimer's disease with late onset, dementia, atherosclerotic heart disease, hypertension, dysphasia, muscle weakness. R1's 12/16/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 00, indicating R1 was severely cognitively impaired, and section G documented R1 required extensive two person assist with transfer and toilet use, and section H documented R1 is frequently incontinent of urine. R1's Care Plan documented in part, Focus (R1) has frequent episodes of incontinence noted r/t Alzheimer's. Will expose self when needing toilet Date initiated 07/18/22 Interventions/Tasks: Incontinence: Check and change as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. Date initiated: 7/18/22. R1's Care Plan also documents, Focus (R1) has impaired skin integrity and is at risk for pressure r/t impaired mobility, incontinence . Date initiated: 7/18/22. Focus (R1) is at risk for falls r/t (related to) confusion, incontinence, impulsive, non complaint psychoactive drug use, poor safety awareness Date initiated: 7/18/22 Interventions/Tasks: 1/2/23 assist and offer toileting during rounds. Date initiated 01/10/23. Focus (R1) requires assist with ADL's (activities of daily living) r/t (related to) Alzheimer's, weakness, impaired balance, Date initiated: 07/18/22 Interventions/Task: Grooming and hygiene requires depended on staff Toileting requires ext (extensive) assist of 2. Date initiated: 07/18/22 On 2/8/23 at 5:40 AM, R1 was sleeping in a chair in the common area by the nurse's station and dining area, in full view of the hall, and had pulled his pants and incontinent brief down around his thighs. R1's incontinent brief was observed to be wet with yellow urine. V3 (Certified Nursing Assistant/CNA) and V7 (Agency Licensed Practical Nurse /LPN) were observed to assist R1 to stand, and pulled up the soiled incontinent brief and R1's pants, then assisted R1 back into the chair. At that time, V3 and V7 walked away from R1. On 2/8/23 at 5:53 AM, 7:20 AM, and 8:02 AM, R1 was again observed sitting in a chair in the common area by the nurse's station and dining area, in full view of the hall, and with his incontinent brief was bulging. Several staff walked by R1, due to the chair being placed in an area staff had to pass by to get to the nurse's station or into the dining room, and was in the direct line of site from the nurse's station. On 2/8/23 at 8:02 AM, R1 was served breakfast by unknown nursing staff sitting in a chair in the common area by the nurse's station and dining area, in full view of the hall and with his incontinent brief bulging. On 2/8/23 at 8:46 AM, 9:07 AM, and 9:16 AM, R1 was again observed sitting in a chair in the common area by the nurse's station and dining area in full view of the [NAME],l and with his incontinent brief bulging. On 2/8/23 at 9:56 AM, R1 was observed to be sitting in the chair by the nurse's station with the front of his incontinent brief bulging and hanging down the inside of his right pant leg. On 2/8/23 at 10:14 AM, R1 was observed to be sitting in the chair by the nurse's station with his pants wet with urine from his groin down to his ankles, and a puddle of urine on the floor under him. On 2/8/23 at 10:24 AM, V17 Licensed Practical Nurse (LPN) walked past R1 and sat down at the nurse's station. On 2/8/23 at 10:27 AM, V16 (CNA) pushed another resident in a wheelchair through R1's urine splattered on the floor. On 2/8/23 at 10:32 AM, an unknown facility staff member, alerted V17 (LPN) R1's pants were wet, and there was puddle of urine in the floor under R1. At that time, V17 found V16; both assisted R1 to the bathroom. Both stated at that time, they had not noticed R1 needed incontinence care. From the time of the first observation of R1 sitting in a soiled incontinence brief at 5:40 am, to 10:32 am when R1 was finally taken to be assisted in changing R1's soiled brief, R1 had been sitting in a soiled incontinence brief for approximately 5 hours and 52 minutes without assistance. During the times of these observations of R1, several staff including nursing and housekeeping were observed to be walking by R1 going about their duties. On 2/8/23 at 11:00AM, after a discussion with V1 (Administrator) about the observations made regarding R1, V1 stated she expected V3 and V7 to have assisted R1 with incontinence care when they saw R1 ' s incontinence brief was soiled. V1 said she expected staff to provide incontinence care for R1 every two hours or any time they saw or suspected he was soiled. V1 said R1 should not have been in need of incontinence care for almost six hours, and that was unacceptable. V1 then stated V3 (CNA) would be suspended for neglect for three days, due to putting the wet incontinence brief back on R1. V1 said V7 (LPN) was an agency nurse, and V1 was not able to suspend her, but would be notifying the staffing agency of her neglect. On 2/8/22 at 1:47 PM, when asked why V3 (CNA) did not offer R1 incontinence care at 5:40 AM when she assisted R1 to pull his pants and incontinent brief back up, she stated she did not see that his incontinence brief was soiled. On 2/8/23 at 1:47 PM, V3 (CNA) said there were two CNA's working on the hall in the facility where R1 resided on 2/7/23 at 6:00 PM to 2/8/23 at 6:00 AM. V3 said two CNAs are not able to complete all the care tasks residents require. V3 said during the 6PM to 6AM shift, residents should be assisted with incontinent care at 12:00 AM, 2:00 AM, and 4:00 AM, and that was it. On 2/8/23 at 12:45 PM, V8 (CNA) said residents should be assisted with incontinent care every two hours. V8 said the 6:00 PM - 6:00 AM shift should complete rounds on incontinent residents around 5:00 AM, and the 6:00 AM - 6:00 PM shift should complete rounds on incontinent residents around 7:00 AM, and every two hours throughout the day. V8 said residents should be assessed for incontinence on the odd hours throughout the day. V8 said if a resident can not tell you if they need incontinence care, staff have to check their incontinence product. On 2/14/23 at 4:12 PM, V2, Director of Nursing (DON), said she expected CNA's to round every two hours to provide toileting assistance or incontinent care for residents. V2 said if a resident is not interviewable, the staff should physically check the resident for being soiled. On 2/9/23 at 9:52 AM, V10 (Licensed Practical Nurse (LPN) / Wound Nurse) said a resident sitting in urine for almost six hours could cause skin breakdown. V10 said CNAs should be completing rounds every 2 hours checking resident's for incontinence and assisting with perineal care if needed. On 2/8/23 at 3:00 PM, V11 (Wound Physician) said a resident sitting in urine for long periods of time could cause skin irritation or dermatitis. The facility's November 22, 2017 Abuse Prevention Program - Policy documented in part . residents have the right to be free from . neglect . neglect is a facilities failure to provide, or willful withholding of, adequate medical care . personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident . neglect is also the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .

Based on observation, interview, and record review, the facility failed to assist residents with incontinence care in a timely manner, and assist residents out of bed prior to meals for 2 out of 5 residents (R1 and R5) reviewed for activities of daily living in a sample of 34 residents. These failures resulted in R1 being left in a soiled urine soaked adult incontinent brief in a public area for approximately 5 hours and 52 minutes. This would cause a reasonable person to experience feelings of discomfort, shame, humiliation, and/or embarrassment. Findings include: 1. R1's face sheet documented an admitted [DATE], and diagnoses including: Alzheimer's disease with late onset, dementia, atherosclerotic heart disease, hypertension, dysphasia, muscle weakness. R1's 12/16/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 00, indicating R1 was severely cognitively impaired, and section G documented R1 required extensive two person assist with transfer and toilet use, and section H documented R1 is frequently incontinent of urine. R1's Care Plan documented in part, Focus (R1) has frequent episodes of incontinence noted r/t Alzheimer's. Will expose self when needing toilet Date initiated 07/18/22 Interventions/Tasks: Incontinence: Check and change as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. Date initiated: 7/18/22. R1's Care Plan also documents, Focus (R1) has impaired skin integrity and is at risk for pressure r/t impaired mobility, incontinence . Date initiated: 7/18/22. Focus (R1) is at risk for falls r/t (related to) confusion, incontinence, impulsive, non complaint psychoactive drug use, poor safety awareness Date initiated: 7/18/22 Interventions/Tasks: 1/2/23 assist and offer toileting during rounds. Date initiated 01/10/23. Focus (R1) requires assist with ADL's (activities of daily living) r/t (related to) Alzheimer's, weakness, impaired balance, Date initiated: 07/18/22 Interventions/Task: Grooming and hygiene requires depended on staff Toileting requires ext (extensive) assist of 2. Date initiated: 07/18/22 On 2/8/23 at 5:40 AM, R1 was sleeping in a chair in the common area by the nurse's station and dining area, in full view of the hall, and had pulled his pants and incontinent brief down around his thighs. R1's incontinent brief was observed to be wet with yellow urine. V3 (Certified Nursing Assistant/CNA) and V7 (Agency Licensed Practical Nurse /LPN) were observed to assist R1 to stand, and pulled up the soiled incontinent brief and R1's pants, then assisted R1 back into the chair. At that time, V3 and V7 walked away from R1. On 2/8/23 at 5:53 AM, 7:20 AM, and 8:02 AM, R1 was again observed sitting in a chair in the common area by the nurse's station and dining area, in full view of the hall, and with his incontinent brief bulging. Several staff walked by R1 due to the chair being placed in an area staff had to pass by to get to the nurse's station or into the dining room, and was in the direct line of site from the nurse's station. On 2/8/23 at 8:02 AM, R1 was served breakfast by unknown nursing staff sitting in a chair in the common area by the nurse's station and dining area, in full view of the hall, and with his incontinent brief bulging. On 2/8/23 at 8:46 AM, 9:07 AM, and 9:16 AM, R1 was again observed sitting in a chair in the common area by the nurse's station and dining area, in full view of the hall, and with his incontinent brief bulging. On 2/8/23 at 9:56 AM, R1 was observed to be sitting in the chair by the nurse's station with the front of his incontinent brief bulging and hanging down the inside of his right pant leg. On 2/8/23 at 10:14 AM, R1 was observed to be sitting in the chair by the nurse's station with his pants wet with urine from his groin down to his ankles and a puddle of urine on the floor under him. On 2/8/23 at 10:24 AM, V17, Licensed Practical Nurse (LPN), walked past R1 and sat down at the nurse's station. On 2/8/23 at 10:27 AM, V16 (CNA) pushed another resident in a wheelchair through R1's urine splattered on the floor. On 2/8/23 at 10:32 AM, an unknown facility staff member alerted V17 (LPN) R1's pants were wet, and there was puddle of urine in the floor under R1. At that time, V17 found V16; both assisted R1 to the bathroom. Both stated at that time, they had not noticed R1 needed incontinence care. From the time of the first observation of R1 sitting in a soiled incontinence brief at 5:40 AM to 10:32 AM, when R1 was finally taken to be assisted in changing, R1's soiled brief R1 had been sitting in a soiled incontinence brief for approximately 5 hours and 52 minutes without assistance. During the times of these observations of R1, several staff including nursing and housekeeping were observed to be walking by R1 going about their duties. On 2/8/23 at 11:00AM, after a discussion with V1 (Administrator) about the observations made regarding R1, V1 stated she expected V3 and V7 to have assisted R1 with incontinence care when they saw R1 ' s incontinence brief was soiled. V1 said she expected staff to provide incontinence care for R1 every two hours, or any time they saw or suspected he was soiled. V1 said R1 should not have been in need of incontinence care for almost six hours, and that was unacceptable. V1 then stated V3 (CNA) would be suspended for neglect for three days, due to putting the wet incontinence brief back on R1. V1 said V7 (LPN) was an agency nurse, and V1 was not able to suspend her but would be notifying the staffing agency of her neglect. On 2/8/23 at 1:47 PM, V3 (CNA) said there were two CNA's working on the hall in the facility where R1 resided on 2/7/23 at 6:00 PM to 2/8/23 at 6:00 AM. V3 said two CNAs are not able to complete all the care tasks residents require. V3 said during the 6PM to 6AM shift, residents should be assisted with incontinent care at 12:00 AM, 2:00 AM, and 4:00 AM and that was it. On 2/8/23 at 12:45 PM, V8 (CNA) said residents should be assisted with incontinent care every two hours. V8 said the 6:00 PM - 6:00 AM shift should complete rounds on incontinent residents around 5:00 AM and the 6:00 AM - 6:00 PM shift should complete rounds on incontinent residents around 7:00 AM and every two hours throughout the day. V8 said residents should be assessed for incontinence on the odd hours throughout the day. V8 said if a resident can not tell you if they need incontinence care staff have to check their incontinence product. On 2/8/22 at 1:47 PM, when asked why V3 (CNA) did not offer R1 incontinence care at 5:40 AM when she assisted R1 to pull his pants and incontinent brief back up, she stated she did not see that his incontinence brief was soiled. On 2/14/23 at 4:12 PM, V2, Director of Nursing (DON), said she expected CNA's to round every two hours to provide toileting assistance or incontinent care for residents. V2 said if a resident is not interviewable, the staff should physically check the resident for being soiled. On 2/9/23 at 9:52 AM, V10 (Licensed Practical Nurse (LPN) / Wound Nurse) said a resident sitting in urine for almost six hours could cause skin breakdown. V10 said CNAs should be completing rounds every 2 hours checking resident's for incontinence and assisting with perineal care if needed. On 2/8/23 at 3:00 PM, V11 (Wound Physician) said a resident sitting in urine for long periods of time could cause skin irritation or dermatitis. The facility's August 2008 Perineal Care policy documented in part .Purpose . the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . Preparation . 1. review the resident's care plan to assess for any special needs of the resident . 2. R5's face sheet documented an admitted [DATE], and diagnoses including: quadriplegia, fracture of neck, neuromuscular dysfunction of bladder, chronic embolism and thrombosis of unspecified deep veins of lower extremity bilateral, recurrent depressive disorders, anxiety disorder, need for assistance with personal care. R5's MDS, dated [DATE], documented a BIMS score of 15, indicating no cognitive impairment. This same MDS documented in section G that R5 was totally dependent for all Activities of Daily Living (ADLs), including transfers. R5's initially dated 7/19/21 care plan documented R5 .has ADL self-care deficiency related to: paralysis . On 2/8/23 at 8:22 AM, R5 was observed to be assisted by unknown nursing staff to eat breakfast in bed. On 2/8/23 at 11:44 AM, R5 said he prefers to be assisted out of bed around 5:00 AM - 5:30 AM. R5 said he required the use of a mechanical lift; he was not always able to be assisted out of bed until after breakfast because the mechanical lift needed two staff to operate. R5 said if there is not enough staff to assist him out of bed at 5:00 AM - 5:30 AM, he has to stay in bed until approximately 8:30 AM, when the staff have completed breakfast tasks. On 2/8/23 at 3:15 PM, V6 (CNA) said R5 prefers to be assisted out of bed around 5:00 AM. V6 said when staff start their shift in the morning, they are expected to get residents up, assist with any incontinence care, and assist them to the dining room if they choose. V6 said because of the workload, if R5 is not assisted out of bed before 6:00 AM, there is not enough time for staff to assist R5 out of bed before breakfast. V6 said there are several days R5 is not assisted out of bed before breakfast. On 2/8/23 at 1:47 PM, V3 (CNA) said she usually worked the hall R5 resided on. V3 said R5 preferred to be assisted out of bed around 5:00 AM. V3 said the facility had been changing the halls staff work on to educate staff on all the residents residing in the facility. V3 stated, it has been chaotic switching staff to different halls. V3 said when a staff works with the same residents regularly, staff will know the specific resident schedules and needs. On 2/14/23 at 4:12 PM, V2 (DON) said she expected staff to assist residents out of bed when they asked.

Based on interview and record review, the facility failed to protect the residents right to be free from neglect by failing to accurately assess, treat, document, and report a decline in condition to the physician and seek timely medical treatment for 1 of 5 residents reviewed for neglect in the sample of 25. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 12/26/22, when the facility failed to monitor R2's vital signs and report a decline in condition to R2's physician and/or seek timely medical treatment. These failures resulted in R2 becoming unresponsive on 12/28/22, and being admitted to the local hospital for end-of-life care, and R2's subsequent death from septic shock due to Covid-19, acute hypoxemic respiratory failure, acute on chronic renal failure, severe hyperkalemia, and severe protein calorie malnutrition. V1, Administrator, was notified of the Immediate Jeopardy on 1/09/23 at 1:55 PM. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 1/10/23, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: 1. R2's facility Admission Record, with a print date of 1/3/23, documents R2 was admitted to the facility on [DATE] with diagnoses that include fracture of right femur, diabetes, anxiety disorder, depression, heart failure, atrial fibrillation, chronic obstructive pulmonary edema, history of pulmonary embolism, and cognitive communication deficit. R2's MDS (Minimum Data Set), dated 10/27/22, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive impairment. This same MDS documents R2 requires assistance of one staff for bed mobility, transfer, dressing, toilet use, eating, and personal hygiene. R2's local emergency services transport record, dated 12/28/22, documents, Upon arrival at scene EMS (Emergency Medical Services) met staff nurse who was unable to give much history of patient (R2). Nurse reported that (R2's) skin was cold, mottling at feet. Nurse reports (R2's) oxygen saturation was in mid-80's. (R2) was currently on oxygen at 4L (liters) nasal cannula .At patient (R2) contact (R2) found unresponsive in bed breathing independently. Other nurse present states that (R2) is normally vocal when being touched, crying out in pain. This writer attempted to wake (R2) but no response from (R2). Sternal rub performed without any response from (R2). Minimal pupil response when pupils were assessed . R2's local hospital record, dated 12/28/22, documents under Emergency Department Provider Notes, C/O: (complaints of) unresponsive. DNR (Do Not Resuscitate). Onset: unk (unknown). EMS (Emergency Medical Services) reports NH (nursing home) RN (registered nurse) was unfamiliar w/ pt (with patient/R2) and called family reporting (R2) was unresponsive. Family wanted (R2) sent in Family notified us (R2) was dx (diagnosed ) w/ Covid on Thursday last week. Family did not know (R2) signed DNR (Do Not Resuscitate) form and stated she never discussed it w/them. They note (R2) had been slowly declining and not eating well. V26 (Physician) examined (R2) and d/w (discussed with) the family the prognosis. Family was given some time to think about it. Ultimately, we agreed to .provide comfort measures only Under History Provided by: EMS personnel documents, .(R2) to ED (Emergency Department) via EMS (Emergency Medical Services) from (name of facility). EMS states that patient has been increasingly less conscious the past couple of days . R2's local hospital records, dated 12/28/22, documents under Physical Exam, .Pt (patient/R2) was unresponsive to painful stimuli .no gag reflex .pupil is not reactive .diaper was dry .skin is mottled (at distal extremities) .She did start to make sounds and have small movements after approximately 500 ml (milliliters) of IVF (intravenous fluid) . R2's local hospital records documents under End of Life Care that R2's diagnoses include Covid positive, acute hypoxemic respiratory failure, anion gap metabolic acidosis, acute on chronic renal failure, severe protein calorie malnutrition, and elevated troponin. R2's local hospital record, dated 12/28/22, documents a chest x-ray with findings documenting, .No acute cardiopulmonary process. R2's local Hospital Discharge Summary, dated 12/30/22, documents, .Primary Discharge Diagnosis Covid positive, acute hypoxemic respiratory failure, acute on chronic renal failure, severe hyperkalemia, anion gap metabolic acidosis, severe protein calorie malnutrition, and elevated troponin . R2's local hospital record, dated 12/28/22 to 12/30/22, documents under Hospital Course,(R2) presented to (name of local hospital) ER (emergency room ) from her nursing facility after becoming unresponsive Family was present throughout most of her time and she was kept comfortable before she passed away peacefully at 8:02 AM on 12/30/2022. R2's Certificate of Death Worksheet documents R2's date of death as 12/30/2022, with cause of death documented as septic shock due to novel corona Covid-19 virus infection, acute hypoxemic respiratory failure, and acute on chronic renal failure. This same form documents significant conditions contributing to death as severe hyperkalemia and severe protein calorie malnutrition. R2's facility Progress Notes document the following: 12/22/22 10:50 AM, Family notified of resident (R2) being placed on isolation r/t (related to) (+) (positive) Covid test. Family thankful for the call. 12/22/22 3:40 AM, New orders per V27 (Nurse Practitioner) Vit C (Vitamin C) 500 mg (milligrams) PO (by mouth) BID (twice daily), Zinc 50 mg daily r/t Covid. 12/24/22 4:57 AM, res (R2) non-compliant with care, refuses to stay in contact isolation. No s/o (signs of) discomfort. Cont. (continue) to receive routine pain meds (medications) as ordered. Congested non prod (productive cough). Cont on abt (antibiotic) therapy as ordered. Hollering freq (frequently) throughout shift. R2's facility Nursing Progress Notes do not document a nursing assessment or update related to R2's physical status until 12/28/22, when R2's progress notes document the following: 12/28/22 2:09 PM, .Resident listless/nonresponsive .Gray color, mouth dry with tip of tongue black in coloration. Blue color noted to all extremities, cold to touch, v/s (vital signs) 96.4 (temperature), 90/50 (blood pressure), 24 (unknown), 26 (unknown), 88 (oxygen saturation) with O2 (oxygen) .Notifications made: (V27, Nurse Practitioner) and POA (power of attorney). 3:52 PM Hospital called report resident is admitted for end of life. Covid positive, hypoxia, family at side. R2's POC (Point of Care) Response, History Nutritional task, with a print date of 1/4/23, documents the following food intakes for R2, 12/25/22 8:46 AM 0-25%, 12:45 PM 26-50% and 12/26/22 12:00 PM 26-50, 12:29 PM 0-25%. There is no documentation of food intake for R2 on 12/27/22. R2's POC Response History, Fluid Intake with meals and outside of meals task, with a print date of 1/4/23, documents R2 had the following fluid intakes, 12/24/22- 1020 cc's (cubic centimeters), 12/25/22- 1000 cc's, 12/26/22- 965 cc's, and 12/27/22- 250 cc's. R2's POC Response History, documents under safety checks tasks, with a print date of 1/4/23, R2 was checked 16 times on 12/24/22, 8 times on 12/25/22, 14 times on 12/26/22, and 12 times on 12/27/22, with the last check documented at 11:40 PM on 12/27/22. R2's Facility Care Plan, last review date of 12/01/22, documents under the Fall focus area an intervention that R2 is to be checked every hour. R2's Order Summary Report, with an order date range of 12/01/22 to 12/31/22, documents the following orders, 12/22/22- 10-day Covid-19 Quarantine Contact and Droplet Precautions, Covid-19 Positive/symptomatic monitoring Q 4 (every 4 hours) .for Covid-19 daily monitoring for 10 days, and maintain droplet isolation precautions at all times r/t Covid + (positive). R2's TAR (Treatment Administration Record), dated 12/1/22 -12/31/22, documents the following physician order, with a start date of 12/22/22 6:00 AM, Covid-19 Positive/symptomatic monitoring Q4 (every four hours): Fever (T>99.9F/temperature greater than 99.9 Fahrenheit), Temp (temperature), P (pulse), RR (respiratory rate), O2 Sat (oxygen saturation) & (and) symptoms (Fever, SOB (shortness of breath), Cough, Sore Throat). R2's TAR documents R2 was monitored every four hours as ordered from 12/22/22 2:00 PM until 12/26/22 2:00 PM. There is no assessment and no vital signs documented on this form, from 12/26/22 2:00 PM until R2 was transferred to the local hospital on 12/28/22. The vital signs documented for 12/25/22 at 10:00 AM, 2:00 PM, and 6:00 PM are all as follows, B/P (blood pressure) 130/66, P (pulse) 72, RR (respiratory rate) 18, T (temperature) 98.5, and O2 sat (oxygen saturation) 92%. R2's MAR (Medication Administration Record), dated 12/01/22 to 12/31/22, documents an order to monitor R2's vital signs every shift, with a start date of 10/20/22. R2's vitals are documented and within normal limits each shift on 12/24/22 and 12/25/22. There are no vital signs documented on 12/26/22. The following vital signs are documented on 12/27/22 6 am-6pm shift, B/P 102/58, P 70, R 16, T 97.1, and O2 sat of 93%. There are no vital signs documented on 12/27/22 6 pm - 6 am shift. This indicates R2's vital signs were to be monitored every four hours and the same vital signs were documented multiple times on 12/25/22, no vital signs were documented after 2:00 PM on 12/26/22, and vital signs were documented once on 12/27/22 6am-6pm shift with none documented on the 6pm-6am shift. On 1/4/23 at 3:21 PM, V31 (Registered Nurse (RN)/Agency Nurse) stated she worked on 12/28/22 beginning at 6:00 AM. V31 stated during the morning medication pass (approximately 8:00 AM), unknown Certified Nursing Assistants told her she needed to assess R2. V31 stated R2 appeared listless, her tongue was black, her legs were mottling, her fingertips were blue, her vital signs were not within normal range, but R2 was comfortable. V31 stated she notified the physician and the family, and the family wanted R2 evaluated at the local emergency room . V31 stated she does not remember being told anything in report on the morning of 12/28/22 regarding R2's condition. On 1/5/23 at 10:45 AM, V15 (Licensed Practical Nurse/LPN) stated she worked on 12/24 and 12/25/22, and R2 was her normal self. When asked why R2's vital signs are all the same readings at each time on 12/25/22, V15 stated the Certified Nursing Assistant's (CNA's) get the vital signs, and V15 was just using the last recorded in R2's electronic health record. When asked about the oxygen saturation of 92%, V15 stated R2 would take her oxygen off. When asked if R2's oxygen saturation was rechecked to determine if they improved after reapplying her oxygen, V15 stated it was continually being rechecked. (There is no documentation in R2's medical record of oxygen saturation rechecks). On 1/5/23 at 10:10 AM, V13 (Certified Nursing Assistant/CNA) stated she provided care to R2 on 12/25, 12/26, and 12/28/22. V13 stated she attempted to feed R2, but R2 wasn't eating. V13 stated R2 was taking fluids. When asked if she checked R2's vital signs, V13 stated she was still in orientation and couldn't do vital signs yet. When asked how R2 appeared on those days, V13 stated R2 appeared, Sick, really sick. V13 stated it was either 12/25 or 12/26/22 when she noticed R2 did not appear well. V13 stated R2 kept telling V13 she was dying. V13 stated she reported R2's appearance and condition to V15 (LPN/Licensed Practical Nurse). On 1/5/23 at 10:24 AM, V14 (Certified Nursing Assistant/CNA) stated she worked on 12/26-12/28/22. V14 stated she provided care to R2 and worked with V13 (CNA). V14 stated on 12/27/22, R2's tongue was going black, and R2's extremities were mottling. V14 stated R2 wouldn't eat anything, and R2 kept taking her oxygen off. V14 stated she made sure R2 stayed clean, dry, and comfortable throughout her shift. V14 stated R2 wouldn't swallow when she attempted to give her a drink, so the liquids would just run out of R2's mouth. V14 stated R2's oxygen saturation wasn't reading when R2 would take her oxygen off, but would go up to 92% when she had the oxygen on. V14 stated she didn't remember what nurse was working on 12/27/22, but she did report R2's condition to the nurse. V14 stated she checked R2's vital signs and kept her comfortable and in bed since she was so sick. When reviewed with V14, there were no vital signs documented, V14 stated when the vital signs are abnormal, she gives them to the nurse to review and document. V14 stated she didn't even think she could put abnormal results in the electronic record. V14 stated R2's blood pressure was low at one point and then high at another. On 1/5/23 at 11:43 AM, V17 (RN/Registered Nurse) stated she was an agency nurse and worked at the facility and provided care to R2 on 12/27/22. V17 stated she held R2's blood pressure medication on 12/27/22 because R2's blood pressure was soft. V17 stated V27 (Nurse Practitioner/NP) was at the facility, and she let her know R2's blood pressure was low and that she held the medication. There is no documentation in R2's medical record of V27 being notified. When asked if there was any follow up vital signs obtained after she held R2's blood pressure medication, V17 stated she was only able to get R2's vital signs one time during her 6 am-6 pm shift. V17 stated she had another resident who was critical that was being sent to the emergency room and four admissions that day. When asked if she notified administration that she couldn't provide the needed care, V17 stated, They are well aware of staffing issues. I don't think I could notify them every day. V17 stated the CNAs did not report a decline in R2's condition to her, and did not get any vital signs on 12/27/22. V17 stated she gave report to V18 (Licensed Practical Nurse/LPN) who worked the shift after her (6 PM-6 AM), and told him to watch R2 since her blood pressure was soft. R2's Facility Progress notes documents on 12/27/22, the following medications were Held r/t (related to) hypotension 8:39 AM-furosemide 40 mg (milligrams), 3:40 PM metoprolol tartrate 50 mg, lisinopril 5 mg, 3:41 PM- spironolactone 25 mg, and 5:33 PM- metoprolol tartrate 50 mg. On 1/6/23 at 1:29 PM, V11 (LPN) stated she worked on 12/27/22, but only saw R2 when she passed medications at 9:00 PM. V11 stated R2's lights were down, and she was going to bed. V11 stated she didn't get report of a decline in R2's condition. On 1/5/23 at 1:01 PM, V18 (Licensed Practical Nurse/LPN) stated worked from 12:00 AM to 6:00 AM on 12/28/22. V18 stated R2 was her normal self, and he had to reapply her oxygen when he would go into her room. V18 stated he administered medications to R2 at 5:00 AM on 12/28/22,, and she took them with no issues. V18 stated he forgot to chart R2's vital signs that were obtained during his shift. V18 stated he remembered R2's blood pressure was high, and R2's oxygen saturation was in the low 90's. V18 stated R2's respirations were in the 20's, not labored, but R2 had heavy breathing. V18 stated no one had reported to him R2's blood pressure was low or that she had a decline in her condition. On 1/5/23 at 2:31 PM, V28 (CNA) stated she took care of R2 beginning on the night of 12/27/22 until early morning on 12/28/22. V28 stated R2 was her normal self. V28 stated she did not check R2's vital signs because she did not have dedicated isolation vital sign equipment available. V28 stated she checked R2 every two hours. When asked if R2 ate or drank anything on her shift V28 stated, I think I gave her some water. On 1/6/23, this surveyor reviewed R2's medical record with V2 (Director of Nurses/DON). V2 confirmed R2 did not have Covid monitoring documented, including assessment and/or vital signs on 12/26/22 at 6:00 PM and 10:00 PM, and no monitoring was documented on 12/27/22. V2 confirmed R2's hourly checks were not completed hourly, and the last hourly check documented was at 11:40 PM on 12/27/22. V2 stated there was one set of vital signs documented on 12/27/22, and R2's blood pressure was 102/58, and her oxygen saturation was 93%. V2 stated there was no documentation in R2's facility progress notes of nursing assessments or physician notification of R2's condition from 12/25/22 until 12/28/22. V2 stated she would expect the nursing staff to notify the physician if a resident has a decline in condition including not eating/drinking, and abnormal vital signs. V2 stated she would expect vital signs to be monitored per current standards or practice, physician orders, and policy and procedure. V2 stated if the nursing staff had notified her of R2's decline she would have called the physician and gotten orders for labs and IV fluids. On 1/5/23 at 1:55 PM, V27 (NP/Nurse Practitioner) stated she believed she saw R2 on the afternoon of 12/27/22 and assessed her. V27 stated R2 was pretty much sleeping, very weak, ill appearing. V27 stated R2 was oxygen dependent, and she was able to get R2 to wake up and answer a couple of question. V27 stated she did not prescribe any new orders for R2. This surveyor reviewed with V27, R2's oxygen saturation of 92%-93% on 12/25 and 12/27/22, vital signs not being monitored, fluid and food intake, and that V17 had held R2's blood pressure medication on 12/27/22. V27 stated she was not aware of that information, and if she had been she would have ordered labs, a chest x-ray, and possibly intravenous fluids. V27 stated if a resident's oxygen is trending low, she typically sends them to the emergency room for evaluation. V27 stated she did a head-to-toe physical assessment of R2 and did not see any mottling. R2's Physician Progress note, dated 12/27/22 (not timed), documents, (R2) is seen today for Covid. She (R2) is resting in bed during exam. Confused per baseline and unable to aid in assessment. Oxygen intact via NC (nasal cannula). No distress noted. She is weak and ill appearing. No concerns reported by nursing. Under Objective the physician progress note, documents, Recent Vitals: Reviewed, Date/Time Vitals taken: today, Reviewed at the nursing home with staff. Physical Exam: Constitutional: General: She is not in acute distress. Appearance: She is well-developed. She is ill-appearing. She is not diaphoretic . Skin: General: Skin is warm and dry .Psychiatric: Speech: Speech normal. Behavior: Behavior is cooperative. Cognition and Memory: Cognition is impaired. Memory is impaired. Judgement: Judgement is inappropriate. There is nothing documented under Assessment/Plan. Under Diagnosis and all orders for this visit the physician progress note documents, Covid. This physician progress note, documents under Plan: Covid: Acute. Covid precautions/isolation per facility protocol: vitamin regimen, .if not already taking or other anticoag. Nursing staff will monitor temp and O2 sat each shift and prn (as needed). Supportive therapy. Will monitor for worsening systemic infections. Orders reviewed/signed. Pt (R2) instructed in importance of adequate fluid to stay hydrated. Pt (R2) instructed to inform nursing staff of questions, concerns, changes or concerns. On 1/10/23 at 1:54 PM, after reviewing V27 (NP) interview on 1/5/23 at 1:55 PM with V27 and V39 (Physician), V27 stated she couldn't say the outcome would have been different for R2 if she had known, R2's vitals were not being monitored as ordered, R2's oxygen saturation was trending down, R2 had a decline in food/fluid intake, R2's blood pressure was low, R2's medication had been held, and R2's extremities were reported as mottling, and been able to order labs, intravenous fluids, and chest x-ray. V39 stated, I don't think it would have, having read (R2's) record from the hospital, it may not have made a difference. On 1/5/23 at 8:50 AM, V25 (emergency room Physician) stated R2 was near dead when she was arrived at the emergency roiagnom on [DATE]. V25 stated R2's family was not aware R2 had signed a Do Not Resuscitate form, so V25 discussed with R2's family the potential outcomes, and they decided to admit her with comfort care measures only. V25 stated R2 appeared like someone who had been pretty sick for a few days. V25 stated if R2 had been assessed at the emergency room a few days before, it would have presumably been a better outcome. V25 stated R2 was mottling and the length of time for that depends on the disease process. V25 stated in his experience, it is a multi-day process. V25 stated fluid intake is incredibly important for someone who is acutely ill. V25 stated R2 was in multiorgan failure and hypoxic when she arrived at the emergency room . V25 stated in the 24 hours prior to her coming to the emergency department, someone should have noticed a decline in R2's condition. V25 stated the odds are good R2 would have made it through the hospitalization if she had been treated earlier. V25 stated at the very least, R2's primary physician should have been notified so they could have ordered labs, fluids, and/or determine if R2 needed evaluated at the emergency room . R2's Facility Care Plan, last review date of 12/01/22, documents a Focus area of (R2) is a risk for s/sx (signs/symptoms) of Covid-19. 12/22/2022 Covid + (positive). Interventions are documented as 10/21/22- Educate Staff, Resident, family and visitors of Covid-19 signs and symptoms and precautions. Follow facility protocol for Covid-19 screening/precautions, observe for s/sx of Covid-19-document and promptly report s/sx: coughing, sneezing, sore throat, respiratory issues, provide alternative methods of communications with family/visitors. 12/22/22- Maintain droplet isolation, maintain droplet precautions. And 12/27/22 - Administer medication as ordered. The facility Abuse Prevention Training Program, dated 11/22/2017, documents, The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention .Federal and state laws and regulations mandate that a nursing home resident has the right to be free from verbal, sexual, physical, and mental abuse, exploitation, corporal punishment, and involuntary seclusion. The following definitions for these actions are based on federal and state laws, regulations, and interpretive guidelines: . Neglect is a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident (201 ILCS 45/1-117). Neglect is also the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress (42 C.F.R. S 483.5). The surveyor confirmed through interview, observation, and record review that the Immediate Jeopardy that began on 12/26/22 was removed on 1/10/2,3 when the facility took the following actions to remove the immediacy: *On 1/9/23, V1 (Administrator), V3 (Infection Control Preventionist), and V18 (Wound Certified Nurse Manager) assessed all residents that are COVID 19 positive or at risk for a decline in condition charts to ensure orders for vital signs and monitoring are in place per MD order. *Paper vital sign sheets were implemented with electronic charting for all residents that are COVID 19 positive or at risk for a decline in condition to ensure accuracy and compliance of all vital signs on 1/9/23. *All staff have been in-serviced by V1, V3, V18 on 1/9/23 regarding assessment, monitoring, acute change in condition, documentation, and implementation of orders timely. *All staff have been in-serviced by V1, V3, V18 on 1/10/23 regarding neglect policy and procedure *In-servicing was completed by V1, V3, V18 on 1/9/23 regarding assessment and monitoring of residents that are positive for COVID 19. *In-servicing was completed by V1, V3, V18 on 1/9/23 regarding notifying MD of acute change in condition and implementation of orders timely. *In-servicing was completed by V1, V3, V18 on 1/9/23 regarding documentation. *In-servicing was completed by V1, V3, V18 on 1/10/23 on neglect policy and procedure. *All employees that were not on duty were contacted by phone on 1/9/23 and 1/10/23 by V1, V3, V18 for verbal compliance of all in-services. *Policy review was completed regarding neglect, change in condition, physician notification, and documentation on 1/10/23. *The Administrator or designee will monitor the following 5 days a week for 6 weeks: The Quality Assurance Committee will monitor the facility's performance by monitoring all audits weekly to ensure the corrections are achieved. The first Quality Assurance Committee meeting will be held on Thursday January 12, 2023. All COVID 19 residents' vital signs are completed per MD orders. All COVID 19 residents' rounds for monitoring acute change in condition, notification to MD with any changes, and implementation of timely orders is being completed.

Based on interview and record review, the facility failed to ensure care was provided per current standards of practice when they failed to accurately assess, treat, document, and report a decline in condition to the physician and seek timely medical treatment for 3 of 5 residents (R2, R3, and R5) residents reviewed for quality of care in the sample of 25. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 12/26/22, when the facility failed to monitor R2's vital signs, report a decline in condition to R2's physician, and/or seek timely medical treatment. These failures resulted in R2 becoming unresponsive on 12/28/22, being admitted to the local hospital for end-of-life care, and R2's subsequent death from septic shock due to Covid-19, acute hypoxemic respiratory failure, acute on chronic renal failure, severe hyperkalemia, and severe protein calorie malnutrition. V1, Administrator, was notified of the Immediate Jeopardy on 1/09/23 at 1:55 PM. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 1/10/23, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: The facility undated Covid-19 Line List documents R2 tested positive for Covid-19 on 12/22/22, R3 tested positive for Covid-19 on 12/19/22, and R5 tested positive for Covid-19 on 12/29/22. 1. R2's facility Admission Record, with a print date of 1/3/23, documents R2 was admitted to the facility on [DATE], with diagnoses that include fracture of right femur, diabetes, anxiety disorder, depression, heart failure, atrial fibrillation, chronic obstructive pulmonary edema, history of pulmonary embolism, and cognitive communication deficit. R2's MDS (Minimum Data Set), dated 10/27/22, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive impairment. This same MDS documents R2 requires assistance of one staff for bed mobility, transfer, dressing, toilet use, eating, and personal hygiene. R2's local emergency services transport record, dated 12/28/22, documents, Upon arrival at scene EMS (Emergency Medical Services) met staff nurse who was unable to give much history of patient (R2). Nurse reported that (R2's) skin was cold, mottling at feet. Nurse reports (R2's) oxygen saturation was in mid-80's. (R2) was currently on oxygen at 4L (liters) nasal cannula .At patient (R2) contact (R2) found unresponsive in bed breathing independently. Other nurse present states that (R2) is normally vocal when being touched, crying out in pain. This writer attempted to wake (R2) but no response from (R2). Sternal rub performed without any response from (R2). Minimal pupil response when pupils were assessed . R2's local hospital record, dated 12/28/22, documents under Emergency Department Provider Notes, C/O: (complaints of) unresponsive. DNR (Do Not Resuscitate). Onset: unk (unknown). EMS (Emergency Medical Services) reports NH (nursing home) RN (registered nurse) was unfamiliar w/ pt (with patient/R2) and called family reporting (R2) was unresponsive. Family wanted (R2) sent in Family notified us (R2) was dx (diagnosed ) w/ Covid on Thursday last week. Family did not know (R2) signed DNR (Do Not Resuscitate) form and stated she never discussed it w/them. They note (R2) had been slowly declining and not eating well. V26 (Physician) examined (R2) and d/w (discussed with) the family the prognosis. Family was given some time to think about it. Ultimately, we agreed to .provide comfort measures only Under History Provided by: EMS personnel documents, .(R2) to ED (Emergency Department) via EMS (Emergency Medical Services) from (name of facility). EMS states that patient has been increasingly less conscious the past couple of days . R2's local hospital records, dated 12/28/22, documents under Physical Exam, .Pt (patient/R2) was unresponsive to painful stimuli .no gag reflex .pupil is not reactive .diaper was dry .skin is mottled (at distal extremities) .She did start to make sounds and have small movements after approximately 500 ml (milliliters) of IVF (intravenous fluid) . R2's local hospital records documents under End of Life Care that R2's diagnoses include Covid positive, acute hypoxemic respiratory failure, anion gap metabolic acidosis, acute on chronic renal failure, severe protein calorie malnutrition, and elevated troponin. R2's local hospital record, dated 12/28/22, documents a chest x-ray with findings documenting, .No acute cardiopulmonary process. R2's local Hospital Discharge Summary, dated 12/30/22, documents, .Primary Discharge Diagnosis Covid positive, acute hypoxemic respiratory failure, acute on chronic renal failure, severe hyperkalemia, anion gap metabolic acidosis, severe protein calorie malnutrition, and elevated troponin . R2's local hospital record, dated 12/28/22 to 12/30/22, documents under Hospital Course,(R2) presented to (name of local hospital) ER (emergency room ) from her nursing facility after becoming unresponsive Family was present throughout most of her time and she was kept comfortable before she passed away peacefully at 8:02 AM on 12/30/2022. R2's Certificate of Death Worksheet documents R2's date of death as 12/30/2022, with cause of death documented as septic shock due to novel corona Covid-19 virus infection, acute hypoxemic respiratory failure, and acute on chronic renal failure. This same form documents significant conditions contributing to death as severe hyperkalemia and severe protein calorie malnutrition. R2's facility Progress Notes document the following.: 12/22/22 10:50 AM, Family notified of resident (R2) being placed on isolation r/t (related to) (+) (positive) Covid test. Family thankful for the call. 12/22/22 3:40 AM New orders per V27 (Nurse Practitioner) Vit C (Vitamin C) 500 mg (milligrams) PO (by mouth) BID (twice daily), Zinc 50 mg daily r/t Covid. 12/24/22 4:57 AM, res (R2) non-compliant with care, refuses to stay in contact isolation. No s/o (signs of) discomfort. Cont. (continue) to receive routine pain meds (medications) as ordered. Congested non prod (productive cough). Cont on abt (antibiotic) therapy as ordered. Hollering freq (frequently) throughout shift. R2's facility Nursing Progress Notes do not document a nursing assessment or update related to R2's physical status until 12/28/22 when R2's progress notes document the following; 12/28/22 2:09 PM, .Resident listless/nonresponsive .Gray color, mouth dry with tip of tongue black in coloration. Blue color noted to all extremities, cold to touch, v/s (vital signs) 96.4 (temperature), 90/50 (blood pressure), 24 (unknown), 26 (unknown), 88 (oxygen saturation) with O2 (oxygen) .Notifications made: V27 (Nurse Practitioner) and POA (power of attorney). 3:52 PM Hospital called report resident is admitted for end of life. Covid positive, hypoxia, family at side. R2's POC (Point of Care) Response History Nutritional task, with a print date of 1/4/23, documents the following food intakes for R2: 12/25/22 8:46 AM 0-25%, 12:45 PM 26-50% and 12/26/22 12:00 PM 26-50%, 12:29 PM 0-25%. There is no documentation of food intake for R2 on 12/27/22. R2's POC Response History Fluid, Intake with meals and outside of meals task, with a print date of 1/4/23, documents R2 had the following fluid intakes: 12/24/22- 1020 cc's (cubic centimeters), 12/25/22- 1000 cc's, 12/26/22- 965 cc's, and 12/27/22- 250 cc's. R2's POC Response History documents under safety checks tasks, with a print date of 1/4/23, R2 was checked 16 times on 12/24/22, 8 times on 12/25/22, 14 times on 12/26/22, and 12 times on 12/27/22 with the last check documented at 11:40 PM on 12/27/22. R2's Facility Care Plan, last review date of 12/01/22, documents under the Fall focus area an intervention that R2 is to be checked every hour. R2's Order Summary Report, with an order date range of 12/01/22 to 12/31/22, documents the following orders: 12/22/22- 10-day Covid-19 Quarantine Contact and Droplet Precautions, Covid-19 Positive/symptomatic monitoring Q 4 (every 4 hours) .for Covid-19 daily monitoring for 10 days and maintain droplet isolation precautions at all times r/t Covid + (positive). R2's TAR (Treatment Administration Record), dated 12/1/22 -12/31/22, documents the following physician order, with a start date of 12/22/22 6:00 AM, Covid-19 Positive/symptomatic monitoring Q4 (every four hours): Fever (T>99.9F/temperature greater than 99.9 Fahrenheit), Temp (temperature), P (pulse), RR (respiratory rate), O2 Sat (oxygen saturation) & (and) symptoms (Fever, SOB (shortness of breath), Cough, Sore Throat). R2's TAR documents R2 was monitored every four hours as ordered from 12/22/22 2:00 PM until 12/26/22 2:00 PM. There is no assessment and no vital signs documented on this form, from 12/26/22 2:00 PM until R2 was transferred to the local hospital on 12/28/22. The vital signs documented for 12/25/22 at 10:00 AM, 2:00 PM, and 6:00 PM are all as follows, B/P (blood pressure) 130/66, P (pulse) 72, RR (respiratory rate) 18, T (temperature) 98.5, and O2 sat (oxygen saturation) 92%. R2's MAR (Medication Administration Record), dated 12/01/22 to 12/31/22, documents an order to monitor R2's vital signs every shift, with a start date of 10/20/22. R2's vitals are documented and within normal limits each shift on 12/24/22 and 12/25/22. There are no vital signs documented on 12/26/22. The following vital signs are documented on 12/27/22 6 am-6pm shift, B/P 102/58, P 70, R 16, T 97.1, and O2 sat of 93%. There are no vital signs documented on 12/27/22 6 pm - 6 am shift. This indicates R2's vital signs were to be monitored every four hours and the same vital signs were documented multiple times on 12/25/22, no vital signs were documented after 2:00 PM on 12/26/22, and vital signs were documented once on 12/27/22 6am-6pm shift with no vital signs documented on the 6pm-6am shift. On 1/4/23 at 3:21 PM, V31 (Registered Nurse (RN)/Agency Nurse) stated she worked on 12/28/22, beginning at 6:00 AM. V31 stated during the morning medication pass (approximately 8:00 AM), unknown Certified Nursing Assistants told her she needed to assess R2. V31 stated R2 appeared listless, her tongue was black, her legs were mottling, her fingertips were blue, her vital signs were not within normal range, but R2 was comfortable. V31 stated she notified the physician and the family, and the family wanted R2 evaluated at the local emergency room . V31 stated she does not remember being told anything in report on the morning of 12/28/22 regarding R2's condition. On 1/5/23 at 10:45 AM, V15 (Licensed Practical Nurse/LPN) stated she worked on 12/24/22 and 12/25/22, and R2 was her normal self. When asked why R2's vital signs are all the same readings at each time on 12/25/22, V15 stated the Certified Nursing Assistant's (CNA's) get the vital signs, and V15 was just using the last recorded in R2's electronic health record. When asked about the oxygen saturation of 92%, V15 stated R2 would take her oxygen off. When asked if R2's oxygen saturation was rechecked to determine if they improved after reapplying her oxygen, V15 stated it was continually being rechecked. (There is no documentation in R2's medical record of oxygen saturation rechecks). On 1/5/23 at 10:10 AM, V13 (Certified Nursing Assistant/CNA) stated she provided care to R2 on 12/25, 12/26, and 12/28/22. V13 stated she attempted to feed R2, but R2 wasn't eating. V13 stated R2 was taking fluids. When asked if she checked R2's vital signs, V13 stated she was still in orientation and couldn't do vital signs yet. When asked how R2 appeared on those days, V13 stated R2 appeared, Sick, really sick. V13 stated it was either 12/25 or 12/26/22 when she noticed R2 did not appear well. V13 stated R2 kept telling V13 she was dying. V13 stated she reported R2's appearance and condition to V15 (LPN/Licensed Practical Nurse). On 1/5/23 at 10:24 AM, V14 (CNA) stated she worked on 12/26-12/28/22. V14 stated she provided care to R2 and worked with V13 (CNA). V14 stated on 12/27/22, R2's tongue was going black, and R2's extremities were mottling. V14 stated R2 wouldn't eat anything, and R2 kept taking her oxygen off. V14 stated she made sure R2 stayed clean, dry, and comfortable throughout her shift. V14 stated R2 wouldn't swallow when she attempted to give her a drink, so the liquids would just run out of R2's mouth. V14 stated R2's oxygen saturation wasn't reading when R2 would take her oxygen off, but would go up to 92% when she had the oxygen on. V14 stated she didn't remember what nurse was working on 12/27/22 day, but she did report R2's condition to the nurse. V14 stated she checked R2's vital signs and kept her comfortable and in bed since she was so sick. When reviewed with V14, there were no vital signs documented, V14 stated when the vital signs are abnormal, she gives them to the nurse to review and document. V14 stated she didn't even think she could put abnormal results in the electronic record. V14 stated R2's blood pressure was low at one point, and then high at another. On 1/5/23 at 11:43 AM, V17 (RN/Registered Nurse) stated she was an agency nurse and worked at the facility and provided care to R2 on 12/27/22. V17 stated she held R2's blood pressure medication on 12/27/22 because R2's blood pressure was soft. V17 stated V27 (Nurse Practitioner/NP) was at the facility, and she let her know R2's blood pressure was low, and that she held the medication. There is no documentation in R2's medical record of V27 being notified. When asked if there was any follow up vital signs obtained after she held R2's blood pressure medication V17 stated she was only able to get R2's vital signs one time during her 6 am-6 pm shift. V17 stated she had another resident who was critical that was being sent to the emergency room and four admissions that day. When asked if she notified administration that she couldn't provide the needed care, V17 stated, They are well aware of staffing issues. I don't think I could notify them every day. V17 stated the CNAs did not report a decline in R2's condition to her, and did not get any vital signs on 12/27/22. V17 stated she gave report to V18 (Licensed Practical Nurse/LPN) who worked the shift after her (6 PM-6 AM) and told him to watch R2 since her blood pressure was soft. R2's Facility Progress notes documents on 12/27/22 the following medications were Held r/t (related to) hypotension: 8:39 AM-furosemide 40 mg (milligrams), 3:40 PM metoprolol tartrate 50 mg, lisinopril 5 mg, 3:41 PM- spironolactone 25 mg, and 5:33 PM- metoprolol tartrate 50 mg. On 1/6/23 at 1:29 PM, V11 (LPN) stated she worked on 12/27/22, but only saw R2 when she passed medications at 9:00 PM. V11 stated R2's lights were down, and she was going to bed. V11 stated she didn't get report of a decline in R2's condition. On 1/5/23 at 1:01 PM, V18 (Licensed Practical Nurse/LPN) stated he worked from 12:00 AM to 6:00 AM on 12/28/22. V18 stated R2 was her normal self, and he had to reapply her oxygen when he would go into her room. V18 stated he administered medications to R2 at 5:00 AM on 12/28/22, and she took them with no issues. V18 stated he forgot to chart R2's vital signs that were obtained during his shift. V18 stated he remembered R2's blood pressure was high, and R2's oxygen saturation was in the low 90's. V18 stated R2's respirations were in the 20's, not labored, but R2 had heavy breathing. V18 stated no one had reported to him R2's blood pressure was low or that she had a decline in her condition. On 1/5/23 at 2:31 PM, V28 (CNA) stated she took care of R2 beginning on the night of 12/27/22 until early morning on 12/28/22. V28 stated R2 was her normal self. V28 stated she did not check R2's vital signs because she did not have dedicated isolation vital sign equipment available. V28 stated she checked R2 every two hours. When asked if R2 ate or drank anything on her shift V28 stated, I think I gave her some water. On 1/6/23, this surveyor reviewed R2's medical record with V2 (Director of Nurses/DON). V2 confirmed R2 did not have Covid monitoring documented, including assessment and/or vital signs on 12/26/22 at 6:00 PM and 10:00 PM, and no monitoring was documented on 12/27/22. V2 confirmed R2's hourly checks were not completed hourly, and the last hourly check documented was at 11:40 PM on 12/27/22. V2 stated there was one set of vital signs documented on 12/27/22, and R2's blood pressure was 102/58 and her oxygen saturation was 93%. V2 stated there was no documentation in R2's facility progress notes of nursing assessments or physician notification of R2's condition from 12/25/22 until 12/28/22. V2 stated she would expect the nursing staff to notify the physician if a resident has a decline in condition including not eating/drinking, and abnormal vital signs. V2 stated she would expect vital signs to be monitored per current standards or practice, physician orders, and policy and procedure. V2 stated if the nursing staff had notified her of R2's decline, she would have called the physician and gotten orders for labs and IV fluids. On 1/5/23 at 1:55 PM, V27 (NP) stated she believed she saw R2 on the afternoon of 12/27/22 and assessed her. V27 stated R2 was pretty much sleeping, very weak, ill appearing. V27 stated R2 was oxygen dependent, and she was able to get R2 to wake up and answer a couple of question. V27 stated she did not prescribe any new orders for R2. This surveyor reviewed with V27, R2's oxygen saturation of 92% and 93% on 12/25 and 12/27/22, vital signs not being monitored, fluid and food intake, and that V17 had held R2's blood pressure medication on 12/27/22. V27 stated she was not aware of that information, and if she had been she would have ordered labs, a chest x-ray, and possibly intravenous fluids. V27 stated if a resident's oxygen is trending low, she typically sends them to the emergency room for evaluation. V27 stated she did a head-to-toe physical assessment of R2, and did not see any mottling. R2's Physician Progress note, dated 12/27/22 (not timed), documents, (R2) is seen today for Covid. She (R2) is resting in bed during exam. Confused per baseline and unable to aid in assessment. Oxygen intact via NC (nasal cannula). No distress noted. She is weak and ill appearing. No concerns reported by nursing. Under Objective the physician progress notes documents, Recent Vitals: Reviewed, Date/Time Vitals taken: today, Reviewed at the nursing home with staff. Physical Exam: Constitutional: General: She is not in acute distress. Appearance: She is well-developed. She is ill-appearing. She is not diaphoretic . Skin: General: Skin is warm and dry .Psychiatric: Speech: Speech normal. Behavior: Behavior is cooperative. Cognition and Memory: Cognition is impaired. Memory is impaired. Judgement: Judgement is inappropriate. There is nothing documented under Assessment/Plan. Under Diagnosis and all orders for this visit the physician progress note documents, Covid. This physician progress note documents under Plan: Covid: Acute. Covid precautions/isolation per facility protocol: vitamin regimen, . if not already taking anticoag (anticoagulant). Nursing staff will monitor temp and O2 sat each shift and prn (as needed). Supportive therapy. Will monitor for worsening systemic infections. Orders reviewed/signed. Pt (R2) instructed in importance of adequate fluid to stay hydrated. Pt (R2) instructed to inform nursing staff of questions, concerns, changes or concerns. On 1/10/23 at 1:54 PM, after reviewing V27 (NP) interview on 1/5/23 at 1:55 PM with V27 and V39 (Physician), V27 stated she couldn't say the outcome would have been different for R2 if she had known R2's vitals were not being monitored as ordered, R2's oxygen saturation was trending down, R2 had a decline in food/fluid intake, R2's blood pressure was low, R2's medication had been held, and R2's extremities were reported as mottling, and she (V27) had been able to order labs, intravenous fluids, and a chest x-ray. V39 (Physician) stated, I don't think it would have, having read (R2's) record from the hospital, it may not have made a difference. On 1/5/23 at 8:50 AM, V25 (emergency room Physician) stated R2 was near dead when she was arrived at the emergency roiagnom on [DATE]. V25 stated R2's family was not aware R2 had signed a Do Not Resuscitate form, so V25 discussed with R2's family the potential outcomes, and they decided to admit her with comfort care measures only. V25 stated R2 appeared like someone who had been pretty sick for a few days. V25 stated if R2 had been assessed at the emergency room a few days before, it would have presumably been a better outcome. V25 stated R2 was mottling and the length of time for that depends on the disease process. V25 stated in his experience, it is a multi-day process. V25 stated fluid intake is incredibly important for someone who is acutely ill. V25 stated R2 was in multiorgan failure and hypoxic when she arrived at the emergency room . V25 stated in the 24 hours prior to her coming to the emergency department, someone should have noticed a decline in R2's condition. V25 stated the odds are good R2 would have made it through the hospitalization if she had been treated earlier. V25 stated at the very least, R2's primary physician should have been notified so they could have ordered labs, fluids and/or determine if R2 needed evaluated at the emergency room . R2's Facility Care Plan, last review date of 12/01/22, documents a Focus area of, (R2) is a risk for s/sx (signs/symptoms) of Covid-19. 12/22/2022 Covid + (positive). Interventions are documented as 10/21/22- Educate Staff, Resident, family and visitors of Covid-19 signs and symptoms and precautions. Follow facility protocol for Covid-19 screening/precautions, observe for s/sx of Covid-19-document and promptly report s/sx: coughing, sneezing, sore throat, respiratory issues, provide alternative methods of communications with family/visitors. 12/22/22- Maintain droplet isolation, maintain droplet precautions. And 12/27/22 - Administer medication as ordered. 2. R3's facility Admission Record, with a print date of 1/11/23, documents R3 was admitted to the facility on [DATE], with diagnoses that include fracture, pleural effusion, heart failure, anemia, chronic kidney disease. R3's MDS, dated [DATE], documents a BIMS score of 10, which indicates R3 has a moderate cognitive impairment. R3's Care Plan, dated 12/28/22, documents a Focus Area of Covid + (positive) on 12/19/22 Resolved. This same care plan documents the following interventions 12/12/22- Educate staff, resident, family, and visitors of Covid-19 signs and symptoms and precautions. Follow facility protocol for Covid-19 screening/precautions. Observe for s/sx (signs/symptoms) of Covid-19-document and promptly report s/sx: coughing, sneezing, sore throat, respiratory issues. Provide alternative methods of communications with family/visitors. 12/20/22- Maintain droplet isolation as ordered. R3's Order Summary Report, dated 1/11/23, documents the following physician orders, Covid-19 Positive/Symptomatic monitoring Q4; Fever (T>99.9F) Temp, P, RR, B/P, O2 Sat & Symptoms (Fever, SOB, Cough, Sore Throat) ., Maintain Droplet Isolation precaution at all times r/t Covid +. R3's TAR (Treatment Administration Record), dated 12/1/22 to 12/31/22, documents a physician order to monitor for Covid-19 symptoms and monitor vital signs every four hours, with a start date of 12/22/22. R3's same MAR does not document Covid monitoring and/or vital signs were done on 12/26/22 at 10:00 PM, 12/27/22 at 2:00 PM, 6:00 PM, and 10:00 PM, and 12/28/22 at 6:00 PM. 3. R5's facility Admission Record, with a print date of 1/10/23, documents R5 was admitted to the facility on [DATE]. R5's MDS, dated [DATE],2 documents a BIMS score of 06, which indicates R5 has a severe cognitive impairment. R5's Care Plan, with a review date of 12/19/22, documents a Focus Area of, (R5) is at risk for s/sx of Covid-19, Covid + 12/29/22. This same care plan documents the following interventions. 12/05/2022- Educate staff, resident, family and visitors of Covid-19 signs and symptoms and precautions. Follow facility protocol for Covid-19 screenings/precautions. Observe for s/sx of Covid-19-document and promptly report s/sx: coughing, sneezing, sore throat, respiratory issues. Provide alternative methods of communication with family/visitors. 1/03/23-maintain droplet precautions. R5's Care Profile, with a print date of 1/12/23, documents a physician order, dated 12/31/22, for, Covid-19 positive/symptomatic monitoring Q4: Fever (T>99.9 F), Temp, P, RR, B/P, O2 Sat & symptoms (Fever, SOB, Cough, Sore Throat) . R5's TAR, dated 12/1/22 to 12/31/22, documents an order to monitor vital signs and for Covid-19 symptoms every four hours for eight days, with a start date of 12/31/22 at 2:00 PM. The same TAR does not document vital signs and/or Covid monitoring was done at 10:00 PM at 12/31/22. R5's TAR, dated 1/1/23 to 1/31/23, documents an order to monitor vital signs and for Covid-19 symptoms every four hours for eight days, with a start date of 12/31/22 at 2:00 PM. The same TAR does not document vital signs and/or Covid monitoring were done as ordered on the following dates/times; 1/1/23 8:00 AM, 1/2/23 2:00 AM and 6:00 PM, 1/4/23 6:00 AM, and from 1/5/23 6:00 AM through 1/8/23. On 1/6/23 at 8:52 AM, V2 (DON) stated she would have expected vital signs/assessments to have been done as ordered and per current standards of practice. The facility undated Notification of Resident Change in Condition Policy documents, .It is the policy of this facility to promptly notify the resident, their legal representative(s) and attending physician of changes in the resident's health condition Standards: 1. A licensed nurse shall promptly inform the resident, consults with the resident's physician and if known, notify the resident's legal representative or an interested member of: .b. A significant change in the resident's physical, mental, or psychosocial status, i.e., deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications 2. The licensed nurse is to use professional judgment in determining changes in condition based on assessment and findings or signs and symptoms of change which could lead to deterioration if not treated. 3. Clinical change in condition is determined by resident visualization, medical record review, clinical assessment findings and care plan review. Review of high-risk clinical issues such as skin breakdown, falls, weight loss, dehydration and others are conducted on a daily basis. 4. Following the assessment, observing signs and symptoms, and obtaining vital signs, the attending physician, family/guardian will be promptly notified of significant findings 7. Changes in the resident's condition will be communicated to the direct care staff by verbal shift-to-shift report, revision in resident assignments and by use of the 24-hour written shift report .11. The licensed nurse will document in the nurse's notes all assessment findings and all attempts to notify physician(s). The facility Guidelines for Notifying Physicians of Clinical Problems, dated 4/2007, documents, Overview: These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely , efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record .The Charge Nurse or supervisor should contact the Attending Physician at any time if they fell a clinical situation requires immediate discussion and management . The facility Policy and Procedure for SARS-CoV-2 (Covid-19), dated 3/22/22, documents under Residents with Confirmed Covid-19 .Monitor the resident every four hours for clinical worsening. Include an assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam to identify and to quickly manage serious infections. The surveyor confirmed through interview, observation, and record review that the Immediate Jeopardy that began on 12/26/22 was removed on 1/10/23 when the facility took the following actions to remove the immediacy: *On 1/9/23, the V1(Administrator), V3 (Infection Control Preventionist), and V18 (Wound Certified Nurse Manager) assessed all residents that are COVID 19 positive or at risk for a decline in condition charts, to ensure orders for vital signs and monitoring are in place per MD order. *Paper vital sign sheets were implemented with electronic charting for all residents that are COVID 19 positive or at risk for a decline in condition to ensure accuracy and compliance of all vital signs on 1/9/23. *All staff have been in-serviced by V1, V3, V18 on 1/9/23 regarding assessment, monitoring, acute change in condition, documentation, and implementation of orders timely. *In-servicing was completed by V1, V3, V18, on 1/9/23 regarding assessment and monitoring of residents that are positive for COVID 19. *In-servicing was completed by V1, V3, V18 on 1/9/23 regarding notifying MD of acute change in condition and implementation of orders timely. *In-servicing was completed by V1, V3, V18 on 1/9/23 regarding documentation. *All employees that were not on duty were contacted by phone on 1/9/23 and 1/10/23 by V1, V3, V18 for verbal compliance of all in-services. *Policy review was completed regarding neglect, change in condition, physician notification, and documentation on 1/10/23. *V1 or designee will monitor the following 5 days a week for 6 weeks: The Quality Assurance Committee will monitor the facility's performance by monitoring all audits weekly to ensure the corrections are achieved. The first Quality Assurance Committee meeting will be held on Thursday January 12, 2023. All COVID 19 residents' vital signs are completed per MD orders. All COVID 19 residents' rounds for monitoring acute change in condition, notification to MD with any changes, and implementation of timely orders is being completed .

Based on observation, interview, and record review, the facility failed to ensure dietary recommendations were implemented for 2 of 3 (R1 and R2) residents reviewed for nutrition in the sample of 25. This failure resulted in R2 having a severe weight loss of 8.5% in less than one month, and R1 having a severe weight loss of 9.5% in one month and 9.3% in two months. Findings Include: 1. R2's facility Admission Record, with a print date of 1/4/23, documents R2 was admitted to the facility on [DATE], with diagnoses that include fracture of right femur, urinary tract infection, diabetes, anxiety, depression, bipolar disorder, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, cognitive communication deficit, and need for assistance with personal care. R2's MDS (Minimum Data Set), dated 10/27/22, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive impairment. This same MDS documents R2 requires assistance of one staff for bed mobility, transfer, dressing, toilet use, eating, and personal hygiene. R2's Care Plan, with a review date of 12/01/22, documents the following Focus Area, with an initiation date of 10/21/22, (R2) is at risk for potential nutritional problem (wt/weight loss) related to anxiety, sob (shortness of breath). The interventions for this Focus Area are documented as 10/21/22- Monitor wts as ordered. Provide and serve diet as ordered. Monitor intake and record every meal. RD (Registered Dietician) to evaluate and make diet changes recommendations PRN (as needed). There are no new interventions documented after 10/21/22. R2's Care Plan further documents the following Focus Area, with an initiation date of 10/21/22, (R2) is at risk for dehydration related to: Diuretic use. The interventions for this focus area are documented as, 10/21/22- Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage and offer fluids to drink. Monitor vital signs as ordered/per protocol and record. Notify MD (Physician) of significant abnormalities. Monitor/document bowel sounds and frequency of BM (bowel movements): provide medication per orders. Monitor/document/report to MD PRN (as needed) s/sx (signs/symptoms) of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips furrowed tongue, new onset confusion dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, or dry/sunken eyes. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. This same Care Plan documents a Focus Area with an initiation date of 10/21/22, R2 requires assist with adl's (activities of daily living) r/t Fatigue, impaired balance, pain. The interventions for this Focus Area with a date of 10/21/22- Eating requires set up supervision. R2's Dietary Nutritional Assessment, dated 10/24/22, documents R2 is 64 inches tall with a weight of 150 pounds. This assessment documents R2 is on a regular, mechanical soft diet, and regular/thin liquids. Eating patterns are documented as 51-100%. Under Additional Comments this assessment documents, Wt. of 150# (pounds) was obtained from admitting paperwork. Resident was admitted to facility on 10/20 from the hospital .She is alert and feeds herself. This nutritional assessment documents a BMI (body mass index) of 18-26. R2's nutritional goal is documented as, Maintain weight and skin integrity. Tolerate current diet with meal intakes >50%. The assessment documents R2's nutritional needs as 68 grams of protein and 1909 ml (milliliters) of fluid. On 1/13/23 at 10:19 AM, V26 (Dietitian) stated when she did the assessment on 10/24/22, the facility had not weighed R2 yet. V26 stated she used the discharge weight documented on R2's hospital discharge records. V26 stated these weights tend to be inaccurate. R2's Progress Notes, dated 11/14/22, documents, RD (Registered Dietitian) Weight Review: Ht (height)-64 (inches), Wt -114.2# (pounds), BMI 19.6. Resident (R2) is showing a significant weight loss of 7.6% x 1 month (123.6# in Oct). PMH (Past Medical History) of CHF (Congestive Heart Failure) on diuretic therapy which can cause some weight fluctuations. Other PMH (Past Medical History) includes depression, anxiety, and bipolar disorder which makes resident increased risk of poor nutritional status and meal intakes. (R2) is receiving a Regular, mech (mechanical) soft diet with thin liquids. She feeds herself with set-up and is consuming 26-100% of her meals. Due to weight loss, recommends starting fortified foods at all meals and add ice cream cup daily with supper for extra calories. Monitor weights and intakes; Refer to RD as needed. R2's Progress Notes, dated 12/19/22, documents, RD Weight Review: Ht -64, Wt -106 # (pounds), BMI -17.9. Underweight. Resident showing significant weight loss of 7.2% x (times) 1 month (114.2# in Nov/November) and 14.2% since her admission ~(approximately) 2 months ago (123.6# in Oct/October). PMH includes UTI (urinary tract infection), anxiety, depression, COPD (Chronic Obstructive Pulmonary Disease), CHF, falls, muscle weakness, and others. Weighed daily and on chronic diuretic therapy which can cause weight fluctuations. R2 is receiving Regular, mech soft diet with thin liquids. RD's recs (recommendation) from last month were ordered 12/05 and continue-fortified foods at meals and ice cream daily with supper. Her meal intakes are varied 0-100%. Per discussed with staff and RD's observation, R2 is very emotional at times and does better when staff are present to encourage her and cue her to eat. Recommend starting mighty shake each morning with breakfast to prevent further weight loss. Monitor weights and intakes; Refer to RD as needed. R2's Weight Summary log documents the following weights: 10/27/22- 123.6 pounds, 11/2- 114.2, 11/27- 109.8, 11/30-108.0, 12/4- 106.0, 12/5- 106.3, 12/6- 106.0, 12/7- 106.0, 12/11- 105.9, 12/12- 104.5, 12/15- 104.2, 12/16- 103.4, 12/17- 104.2, 12/21- 103.2, 12/22 103.0, 12/23- 100.0, 12/24/22- 97.0 pounds. This indicates a severe weight loss of 8.5% from 11/27/22 to 12/24/22 and a severe weight loss of 21.5% in 3 months. R2's POC (Point of Care) Response History form, with a print date of 1/4/23, documents the types of assistance a resident may receive with eating as: Independent - No help or staff oversight at any time, Supervision - Oversight, encouragement or cueing, Limited Assistance- Resident highly involved in activity: staff provide guided maneuvering of limbs or other non-weight bearing assistance, Extensive Assistance- Resident involved in activity, staff provide weight-bearing support. This same form documents R2 received the following assistance with meals, 12/19-independent, 12/20- independent one meal limited assistance two meals, 12/20-independent 2 meals, supervision 1 meal, 12/21-independent 2 meals, supervision 1 meal, 12/22-independent 2 meals, supervision 1 meal, 12/23-independent 3 meals, 12/24-independent 2 meals, limited assistance 1 meal, 12/25 independent 2 meals, 12/26-independent 1 meal, extensive assistance 1 meal, 12/27/22-independent 1 meal. This same form does not document the type of assistance R2 received for a 3rd meal on 12/25 and 12/26 or for two meals on 12/27/22. R2's POC Response History form, with a print date of 1/4/23, documents under Question 2- How resident eats and drinks, regardless of skill . This same form documents R2 received set up help only, for three meals on 12/19, 12/21, 12/22, 12/23, for one meal on 12/20, two meals on 12/24, and one meal on 12/26/22. This form documents R2 received One Person Physical Assist on 12/20 for 2 meals, 12/24 for 1 meal, and 12/26 for 1 meal. This form documents R2 received no set up or physical help for one meal on 12/27, and does not document any type of support R2 received for the other two meals on 12/27/22. On 1/4/23 at 2:30 PM, V26 (Dietitian) stated staff had to be patient with R2, because R2 was tearful all the time. V26 stated she needed staff to make sure they spent time with R2 to encourage her to eat. V26 stated she wonders if that was happening, and if that was why R2's weight declined. V26 stated she expected staff to be with R2 when she ate, and that was why she made it a specific recommendation for staff to sit with R2 while she ate. On 1/4/23 at 11:15 AM, V20 (Dietary Manager) stated if a resident has a weight loss, they refer that resident to the Dietitian, who makes recommendations, and then the facility implements the interventions. V20 stated they do not have to wait for a physician order to implement the interventions and the floor nursing staff are the nurses who notify the physician of a weight loss. V20 stated the nurses administer the 2.0 cal (calorie) supplement and Boost supplements, and Dietary staff serve the mighty shakes. V20 stated she remembered R2, and that R2 was depressed and struggled to eat at times because of depression. V20 stated R2 was served mighty shakes, ice cream, and fortified foods. On 1/5/23 at 8:14 AM, V20 stated she believed R2 ate more meals in her room than in the dining room. V20 stated she couldn't remember the level of assistance R2 required. On 1/4/23 at 3:34 PM, V18 (LPN/Licensed Practical Nurse) stated the Dietitian sends him the dietary recommendations and he takes them to V27 (NP/Nurse Practitioner) to sign the orders for the recommendations. V18 stated he was responsible for monitoring the resident weights between the dietitians visits to the facility. V18 stated there had been a lot of inconsistencies in the facility weights, so they had recently started a new system. After reviewing R2's medical record (POC History) with V18, V18 stated R2 should have been receiving assistance at mealtimes. V18 stated he had seen CNA (Certified Nursing Assistant) staff redirecting R2 back to her table during mealtimes, but since R2 had been diagnosed with Covid-19, she had been isolated to her room and not eating in the dining room. On 1/5/23 at 9:35 AM, V23 (CNA Supervisor) stated R2 required assistance to eat at times. When asked if she was aware of a dietary recommendation for staff to sit with R2 and encourage her during meals, V23 stated she was not aware of that. V23 stated there are staff in the dining room to encourage residents to eat. When asked if R2 ate in the dining room after being diagnosed with Covid 19 on 12/22/22, V23 stated R2 would have been served her meals in her room while on isolation. On 1/5/23 at 9:50 AM, V12 (CNA) stated she was familiar with R2, and when asked what assistance R2 required to eat, V12 stated R2 fed herself. V12 stated they would put R2's food down and walk away, and R2 would eat. On 1/5/23 at 11:32 AM, V16 (CNA) stated R2 would sometimes eat independently, and other times would require different levels of assistance. On 1/6/23 at 8:52 AM, V2 (Director of Nurses/DON) stated she was not aware R2 had a significant weight loss. V2 stated she was not sure what type of assistance R2 required to eat. V2 stated she was not made aware of R2's decline in condition, including not eating or drinking until 12/28/22, when R2 was transferred to the local hospital for evaluation. This surveyor reviewed R2's POC History Response forms with V2, and V2 stated it appeared as if R2 was independent with eating a lot of December 2022, with some supervision and limited assistance documented. V2 stated she would have expected the nursing staff to notify R2's physician of her decline, including R2's decline in food and fluid intakes. On 1/5/23 at 1:55 PM, V27 (Nurse Practitioner) stated she was not notified R2 was not eating or drinking, and if she had been, she would have ordered lab work and intravenous fluids. V27 stated she would expect the nursing staff to notify her if a resident has a significant weight loss and that they would follow the dietitian's recommendations. On 1/10/23 at 1:54 PM, when asked if he thought implementing R2's dietary recommendations of having a staff member sit with her while she ate would have prevented R2's weight loss, V39 (Physician) stated, I can't imagine that would have made a tremendous difference. V39 then asked V27 (NP) what she thought, and V27 stated, I don't know that I saw anyone sit down with her (R2). I can't say that it would have made a difference though. 2. R1's facility Admission Record, with a print date of 1/4/23, documents R1 was admitted to the facility on [DATE] with diagnoses that include vascular dementia, heart failure, major depressive disorder, chronic kidney disease, muscle weakness, and dysphagia. R1's MDS, dated [DATE], documents a BIMS score of 10, which indicates R1 has a moderate cognitive impairment. This same MDS documents R1 requires assist of staff to set up for meals. R1's Care Plan, review date 12/01/22, documents a Focus Area initiation date 10/24/22 of (R1) is at risk for nutritional problem (wt loss) related to: depression, pain, GERD (gastroesophageal reflux disease), dementia. The Interventions documented for this focus area are as follows: 10/24/22 Monitor wts as ordered .Monitor/document/report to MD (physician) PRN (as needed) for s/sx (signs/symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appears concerned during meals .Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss > 5% in one month, >7.5% in 3 months, >10% in 6 months .Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated .Provide served diet as ordered. Monitor intake and record q (every) meal .RD to evaluate and make diet change recommendations PRN. R1's weight summary documents the following weights, 10/21/22- 158.0, 10/23- 157.4, 11/2- 155.6, 12/13- 156.1, 12/22- 156.1, 12/23- 151.2, 12/24- 141.2, 12/30- 140.8, 12/31- 141.7, 1/3/23- 141.2, 1/4/23 144.4 pounds. This indicates a 9.5% weight loss in one month and a 9.3% weight loss in 2 months. R1's Request for Diet Change, dated 10/24/22, documents under Summary, RD Initial Assessment: Ht-75 (inches), Wt-157.4#, BMI-19.7. Resident (R1) was admitted to facility on 10/21 from (name of regional facility). Recent fall with 12 sutures to R (right) brow line on arrival. Another fall noted since admission. Resident (R2) is alert with confusion that is new per report. PMH of stroke, vascular dementia, CHF (Congestive Heart Failure), heart disease, HTN (hypertension), HLD (hypersensitivity lung disease), depression, anxiety, CKD3 (Chronic Kidney Disease Stage 3), spinal stenosis, dysphagia, and constipation. Meds reviewed. No recent labs available to review. He is receiving a regular diet with thin liquids. Feeds self with intakes 51-100%. Start fortified foods at all meals and 2.0 cal supplement 60 cc BID (twice daily) to support weight maintenance. Monitor weights and intakes. Refer to RD as needed. On 1/5/23 at 8:07 AM, V12 (CNA) was observed serving R1 breakfast. R1's room tray had scrambled eggs, ground sausage, toast, and orange juice. V12 stated R1 did not have any cereal on his tray, and would get it if he asked for it. On 1/5/23 at 9:50 AM, V12 stated she was not aware of any supplements R1 received with his meals. R1's undated dietary card documents R1 is served a regular mechanical soft diet. The card does not document R1 is served fortified foods. R1's Medication Administration Records (MAR) and Treatment Administration Records (TAR), dated 11/1/22 to 11/30/22, 12/1/22 to 12/31/22, and 1/1/22 to 1/31/22, do not document an order of administration of 2.0 cal 60 cc BID. R1's Care Profile, with a print date of 1/12/23 ,documents a physician order for Resource 2.0 Nutritional Supplement 60 ml (milliliters) two times daily with a start date of 1/9/23. R1's TAR/Treatment Order Administration Record, dated 1/1/23 to 1/31/23, documents a physician order to weigh R1 daily and call physician if weight is greater 3 pounds in one day, or 5 pounds in one week, with a start date of 12/21/22. On 1/5/23 at 10:45 AM, V15 (LPN/Licensed Practical Nurse) stated the floor nurse was responsible for notifying the physician of any significant weight loss, and it should be documented in the progress notes if they are notified. V15 reviewed R1's progress notes and was not able to locate a note documenting R1's physician was notified of R1's weight loss. V15 stated R1 had an order for 2.0 cal, and he didn't like it. This surveyor reviewed R1's physician orders with V15, and the order for 2.0 cal was not documented at this time. On 1/4/23 at 2:30 PM, V26 (Dietitian) stated she had a general concern about the facility getting residents weighed timely and accurately. V26 stated she pulls a monthly weight report to review when she makes her visits to the facility to assess residents. V26 stated she sends her report to V1 (Administrator), V18 (LPN) and pretty much everyone. V26 stated it is V18's responsibility to take her recommendations and get them signed off on by the physician. V26 stated she thinks there was a time V18 was behind in getting the orders put into the electronic health system. V26 stated when she ran the weight change report for R1, it did not show a weight loss since it is a monthly weight report and doesn't show the weights that are obtained daily/weekly. V26 stated the ten-pound drop should have been a trigger to notify the physician, especially with the physician order to do so. V26 was asked if there was anyone monitoring the weights and notifying her if anyone triggers a significant weight change, and V26 replied not that I am aware of. V26 stated she would have expected the recommendations of 2.0 cal and fortified foods to have been implemented, and it not being implemented could have had an impact on R1's weight loss. On 1/5/23 at 8:14 AM, V20 (Dietary Manager) stated she was not aware R1 should have been receiving fortified foods, and if R1 had been served that diet this morning, he would have been served oatmeal. On 1/6/23 at 8:52 AM, V2 (DON/Director of Nurses) stated she had heard R1 had a 10-pound weight loss. V2 stated she felt like it could be an error, and R1 should be reweighed. V2 stated V18 (LPN) is responsible for monitoring weights. V2 stated she would have expected V27 (NP/Nurse Practitioner) and V26 (Dietitian) to be notified of a significant weight loss, and for R1 to have been reweighed immediately. When asked why the Dietitian's recommendations of 2.0 cal and fortified foods weren't implemented, V2 stated V18 is supposed to be updating that. V2 stated the nurses could also get the orders from V27 and put the orders in. On 1/5/23 at 1:55 PM, when asked if she had been notified of R1's weight loss, V27 (NP) stated it would be hard to say. V27 stated weight losses usually go to the Dietitian. V27 stated she had not been notified of R1's weight loss because she would have done a visit if she had. V27 stated she would expect R1's weights would be done daily as ordered, she would be notified of any significant weight change, and the dietitian's recommendations would be sent to V27 for review. On 1/10/23 at 1:54 PM, when asked if implementing R1's dietary recommendations would have prevented his weight loss, V39 (Physician) deferred to V27 (NP) who was present for the interview, and V27 stated, It wouldn't have hurt but there is no way to predict the outcome. Both V27 and V39 stated they did not remember the facility staff notifying them of R1's weight loss. The facility Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated 8/2008, documents under Assessment and Recognition, 1. Monitor and document the weight and nutritional status of residents in a format which permits readily available month-to-month comparisons. Under Cause Identification the protocol documents, 1. The physician and/or designee will review possible causes of anorexia or weight loss with the nursing staff and/or dietitian before ordering interventions. a. For individuals with recent or rapid weight loss (for example more than a pound a day), the staff and physician should consider possible fluid and electrolyte imbalance as a cause Monitoring .1. The physician and staff will monitor the nutritional status, response to interventions, and possible complications of such interventions .of individuals with impaired nutritional status. 2. The physician will help staff adjust nutritional interventions and will modify the treatment of underlying causes of impaired nutritional status depending on the resident's responses, wishes, prognosis, complications, etc.

Based on interview and record review, the facility failed to operationalize their policy regarding identifying, monitoring, and treating pressure wounds for 2 (R1, R3) of 3 residents reviewed for neglect in a sample of 7. This failure resulted in R3's wound declining to an unstageable large sacral decubitus ulcer, necrotizing soft tissue infection, and [CONDITION(S)] over the course of 6 weeks, until hospitalized on [DATE] for abnormal labs as documented by the facility. R3 underwent a wide debridement of necrotizing soft tissue infection of sacrum and bilateral gluteal regions, placed on a wound vac, comfort care, hospice, and subsequently passed away in the hospital on 4/06/22 due to [CONDITION(S)] with multi-organ failure. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 2/14/22, when the facility neglected to identify and treat a stage II pressure ulcer to R3's bottom per hospital discharge orders. V1 (Administrator) was notified via phone call with V19 (Registered Nurse - RN) of the Immediate Jeopardy on 4/15/22 at 3:30 PM. The immediacy was removed on 4/14/22. While the immediacy was removed on 4/14/22, the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff as needed and evaluate the effectiveness of their interventions. The findings include: 1. R3's Admission Record profile sheet documents admission to this facility on 12/07/20. to include the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's most recent quarterly Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact with a BIMS (Brief Interview for Mental Status) of 14, and assessed to require the following: extensive two plus person physical assist for bed mobility, dressing, transfer and indicates transfer occurred only once or twice in a 7-day period; walking in room or corridor did not occur; one person physical assist with locomotion on and off unit and occurred only once or twice in a 7-day period; supervision and one person physical assist with eating; and extensive one person physical assist with toilet use and personal hygiene. R3's care plan, dated 12/08/20, updated on 04/14/21, documents an intervention under the focus area for falls that R3 requires a mechanical lift with two person-assist for transfers, date Initiated/created: 3/22/2021. Also included in R3's care plan: Focus Area - R3 is at risk for pressure injury development related to impaired mobility; 3/2/2022 wound left buttock; 3/25/2022 wound to right lower back revised on 3/31/22. Goal - R3 will have intact skin, free of redness, blisters, or discoloration by/through review date, revised 12/09/21, target date 5/25/22. Interventions in part - Administer treatments as ordered and monitor for effectiveness. Requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing, date initiated/created: 3/31/2022; Turn every 1-hour, date initiated/created: 3/21/2022 by: V30 (Licensed Practical Nurse - LPN/Wound Nurse); low air-loss mattress, date initiated/created: 1/21/2021; Needs assistance to turn/reposition approximately every 2 hours, more often as needed or requested, date initiated/created: 12/29/2020; Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated, date initiated/created: 3/22/2021; Provide pressure reducing mattress to bed/ pad to wheelchair, date initiated/created: 12/29/2020; Use lifting device, draw sheet, etcetera to reduce friction, date initiated/created: 12/29/2020; Weekly skin check. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, or discoloration noted during bathing or daily care, date initiated/created: 12/08/2020. R3's cumulative Order Review Report includes the following - skin checks, with an original start date upon admission of 12/08/20, end date 2/11/22. R3's January 2022 TAR (Treatment Administration Record) documents - skin checks (Monday and Thursday) I = Intact; N = New; W = Wound every day-shift Monday, Thursday, start date 12/10/20, d/c (discontinue) date 2/11/22. R3's skin checks were completed on 1/06, 1/10, 1/13, 1/20, 1/24, and 1/27, all indicating intact skin. There was no skin check documented as being performed on 1/03, 1/17, 1/24, or 1/31. 4 out of 9 skin check days were not documented as completed. R3's January 2022 TAR also documents - [MEDICATION(S)] apply to both buttocks topically every shift for wound prevention. Cleans with wound cleanser and pat dry. Apply z-guard every shift (1st shift 6A-6P and 2nd shift 6P-6A), start date 3/17/21, d/c date 2/07/22. This TAR documents preventative treatment was provided on one shift only, instead of both shifts, as ordered - 1/01; 1/02; 1/5; 1/07; 1/09 - 1/12; 1/14 - 1/19; 1/23; 1/25; 1/26; 1/28, and 1/29. This TAR is completely blank on 1/03; 1/17; 1/21; 1/22; 1/24; and 1/31. R3's January 2022 TAR documents z-guard not documented as applied as ordered 30 out of 62 application times on 1/01, 1/02, 1/03, 1/05, 1/07, 1/09-1/12, 1/14-1/19, 1/21-1/26, 1/28, 1/29, and 1/31. On 4/07/22 at 1:49 PM, when asked about the numerous blanks on R3's January TAR, V30 (LPN) stated V30 did not know why they were blank. V30 stated R3 had pretty good skin in January. The facility was unable to confirm why these treatment dates and times were blank or provide documentation treatment was provided as ordered. R3's progress note, dated 1/31/22 at 11:34 PM, reports R3 had complaints of shortness of breath and was transferred to the local emergency room for evaluation and treatment at this time. R3's local hospital emergency room notes, dated 2/01/22 at 2:19 AM, documents a chief complaint of shortness of breath with subsequent admission for treatment. R3 was discharged back to the facility on [DATE]. Included in R3's hospital record for this admission is a Wound Nurse Note, dated 2/07/22 at 12:27 PM, by V28 (Registered Nurse - RN) - Consult completed for redness on coccyx. A picture was updated to pt (patient) chart. Pt has some blanchable redness, skin is C/D/I (clean, dry, intact). Triad applied to B/L (bilateral) and coccyx. A silicone bordered foam pad was applied to sacral region. B/L heels observed blanchable C/D/I. B/L pedal pulses 1+. B/L feet cold to touch. Pt stated she was cold. A warm blanket was placed over her after assessment was completed. Wound care will sign off at this time. Please consult again for any other wound care concerns. R3's In-patient Discharge Summary, dated 2/14/22 at 12:05 PM, includes - Physical Exam at Discharge: .Skin: Stage II pressure ulcer bottom. (R3's) Primary Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Pictures, dated 2/01/22 and 2/14/22 of coccyx/sacral area included in record. R3's hospital after visit summary, dated 2/14/22, gives instructions to continue the following to include - [MEDICATION(S)] 20% ointment apply 1 application topically 2 times a day (apply to both buttocks for wound prevention). R3's facility admission evaluation note, dated 2/14/22 at 5:28 PM, documents no skin issues. R3's Braden Assessments - 2/14/22 - 13 moderate risks; 2/21/22 - 11 high risk; 2/28/22 - 15 low risk; 3/07/22 - 12 high risk; 3/15/22 - 16 low risk. On 3/31/22 at 1:49 PM, V2 (Director of Nursing - DON) stated the reason why R3's Braden scale scores from 2/14/22 to 3/15/22 were so up and down, is because at different times R3 would be able to position herself better than others; some days R3 could get out of bed on R3's own, so the severity went back and forth depending on how R3 was the day of the assessment. V2 stated, When (R3) discharged from the hospital and back to our facility, on 2/15/22, when I was in the room, the CNA (Certified Nursing Assistant, V24) pointed to her sacral area and asked what the dressing was. I observed a ([MEDICATION(S)]) dressing in place from the hospital from her discharge on 2/14/22. I knew it was not our dressing because we don't use that type. V2 stated V2 told V24 to Get with (R3's) nurse to notify (V30, LPN/Wound Nurse) to come and assess what was under the ([MEDICATION(S)]) dressing. When asked why V30's weekly skin/wound evaluation documentation for R3, beginning 3/07/22 until R3's hospital admission on 3/25/22 were incomplete and unsigned, V2 stated V30 previously reported to V2 that V30 was approximately 4 weeks behind on V30's paperwork. V2 stated V2 did not realize R3's wound had declined to the point it had until V2 went back into the role of DON on Monday, 3/21/22. V2 stated V2 doesn't know if the decline could have been prevented. V2 agreed there was a delay in processing the orders. V2 stated, (V32, Wound Physician) gives a recommendation or order, (V30) does the treatment right then. I don't know why, according to the paperwork here, it's taking a day or two to put the order in for the rest of the nurses to follow. R3's cumulative Order Review Report Summary documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] = Intact; N = New; W = Wound one time a day every Monday, Thursday for wound prevention, order date 2/14/22; start date 2/17/22; end date 3/26/22. R3's February 2022 TAR documents two sets of skin check instructions. One (1) prior to R3 admitting to the hospital on 2/01/22, and a second (2) when R3 returned to the facility on [DATE] as follows: 1) Skin checks (Monday and Thursday) I = Intact; N = New; W = Wound, every day-shift Monday, Thursday, start dated 12/10/20, discontinue date 2/11/22. This TAR documents on 2/03/22 by V7 (Registered Nurse/RN), the skin check is coded as a 3, indicating R3 is absent from home/hospitalized . A second skin check dated 2/10/22 was documented as I for intact by V30, at which time R3 was still in the hospital. 2) Skin checks weekly and set schedule, I = Intact; N = New; W = Wound one time a day every Monday, Thursday for wound prevention, start date 2/17/22; end date 3/26/22. A skin check was performed on Thursday, 2/17/22 by V4 (LPN). V4 indicates a wound was present on this date by documenting W. R3's next scheduled skin check, dated 2/21/22 is blank. The facility is unable to provide a reason it's blank or documentation that it was done. On 4/05/22 at 10:55 AM, V4 stated the W she documented on R3's skin checks, dated 2/17/22, looked like a shear wound on the buttock, with redness around the middle. V4 did not remember which side, but stated V4 believed it was the left buttock. When wound pictures from 2/24/22 and 2/28/22 of the right and left buttock were shown to V4, V4 she stated V4 does not recall observing the right buttock wound, or any documentation in R3's record regarding treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 stated V4's understanding is (V30) treats any wound with a covered dressing because that resident is on the weekly wound round list with the physician. (V30) treats those wounds daily and as ordered. The nurses scheduled on Saturday and Sunday provide wound care as ordered when (V30) is not scheduled to work. R3's February 2022 TAR continues to document - [MEDICATION(S)] 20% ointment apply to both buttocks topically every shift for wound prevention. Cleanse with wound cleanser and pat dry, apply z-guard every shift (6A-6P; 6P-6A), start date 3/27/21, discontinue date 2/07/22. There is no order in R3's record or documentation on R3's February 2022 TAR for [MEDICATION(S)] 20% ointment apply 1 application topically 2 times a day (apply to both buttocks for wound prevention) as documented on R3's hospital discharge summary instructions, dated 2/14/22. R3's February 2022 TAR skin checks, dated 2/24/22 and 2/28/22, are blank, however, V30 (LPN-Wound Nurse) performed a Skin and Wound Evaluation with R3 on these dates to include pictures. On 2/24/22, R3's skin and wound evaluation documents an abrasion to the left buttock as a new, in-house acquired wound measuring 0.6 cm (centimeters) in area x 1.2 cm length x 0.6 cm width with depth, undermining, and tunneling marked not applicable; 100% granulation with no evidence of infection, moderate serosanguineous exudate with no odor; edges attached; surrounding tissue normal in color; induration of less than 2cm around the wound; no swelling or edema; normal temperature; no pain reported; with goal of being healable. The attached picture of the left buttock, dated 2/24/22 documents a minute-old abrasion with visible multiple red areas that are open with skin peeling present. On 2/24/22, R3's skin and wound evaluation documents an undiagnosed wound to the right buttock as a new, in-house acquired wound measuring 1.3 cm x 1.8 cm x 0.9 cm with depth, undermining, and tunneling marked not applicable; 100% granulation with no evidence of infection, moderate serosanguineous exudate with no odor; edges attached; surrounding tissue normal in color; induration of less than 2cm around the wound; no swelling or edema; normal temperature; no pain reported; with goal of being healable. The attached picture of the right buttock, dated 2/24/22, documents an undiagnosed minutes old area that is visible in the picture as a dark purple area with surrounding [CONDITION(S)]. On 4/07/22 at 1:49 PM, V30 looked at R3's picture V30 took from 2/24/22, and stated V30 would assess the left buttock wound as an abrasion or maybe a stage I, since the skin is curled back and it's open. V30 stated, Sometimes if I don't know what a wound is, I leave them blank and ask (V32) to classify them and then go back and fill out the skin and wound evaluation that time. V30 looked at the skin and wound evaluation of R3's right buttock, dated 2/24/22, and stated V30 would describe it as an unstageable DTI (deep tissue injury). V30 confirmed there was no order for treatment to either R3's left or right buttock for February, only skin checks on R3's February TAR, and V32 would not have known about R3's wound to this point. R3's cumulative Order Review Report documents an order, dated 3/02/22, for [MEDICATION(S)] ointment 2% apply to left buttock topically as needed for wound AND apply to left buttock topically every day-shift for wound, cleanse with wound cleanser, apply [MEDICATION(S)], and dry dressing. Start date 3/02/22, end date 3/08/22. This order does not include the right buttock. On 4/07/22 at 1:49 PM, V30 continues to state R3's right buttock wound may not have been brought forward to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V30's hand-written wound note - 3/01/22: left buttock 0.9cm x 0.7cm with moderate 100% granulation; right buttock 1.2cm x 1.4cm with moderate 100% granulation - treated with [MEDICATION(S)], DD (dry dressing). R3's progress skin/wound note, dated 3/01/22 at 7:08 AM by V32 (Wound Physician) documents R3 has wounds to bilateral buttocks, described as an abrasion with an onset within a week. V32 describes the wound as open with a dry scab. Location: Right buttock: 1.2 cm x 1.4 cm x 0.1 cm with moderate drainage and 100% granulation. Left buttock: 0.9 cm x 0.7 cm x 0.1 cm with moderate drainage and 100% granulation. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: Dressing. Dressings: [MEDICATION(S)] with dry dressings change daily and PRN (as needed). R3's progress note, dated 3/01/22 at 2:18 PM by V30, documents V30 spoke to R3 regarding R3's wound, and R3 had no questions or concerns. R3's March 2022 TAR documents the following - 1) Skin checks weekly and set schedule, I = Intact; N = New; W = Wound, one time a day every Mon, Thurs for wound prevention, start date 12/17/22 end date 3/26/22; 2) [MEDICATION(S)] ointment 2% (percent) apply to left buttock topically as needed for wound - start date 3/02/22, end date 3/08/22. 3) Santyl ointment 250 unit/gram ([MEDICATION(S)]) apply to sacrum topically every dayshift for wound, cleanse with wound cleanser, pat dry, apply Santyl, calcium alginate, and dry dressing - start date 3/09/22, end date 3/26/22. 4) Santyl ointment 250 unit/gram ([MEDICATION(S)]) apply to right lower back topically every dayshift for unstageable wound, cleanse with wound cleanser, pat dry, apply Santyl with calcium alginate, and dry dressing, start date 3/26/22, end date 3/26/22. R3's March TAR has one skin checks area documented as completed on 3/03/22, and coded with a 3, indicating a wound is present; Skin and wound evaluations forms dated 3/07, 3/14, and03/21 were not completed, and were unsigned by V30. R3's skin checks for 3/10, 3/17, and 3/24 are blank. The facility did not provide documentation skin checks were completed on these days. Also pertinent on this TAR treatment with [MEDICATION(S)] ointment 2% apply to left buttock every dayshift (6A-6P) for wound, cleanse with wound cleanser, apply [MEDICATION(S)], and dry dressing. Start date 3/02/22, end date 3/08/22. The date 3/04/22 is blank. The date 3/08/22, signed by V30, is coded as 9 for see progress notes. The facility did not provide a corresponding progress note regarding this skin check. This TAR does not include the right buttock, and the facility was unable to provide documentation of treatment to the right buttock other than on V30's wound round days when V30 provided V30's hand-written notes on 3/01/22 and 3/08/22. R3's Skin and Wound Evaluation, dated 3/07/22 at 10:20 AM - Abrasion to sacrum new in house acquired at 10.2cm x 3.0cm x 5.3cm, depth not applicable. The remainder of the evaluation is blank, and had not been signed off by V30. Wound evaluation picture, dated 3/07/22, documents sacral abrasion 11-day old in house acquired as 10.18cm x 2.99cm x 5.3cm. V30's hand-written note - 3/08/22: left buttock no measurements, right buttocks no measurements, sacrum 3.0cm x 5.3cm with moderate 100% granulation - treated with Santyl and CA (calcium alginate), DD, marked as decline. R3's progress note, dated 3/08/22 at 11:21 AM by V30, documents, Spoke with resident in regard to wound. Expressed the importance for resident to rotate side to side to keep pressure off wound. Resident verbalizes understanding. Resident has no questions or complaints at this time. R3's skin/wound note, dated 3/08/22 at 6:49 AM by V32, documents buttock wounds within a week as an open abrasion with dry scab. Wound to buttock has migrated to fuse at the sacrum. Pt is bed bound. Sacrum 3.0cm x 5.3cm x 0.1cm moderate drainage 100% slough with 0% granulation. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . There is marked decline observed in the corresponding picture, dated 3/07/22, with redness evident from the right hip across the buttock, sacral area, and visible on the lower back region. This surveyor observed R3's wound picture. R3's buttocks/sacral area appear inflamed and swollen even in the picture, with a large purple/black area across the right buttock to the sacral region. R3's cumulative Order Review Report documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's March TAR document is blank on 3/09/22, 3/18, and 3/24, when R3 should have received Santyl ointment 250 unit/gram ([MEDICATION(S)]) apply to sacrum topically every day-shift for wound, cleanse with wound cleanser, pat dry, apply Santyl, calcium alginate, and dry dressing - start date 3/09/22, end date 3/26/22. The facility did not provide an explanation or documentation why the treatment was not done on these dates R3's Skin and Wound Evaluation, dated 3/14/22 at 10:26 AM - Abrasion to sacrum new in house acquired at 9.1cm x 2.1cm x 6.1cm, depth not applicable. The remainder of the evaluation is incomplete. Wound evaluation picture, dated 3/14/22, documents sacral abrasion 18 days old in house acquired at 9.14cm x 2.09cm x 6.07cm. This picture has a marked increase in size difference appearing larger in the picture taken on 3/07/22. V30's hand-written note - 3/15/22: sacrum 2.1cm x 6.1cm with moderate 80% S (slough), 20% G (granulation) - treated with Santyl, CA (calcium alginate), DD (dry dressing). Written on this sheet is - silicone, 1-hour turn schedule, high protein diet. R3's skin/wound note, dated 3/15/22 at 6:44 AM by V32, documents - patient has wound: buttocks wounds. Onset within a week. Type of wound: abrasion, open with dry scab. Wound to buttock has migrated to fuse at the sacrum. Pt is bed bound .location: sacrum 2.1cm x 6.1cm x 0.1cm abrasion with moderate 80% slough and 20% granulation. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's progress note, dated 3/15/22 at 11:37 AM by V30, documents - Spoke with resident in regards to current wound. Reminded resident to make sure she is turning side to side to keep off her sacrum. Will place on a 1-hour turn schedule. Resident has no questions or concerns at this time. R3's skin and wound evaluation, dated 3/21/22 at 12:49 PM by V30 - Abrasion to sacrum new in house acquired at 19.5cm x 5.4cm x 4.1cm, depth not applicable. The remainder of the evaluation is incomplete. Wound evaluation picture, dated 3/21/22, documents 25 day old in house acquired sacral abrasion at 19.46cm x 5.41cm x 4.14 cm. R3's wound in this picture has significantly declined when compared to the assessment picture from 3/14/22, with obvious depth and a dark, necrotic looking wound to the right hip as seen in the corner of the sacral photograph. R3's skin and wound evaluation, dated 3/21/22 at 12:49 PM - Pressure to right lower back (slough and/or eschar), new in house acquired and unstageable (obscured full-thickness skin and tissue loss) at 4.6cm x 2.3cm x 2.7cm, depth not applicable. The remainder of this evaluation is incomplete. Wound evaluation picture, dated 3/21/22, documents new unstageable pressure (slough and/or eschar) minute old in house acquired right lower back wound at 4.63cm x 2.27cm x 2.69cm. R3's skin/wound note, dated 3/22/22 at 6:45 AM by V32, documents - patient has wound: buttocks wounds with a new wound of lower back. Onset: months. Type of wound: abrasion. Status: open, wound was to buttocks but migrated to fuse at the sacrum. Pt is bedbound. Location: sacrum 5.4cm x 4.1cm x 0.1cm abrasion with moderate drainage and 80% slough, 20% granulation. Wound: right lower back pressure wound - unstageable with 100% slough. 2.3cm x 2.7cm x 0.1cm. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: dressing, added abd (army battle dressing) pad with Santyl with dry dressings change daily and prn with 1-hour turn schedule and prostat juice. R3's hand-written wound note by V30, dated 3/22/22, documents - sacrum abrasion/worsen 5.4cm x 4.1cm with 80% S, 20% G, moderate; right lower back new (unstageable change) 2.3cm x 2.7cm 100% S moderate - both areas treated with Santyl, CA, DD. Written on sheet - Add high protein diet, Prostat with juice, able to make own decisions? On 4/07/22 at 1:49 PM, V30 explained V32 documents V32's wound assessments in the electronic record, along with the measurements, description, and everything from week to week, including V32's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked about R3's wound note written by V32, dated 3/01/22, referencing both the left and right buttock wound with orders to treat, V30 stated V30 thought the orders for R3's right buttock got put on the POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V30 did not remember what or who prompted V30 to do R3's skin and wound evaluation, and take pictures on 2/24/22 or 2/28/22, but V32 would not have been aware of any wounds until 3/01/22, when V32 made V32's first note. V30 stated V30 was told the pictures had to be within 7 days of seeing the wound doctor, so V30 may have input the measurement and descriptions from 3/01/22 into the documents for 2/24/22 and 2/28/22. V30 stated R3 was ordered to be on a 1-hour turn schedule on 3/15/22, as documented in V32's wound note. V30 stated V30swears V30 put the order on the POS and CNA tasks, but this did not get documented in the tasks at all, or on the POS or care plan until 3/21/22. The 1-hour turn schedule was never implemented, due to not being put in the tasks where the CNAs could follow the recommendation. V30 remembered doing this, but must not have saved it in the computer. V30 stated V30 remembers telling the CNAs R3 was on a 1-hour turn schedule, but it's not documented, and was not done. V30 confirmed there was no documentation of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The right buttock did not get brought forward from V32's note on 3/01/22. V30 confirmed V30 provides resident wound treatment on Monday - Friday for all covered wounds V32 has on V32's weekly rounds. V30 stated V32 did give treatment orders for R3 on 3/01/22 for [MEDICATION(S)] to bilateral buttocks with dry dressing. V30 did not include the right buttock on the orders or TAR. That is V30's fault. V30 may not have put it in the computer, but treatment was being done to R3's bilateral buttocks, and provided hand-written wound sheets indicating it was done, just not documented on the POS or TAR. V30 stated V30 would not have been there on the weekends to provide treatment, so the nurses would not have known to treat R3's right buttock, because it was not in the computer. V30 stated V30 only had documentation wound care to R3's right buttock was done by V30 during the week, as described in V30's hand-written notes on 3/01, 3/08, 3/15, and 3/22. V30 could not confirm full treatment was completed on any other days to the right buttock. V30's provided V30's wound treatment notes for 3/01, 3/08, 3/15, and 3/22, but was unable to confirm R3's treatment to the right buttock was completed on any other days during the week, or on the weekends. When asked if V30 observed R3's wounds declining, V30 stated R3's wound did smell slightly, and gradually got worse with the decaying of the skin. V30 had no idea when V30 first noticed the odor, but because of R3's decline, V30 honestly thought it was Kennedy ulcer because (R3) just laid there. V30 stated V32 never mentioned a Kennedy ulcer to V30. V30 continued to state on 3/24/22, R3's sacral wound stunk to high heaven, with a lot of drainage. That's when V30 got an order from V31 (Nurse Practitioner - NP) who works in the facility to do a wound culture, and V31 ordered labs on 3/25/22. V30 again confirmed R3 received no treatment to either buttock between 2/15/22 and 3/01/22. When asked about 3/09, 3/18, and 3/24 being blank for treatment on the TAR, V30 stated V30 could have forgotten to document on the TAR. R3's cumulative Order Review Report documents - Santyl ointment 250 unit/gram ([MEDICATION(S)]) apply to right lower back topically as needed for unstageable AND apply to right lower back topically every day shift for unstageable wound, cleanse with wound cleanser, pat dry, apply Santyl with calcium alginate, and dry dressing, order/start date 3/25/22, end date 3/26/22; 1-hour turn schedule order date 3/21/22 with no start date; obtain wound culture to sacrum for possible infection, order date 3/24/22; [MEDICATION(S)] table 15 mg (milligram) give 1 tablet by mouth at bedtime for appetite, order/start date 3/22/22, end date 3/26/22; Pro-Stat liquid give 30 ml (milliliter) by mouth three times a day for wound healing mix with a juice, order/start date 3/25/22, end date 3/26/22; lab: complete blood count with differential and CMP (comprehensive metabolic panel) one time only for lab monitoring for 1 day, order/start dated 3/25/22, end date 3/26/22. R3's March 2022 MAR (Medication Administration Record) documents R3 received two doses of [MEDICATION(S)] on 3/23/22 and 3/24/22, and one dose of Pro-Stat on 03/25/22. R3's progress notes are as follows - On 3/24/22 at 11:24 AM, V30 documents a wound culture was obtained to the sacrum due to decline in wound and possible infection. On 3/25/22 at 11:14 AM, V30 writes, Spoke with resident in regards to current wounds. Resident has no questions or concerns at this time . On 3/25/22 at 3:52 PM - new order for labs received from V31 (Nurse Practitioner - NP). Drawn and picked up by lab. On 3/25/22 at 9:40 PM - facility received a call from lab regarding abnormal results for R3. Verbal orders to send to hospital due to hemoglobin at 6.3. Resident transported to local hospital emergency room via ambulance at 9:11 PM. 3/25/22 at 10:19 PM - facility received call from local hospital emergency room to report R3 was receiving blood transfusion at the moment. 3/25/22 at 10:40 PM - hospital called facility requesting POA (power of attorney) paperwork be faxed to them. R3's hospital Transfer Form completed by V10 (LPN) documents reason for transfer as abnormal hemoglobin or hematocrit (low). Skin wound care for pressure ulcers/injuries (stage, location) is blank. Other wounds or bruises present is marked no. R3's lab work taken on 3/25/22 was marked as received by the facility on 3/28/22 - Wound culture final result: Heavy growth proteus mirabilis with additional heavy growth mixed skin flora. Gram stain result: Rare polymorphonuclear leukocytes; many gram-positive cocci in pairs and clusters; many gram positive bacilli; few gram-negative bacilli. R3 is currently admitted to the local hospital. V30's hand-written wound note form, dated 3/29/22, documents R3 is in the hospital. R3's hospital notes are as follows - ED (emergency department) HPI (history of present illness), dated 3/25/22 at 10:56 AM by V25 (hospital physician)- Abnormal lab (hemoglobin 6.0 per nursing home) .per emergency medical services 6.0 hemoglobin, patient on 4 liters nasal cannula per baseline .multiple bedsores. Patient pleasantly confused upon arrival, unable to tell year. Pale but responding to staff. Paperwork from nursing home states hemoglobin 6.3 with history of [CONDITION(S)]. Physical exam - .Skin comments: Large bandaged sacral decubitus with approximately 5cm of surrounding [CONDITION(S)], warm to touch .She remained overall stable through her emergency department course. She had [CONDITION(S)]. On head-to-toe examination the sacral decubitus ulcer with evidence of surrounding [CONDITION(S)] was appreciated, and I believe that this is the mostly likely source. I absolutely believe that she requires hospitalization for continued evaluation and treatment. I discussed all currently available information directly with V22 (hospital physician) who agrees to bring this patient onto their service and agrees to transfer care. Clinical impression: [CONDITION(S)] with acute organ dysfunction due to unspecified organism; [CONDITION(S)] of buttock; pressure injury of skin of sacral region, unspecified injury stage. R3's patient image of the left buttock, dated 3/25/22 at 11:21 PM, captures a very large, black/necrotic, infected area to the entire back side with the right lower back/hip area visible in this scan, also observed as black and necrotic. 3/26/22 HP (history & physical) by V22 (hospital physician) - Active hospital problems and plan: .Severe [CONDITION(S)] likely from necrotic sacral ulcer .please consult surgeon in the m

Based on interview, observation, and record review the facility failed to identify, monitor, and treat a pressure wound for 3 (R1, R3, R4) of 3 residents reviewed for pressure ulcers in a sample of 7. This failure resulted in R3's wound declining to an unstageable large sacral decubitus ulcer, necrotizing soft tissue infection, and [CONDITION(S)] over the course of 6 weeks, until hospitalized on [DATE] for abnormal labs as documented by the facility. R3 underwent a wide debridement of necrotizing soft tissue infection of sacrum and bilateral gluteal regions, placed on a wound vac, comfort care, hospice, and subsequently passed away in the hospital on 4/06/22, due to [CONDITION(S)] with multi-organ failure. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 2/14/22, when the facility failed to identify and treat a stage II pressure ulcer to R3's bottom per hospital discharge orders. V1 (Administrator) and V6 (Register Nurse - RN/Assistant Director of Nursing - ADON) were notified of the Immediate Jeopardy on 4/14/22 at 10:32 AM. The surveyor confirmed by observations, record review, and interview, that the Immediate Jeopardy was removed on 4/14/22. While the immediacy was removed on 4/14/22, the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff as needed and evaluate the effectiveness of their interventions. The findings include: 1. R3's Admission Record profile sheet documents admission to this facility on 12/07/20, to include the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's most recent quarterly Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact, with a BIMS (Brief Interview for Mental Status of 14, and assessed to require the following - extensive two plus person physical assist for bed mobility, dressing, transfer and indicates transfer occurred only once or twice in a 7-day period; walking in room or corridor did not occur; one person physical assist with locomotion on and off unit and occurred only once or twice in a 7-day period; supervision and one person physical assist with eating; and extensive one person physical assist with toilet use and personal hygiene. R3's care plan, dated 12/08/20, updated on 4/14/21, documents an intervention under the focus area for falls R3 requires a mechanical lift with two person-assist for transfers, date Initiated/created: 3/22/2021. Also included in R3's care plan: Focus Area - R3 is at risk for pressure injury development related to impaired mobility; 3/2/2022 wound left buttock; 3/25/2022 wound to right lower back revised on 3/31/22. Goal - R3 will have intact skin, free of redness, blisters, or discoloration by/through review date, revised 12/09/21, target date05/25/22. Interventions in part - Administer treatments as ordered and monitor for effectiveness. Requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing, date initiated/created: 3/31/2022; Turn every 1-hour, date initiated/created: 3/21/2022 by: V30 (Licensed Practical Nurse - LPN/Wound Nurse); low air-loss mattress, date initiated/created: 1/21/2021; Needs assistance to turn/reposition approximately every 2 hours, more often as needed or requested, date initiated/created: 12/29/2020; Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated, date initiated/created: 3/22/2021; Provide pressure reducing mattress to bed/ pad to wheelchair, date initiated/created: 12/29/2020; Use lifting device, draw sheet, etcetera to reduce friction, date initiated/created: 12/29/2020; Weekly skin check. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, or discoloration noted during bathing or daily care, date initiated/created: 12/08/2020. R3's cumulative Order Review Report includes the following - skin checks with an original start date upon admission of 12/08/20, end date 2/11/22. R3's January 2022 TAR (Treatment Administration Record) documents - skin checks (Monday and Thursday) I = Intact; N = New; W = Wound every day-shift Monday, Thursday, start date 12/10/20, d/c (discontinue) date 2/11/22. R3's skin checks were completed on 1/06, 1/10, 1/13, 1/20, 1/24, and 1/27, all indicating intact skin. There was no skin check documented as being performed on 1/03, 1/17, 1/24, or 1/31. 4 out of 9 skin check days were not documented as completed. R3's January 2022 TAR also documents - [MEDICATION(S)] apply to both buttocks topically every shift for wound prevention. Cleans with wound cleanser and pat dry. Apply z-guard every shift (1st shift 6A-6P and 2nd shift 6P-6A), start date 3/17/21, d/c date 2/07/22. This TAR documents preventative treatment was provided on one shift only, instead of both shifts, as ordered - 1/01; 1/02; 1/5; 1/07; 1/09 - 1/12; 1/14 - 1/19; 1/23; 1/25; 1/26; 1/28, and 1/29. This TAR is completely blank on 1/03; 1/17; 1/21; 1/22; 1/24; and 1/31. R3's January 2022 TAR documents z-guard not documented as applied as ordered 30 out of 62 application times on 1/01, 1/02, 1/03, 1/05, 1/07, 1/09-1/12, 1/14-1/19, 1/21-1/26, 1/28, 1/29, and 1/31. On 4/07/22 at 1:49 PM, when asked about the numerous blanks on R3's January TAR, V30 (Licensed Practical Nurse/LPN) stated V30 did not know why they were blank. V30 stated R3 had pretty good skin in January. The facility was unable to confirm why these treatment dates and times were blank or provide documentation treatment was provided as ordered. R3's progress note, dated 1/31/22 at 11:34 PM, reports R3 had complaints of shortness of breath and was transferred to the local emergency room for evaluation and treatment at this time. R3's local hospital emergency room notes, dated 2/01/22 at 2:19 AM, documents a chief complaint of shortness of breath with subsequent admission for treatment. R3 was discharged back to the facility on [DATE]. Included in R3's hospital record for this admission is a Wound Nurse Note, dated 2/07/22 at 12:27 PM, by V28 (Registered Nurse - RN) - Consult completed for redness on coccyx. A picture was updated to pt (patient) chart. Pt has some blanchable redness, skin is C/D/I (clean, dry, intact). Triad applied to B/L (bilateral) and coccyx. A silicone bordered foam pad was applied to sacral region. B/L heels observed blanchable C/D/I. B/L pedal pulses 1+. B/L feet cold to touch. Pt stated she was cold. A warm blanket was placed over her after assessment was completed. Wound care will sign off at this time. Please consult again for any other wound care concerns. R3's In-patient Discharge Summary, dated 2/14/22 at 12:05 PM, includes - Physical Exam at Discharge: .Skin: Stage II pressure ulcer bottom. R3's Primary Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Pictures, dated 2/01/22 and 2/14/22, of coccyx/sacral area included in record. R3's hospital after visit summary, dated 2/14/22, gives instruction to continue the following to include - [MEDICATION(S)] 20% ointment apply 1 application topically 2 times a day (apply to both buttocks for wound prevention). R3's facility admission evaluation note, dated 2/14/22 at 5:28 PM, documents no skin issues. R3's Braden Assessments - 2/14/22 - 13 moderate risks; 2/21/22 - 11 high risk; 2/28/22 - 15 low risk; 3/07/22 - 12 high risk; 3/15/22 - 16 low risk. On 03/31/22 at 1:49 PM, V2 (Director of Nursing - DON) stated the reason why R3's Braden scale scores from 2/14/22 to 3/15/22 were so up and down is because at different times V2 would be able to position herself better than others; some days R3 could get out of bed on R3's own, so the severity went back and forth depending on how R3 was the day of the assessment. V2 stated, When (R3) discharged from the hospital and back to our facility, on 2/15/22, when I was in the room, the CNA (Certified Nursing Assistant, V24) pointed to (R3's) sacral area and asked what the dressing was. I observed a ([MEDICATION(S)]) dressing in place from the hospital from her discharge on 2/14/22. I knew it was not our dressing because we don't use that type. V2 stated V2 told V24 to Get with R3's nurse to notify V30 (LPN/Wound Nurse) to come and assess what was under the ([MEDICATION(S)]) dressing. When asked why V30's weekly skin/wound evaluation documentation for R3 beginning 3/07/22 until R3's hospital admission on 3/25/22 were incomplete and unsigned, V2 stated V30 previously reported to V2 that V30 was approximately 4 weeks behind on V30's paperwork. V2 stated V2 did not realize R3's wound had declined to the point it had, until V2 went back into the role of DON on Monday, 3/21/22. V2 stated V2 doesn't know if the decline could have been prevented. V2 agreed on is there is a delay in processing the orders. V2 stated, (V32, Wound Physician) gives a recommendation or order, (V30) does the treatment right then. I don't know why, according to the paperwork here, it's taking a day or two to put the order in for the rest of the nurses to follow. R3's cumulative Order Review Report Summary documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] = Intact; N = New; W = Wound one time a day every Monday, Thursday for wound prevention, order date 2/14/22; start date 2/17/22; end date 3/26/22. R3's February 2022 TAR documents two sets of skin check instructions. One (1) prior to R3 admitting to the hospital on 2/01/22, and a second (2) when R3 returned to the facility on [DATE] as follows: 1) Skin checks (Monday and Thursday) I = Intact; N = New; W = Wound, every day-shift Monday, Thursday, start date 12/10/20, discontinue date 2/11/22. This TAR documents on 2/03/22 by V7 (RN), the skin check is coded as a 3, indicating R3 is absent from home/hospitalized . A second skin check, dated 2/10/22 ,was documented as I for intact by V30, at which time R3 was still in the hospital. 2) Skin checks weekly and set schedule, I = Intact; N = New; W = Wound one time a day every Monday, Thursday for wound prevention, start date 2/17/22; end date 3/26/22. A skin check was performed on Thursday, 2/17/22 by V4 (LPN). V4 indicates a wound was present on this date by documenting W. R3's next scheduled skin check, dated 2/21/22 is blank. The facility is unable to provide a reason it's blank or documentation that it was done. On 4/05/22 at 10:55 AM, V4 stated the W she documented on R3's skin checks, dated 2/17/22, looked like a shear wound on the buttock, with redness around the middle. V4 did not remember which side, but stated V4 believed it was the left buttock. When wound pictures from 2/24/22 and 2/28/22 of the right and left buttock were shown to V4, V4 she stated V4 does not recall observing the right buttock wound, or any documentation in R3's record regarding treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 stated V4's Understanding is that (V30) treats any wound with a covered dressing because that resident is on the weekly wound round list with the physician. (V30) treats those wounds daily and as ordered. The nurses scheduled on Saturday and Sunday provide wound care as ordered when (V30) is not scheduled to work. R3's February 2022 TAR continues to document - [MEDICATION(S)] 20% ointment apply to both buttocks topically every shift for wound prevention. Cleanse with wound cleanser and pat dry, apply z-guard every shift (6A-6P; 6P-6A), start date 3/27/21, discontinue date 2/07/22. There is no order in R3's record or documentation on R3's February 2022 TAR for [MEDICATION(S)] 20% ointment apply 1 application topically 2 times a day (apply to both buttocks for wound prevention) as documented on R3's hospital discharge summary instructions, dated 2/14/22. R3's February 2022 TAR skin checks, dated 2/24/22 and 2/28/22 are blank, however, V30 (LPN-Wound Nurse) performed a Skin and Wound Evaluation with R3 on these dates to include pictures. On 2/24/22, R3's skin and wound evaluation documents an abrasion to the left buttock as a new, in-house acquired wound measuring 0.6 cm (centimeters) in area x 1.2 cm length x 0.6 cm width with depth, undermining, and tunneling marked not applicable; 100% granulation with no evidence of infection, moderate serosanguineous exudate with no odor; edges attached; surrounding tissue normal in color; induration of less than 2cm around the wound; no swelling or edema; normal temperature; no pain reported; with goal of being healable. The attached picture of the left buttock, dated 2/24/22, documents a minute-old abrasion with visible multiple red areas that are open with skin peeling present. On 2/24/22, R3's skin and wound evaluation documents an undiagnosed wound to the right buttock as a new, in-house acquired wound measuring 1.3 cm x 1.8 cm x 0.9 cm with depth, undermining, and tunneling marked not applicable; 100% granulation with no evidence of infection, moderate serosanguineous exudate with no odor; edges attached; surrounding tissue normal in color; induration of less than 2cm around the wound; no swelling or edema; normal temperature; no pain reported; with goal of being healable. The attached picture of the right buttock, dated 2/24/22, documents an undiagnosed minutes old area that is visible in the picture as a dark purple area with surrounding [CONDITION(S)]. On 4/07/22 at 1:49 PM, V30 looked at R3's picture V30 took from 2/24/22, and stated V30 would assess the left buttock wound as an abrasion, or maybe a stage I, since the skin is curled back and it's open. V30 stated, Sometimes if I don't know what a wound is, I leave them blank and ask (V32) to classify them, and then go back and fill out the skin and wound evaluation that time. V30 looked at the skin and wound evaluation of R3's right buttock, dated 2/24/22, and stated V30 would describe it as an unstageable DTI (deep tissue injury). V30 confirmed there was no order for treatment to either R3's left or right buttock for February, only skin checks on R3's February TAR, and V32 would not have known about R3's wound to this point. R3's cumulative Order Review Report documents an order, dated 3/02/22, for [MEDICATION(S)] ointment 2% apply to left buttock topically as needed for wound AND apply to left buttock topically every day-shift for wound, cleanse with wound cleanser, apply [MEDICATION(S)], and dry dressing. Start date, 3/02/22, end date 3/08/22. This order does not include the right buttock. On 4/07/22 at 1:49 PM, V30 continues to state R3's right buttock wound may not have been brought forward to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V30's hand-written wound note - 3/01/22: left buttock 0.9cm x 0.7cm with moderate 100% granulation; right buttock 1.2cm x 1.4cm with moderate 100% granulation - treated with [MEDICATION(S)], DD (dry dressing). R3's progress skin/wound note, dated 3/01/22 at 7:08 AM, by V32 (Wound Physician) documents R3 has wounds to bilateral buttocks described as an abrasion with an onset within a week. V32 describes the wound as open with a dry scab. Location: Right buttock: 1.2 cm x 1.4 cm x 0.1 cm with moderate drainage and 100% granulation. Left buttock: 0.9 cm x 0.7 cm x 0.1 cm with moderate drainage and 100% granulation. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: Dressing. Dressings: [MEDICATION(S)] with dry dressings change daily and PRN (as needed). R3's progress note, dated 3/01/22 at 2:18 PM by V30, documents V30 spoke to R3 regarding R3's wound and R3 had no questions or concerns. R3's March 2022 TAR documents the following - 1) Skin checks weekly and set schedule, I = Intact; N = New; W = Wound, one time a day every Mon, Thurs for wound prevention, start date 12/17/22 end date 3/26/22; 2) [MEDICATION(S)] ointment 2% (percent) apply to left buttock topically as needed for wound - start date 3/02/22, end date 3/08/22. 3) Santyl ointment 250 unit/gram ([MEDICATION(S)]) apply to sacrum topically every dayshift for wound, cleanse with wound cleanser, pat dry, apply Santyl, calcium alginate, and dry dressing - start date 3/09/22, end date 3/26/22. 4) Santyl ointment 250 unit/gram ([MEDICATION(S)]) apply to right lower back topically every dayshift for unstageable wound, cleanse with wound cleanser, pat dry, apply Santyl with calcium alginate, and dry dressing, start date 3/26/22, end date 3/26/22. R3's March TAR has one skin checks area documented as completed on 3/03/22, and coded with a 3, indicating a wound is present; Skin and wound evaluations forms, dated 3/07, 3/14, and 3/21, were not completed and were unsigned by V30. R3's skin checks for 3/10, 3/17, and 3/24 are blank. The facility did not provide documentation skin checks were completed on these days. Also pertinent on this TAR, treatment with [MEDICATION(S)] ointment 2% apply to left buttock every dayshift (6A-6P) for wound, cleanse with wound cleanser, apply [MEDICATION(S)], and dry dressing. Start date 3/02/22, end date 3/08/22. The date 3/04/22 is blank. The date 3/08/22, signed by V30, is coded as 9 for see progress notes. The facility did not provide a corresponding progress note regarding this skin check. This TAR does not include the right buttock, and the facility was unable to provide documentation of treatment to the right buttock other than on V30's wound round days when V30 provided V30's hand-written notes on 3/01/22 and 3/08/22. R3's Skin and Wound Evaluation, dated 3/07/22 at 10:20 AM - Abrasion to sacrum new in house acquired at 10.2cm x 3.0cm x 5.3cm, depth not applicable. The remainder of the evaluation is blank and has not been signed off by V30. Wound evaluation picture, dated 3/07/22, documents sacral abrasion 11-day old in house acquired as 10.18cm x 2.99cm x 5.3cm. V30's hand-written note - 3/08/22: left buttock no measurements, right buttocks no measurements, sacrum 3.0cm x 5.3cm with moderate 100% granulation - treated with Santyl and CA (calcium alginate), DD, marked as decline. R3's progress note, dated 3/08/22 at 11:21 AM by V30, documents, Spoke with resident in regard to wound. Expressed the importance for resident to rotate side to side to keep pressure off wound. Resident verbalizes understanding. Resident has no questions or complaints at this time. R3's skin/wound note, dated 3/08/22 at 6:49 AM by V32, documents buttock wounds within a week as an open abrasion with dry scab. Wound to buttock has migrated to fuse at the sacrum. Pt is bed bound. Sacrum 3.0cm x 5.3cm x 0.1cm moderate drainage 100% slough with 0% granulation. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . There is marked decline observed in the corresponding picture, dated 3/07/22, with redness evident from the right hip across the buttock, sacral area, and visible on the lower back region. This surveyor observed R3's wound picture. R3's buttocks/sacral area appear inflamed and swollen even in the picture, with a large purple/black area across the right buttock to the sacral region. R3's cumulative Order Review Report documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's March TAR document is blank on 3/09/22, 3/18, and 3/24 when R3 should have received Santyl ointment 250 unit/gram ([MEDICATION(S)]) apply to sacrum topically every day-shift for wound, cleanse with wound cleanser, pat dry, apply Santyl, calcium alginate, and dry dressing - start date 3/09/22, end date 3/26/22. The facility did not provide an explanation or documentation why the treatment was not done on these dates R3's Skin and Wound Evaluation, dated 3/14/22 at 10:26 AM - Abrasion to sacrum new in house acquired at 9.1cm x 2.1cm x 6.1cm, depth not applicable. The remainder of the evaluation is incomplete. Wound evaluation picture, dated 3/14/22, documents sacral abrasion 18 days old in house acquired at 9.14cm x 2.09cm x 6.07cm. This picture has a marked increase in size difference appearing larger in the picture taken on 3/07/22. V30's hand-written note - 3/15/22: sacrum 2.1cm x 6.1cm with moderate 80% S (slough), 20% G (granulation) - treated with Santyl, CA (calcium alginate), DD (dry dressing). Written on this sheet is - silicone, 1-hour turn schedule, high protein diet. R3's skin/wound note, dated 3/15/22 at 6:44 AM by V32, documents - patient has wound: buttocks wounds. Onset within a week. Type of wound: abrasion, open with dry scab. Wound to buttock has migrated to fuse at the sacrum. Pt is bed bound .location: sacrum 2.1cm x 6.1cm x 0.1cm abrasion with moderate 80% slough and 20% granulation. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's progress note, dated 3/15/22 at 11:37 AM by V30, documents - Spoke with resident in regards to current wound. Reminded resident to make sure she is turning side to side to keep off her sacrum. Will place on a 1-hour turn schedule. Resident has no questions or concerns at this time. R3's skin and wound evaluation, dated 3/21/22 at 12:49 PM by V30 - Abrasion to sacrum new in house acquired at 19.5cm x 5.4cm x 4.1cm, depth not applicable. The remainder of the evaluation is incomplete. Wound evaluation picture, dated 3/21/22 documents 25 day old in house acquired sacral abrasion at 19.46cm x 5.41cm x 4.14 cm. R3's wound in this picture has significantly declined when compared to the assessment picture from 3/14/22, with obvious depth and a dark, necrotic looking wound to the right hip as seen in the corner of the sacral photograph. R3's skin and wound evaluation, dated 3/21/22 at 12:49 PM - Pressure to right lower back (slough and/or eschar), new in house acquired and unstageable (obscured full-thickness skin and tissue loss) at 4.6cm x 2.3cm x 2.7cm, depth not applicable. The remainder of this evaluation is incomplete. Wound evaluation picture dated 03/21/22 documents new unstageable pressure (slough and/or eschar) minute old in house acquired right lower back wound at 4.63cm x 2.27cm x 2.69cm. R3's skin/wound note, dated 3/22/22 at 6:45 AM by V32, documents - patient has wound: buttocks wounds with a new wound of lower back. Onset: months. Type of wound: abrasion. Status: open, wound was to buttocks but migrated to fuse at the sacrum. Pt is bedbound. Location: sacrum 5.4cm x 4.1cm x 0.1cm abrasion with moderate drainage and 80% slough, 20% granulation. Wound: right lower back pressure wound - unstageable with 100% slough. 2.3cm x 2.7cm x 0.1cm. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: dressing, added abd (army battle dressing) pad with Santyl with dry dressings change daily and prn with 1-hour turn schedule and prostat juice. R3's hand-written wound note by V30, dated 3/22/22 documents - sacrum abrasion/worsen 5.4cm x 4.1cm with 80% S, 20% G, moderate; right lower back new (unstageable change) 2.3cm x 2.7cm 100% S moderate - both areas treated with Santyl, CA, DD. Written on sheet - Add high protein diet, Prostat with juice, able to make own decisions? On 4/07/22 at 1:49 PM, V30 explained V32 documents V32's would assessments in the electronic record along with the measurements, description, and everything from week to week, including his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked about R3's wound note written by V32, dated 3/01/22, referencing both the left and right buttock wound with orders to treat, V30 stated V30 thought the orders for R3's right buttock got put on the POS and TAR. V30 did not remember what or who prompted V30 to do R3's skin and wound evaluation and take pictures on 2/24/22 or 2/28/22, but V32 would not have been aware of any wounds until03/01/22 when V32 made V32's first note. V30 stated V30 was told the pictures had to be within 7 days of seeing the wound doctor, so V30 may have input the measurement and descriptions from 3/01/22 into the documents for 2/24/22 and 2/28/22. V30 stated R3 was ordered to be on a 1-hour turn schedule on 3/15/22, as documented in V32's wound note. V30 stated V30 swears V30 put the order on the POS and CNA tasks, but this did not get documented in the tasks at all, or on the POS or care plan until 3/21/22. The 1-hour turn schedule was never implemented, due to not being put in the tasks where the CNAs could follow the recommendation. V30 remembered doing this, but must not have saved it in the computer. V30 stated V30 remembers telling the CNAs R3 was on a 1-hour turn schedule, but it's not documented, and was not done. V30 confirmed there was no documentation of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The right buttock did not get brought forward from V32's note on 3/01/22. V30 confirmed V30 provides resident wound treatment on Monday - Friday for all covered wounds V32 has on V32's weekly rounds. V30 stated V32 did give treatment orders for R3 on 3/01/22 for [MEDICATION(S)] to bilateral buttocks with dry dressing. V30 did not include the right buttock on the orders or TAR. That is V30's fault. V30 may not have put it in the computer, but treatment was being done to R3's bilateral buttocks, and provided hand-written wound sheets indicating it was done, just not documented on the POS or TAR. V30 stated V30 would not have been there on the weekends to provide treatment, so the nurses would not have known to treat R3's right buttock, because it was not in the computer. V30 stated V30 only had documentation wound care to R3's right buttock was done by V30 during the week, as described in V30's hand-written notes on 3/01, 3/08, 3/15, and 3/22. V30 could not confirm full treatment was completed on any other days to the right buttock. V30's provided V30's wound treatment notes for 3/01, 3/08, 3/15, and 3/22, but was unable to confirm R3's treatment to the right buttock was completed on any other days during the week or on the weekends. When asked if V30 observed R3's wounds declining, V30 stated R3's wound did smell slightly, and gradually got worse with the decaying of the skin. V30 had no idea when V30 first noticed the odor, but because of R3's decline, V30 honestly thought it was Kennedy ulcer because she just laid there. V30 stated V32 never mentioned a Kennedy ulcer to V30. V30 continued to state on 3/24/22, R3's sacral wound stunk to high heaven with a lot of drainage. That's when V30 got an order from V31 (Nurse Practitioner - NP), who works in the facility, to do a wound culture, and V31 ordered labs on 0/25/22. V30 again confirmed R3 received no treatment to either buttock between 2/15/22 and 3/01/22. When asked about 3/09, 3/18, and 3/24 being blank for treatment on the TAR, V30 stated V30 could have forgotten to document on the TAR. R3's cumulative Order Review Report documents - Santyl ointment 250 unit/gram ([MEDICATION(S)]) apply to right lower back topically as needed for unstageable AND apply to right lower back topically every day shift for unstageable wound, cleanse with wound cleanser, pat dry, apply Santyl with calcium alginate, and dry dressing, order/start date 3/25/22, end date 3/26/22; 1-hour turn schedule order date 3/21/22 with no start date; obtain wound culture to sacrum for possible infection, order date 3/24/22; [MEDICATION(S)] table 15 mg (milligram) give 1 tablet by mouth at bedtime for appetite, order/start date 3/22/22, end date 3/26/22; Pro-Stat liquid give 30 ml (milliliter) by mouth three times a day for wound healing mix with a juice, order/start date 3/25/22, end date 3/26/22; lab: complete blood count with differential and CMP (comprehensive metabolic panel) one time only for lab monitoring for 1 day, order/start dated 3/25/22, end date 3/26/22. R3's March 2022 MAR (Medication Administration Record) documents she received two doses of [MEDICATION(S)] on 3/23/22 and 3/24/22, and one dose of Pro-Stat on 3/25/22. R3's progress notes are as follows - On 3/24/22 at 11:24 AM, V30 documents a wound culture was obtained to the sacrum due to decline in wound and possible infection. On 3/25/22 at 11:14 AM, V30 writes, Spoke with resident in regards to current wounds. Resident has no questions or concerns at this time . On 3/25/22 at 3:52 PM - new order for labs received from V31 (Nurse Practitioner - NP). Drawn and picked up by lab. On 3/25/22 at 9:40 PM - facility received a call from lab regarding abnormal results for R3. Verbal orders to send to hospital due to hemoglobin at 6.3. Resident transported to local hospital emergency room via ambulance at 9:11 PM. 3/25/22 at 10:19 PM - facility received call from local hospital emergency room to report R3 was receiving blood transfusion at the moment. 3/25/22 at 10:40 PM - hospital called facility requesting POA (power of attorney) paperwork be faxed to them. R3's hospital Transfer Form completed by V10 (LPN) documents reason for transfer as abnormal hemoglobin or hematocrit (low). Skin wound care for pressure ulcers/injuries (stage, location) is blank. Other wounds or bruises present is marked no. R3's lab work taken on 3/25/22 was marked as received by the facility on 3/28/22 - Wound culture final result: Heavy growth proteus mirabilis with additional heavy growth mixed skin flora. Gram stain result: Rare polymorphonuclear leukocytes; many gram-positive cocci in pairs and clusters; many gram positive bacilli; few gram-negative bacilli. R3 is currently admitted to the local hospital. V30's hand-written wound note form, dated 3/29/22, documents R3 is in the hospital. R3's hospital notes are as follows - ED (emergency department) HPI (history of present illness), dated 3/25/22 at 10:56 AM by V25 (hospital physician)- Abnormal lab (hemoglobin 6.0 per nursing home) .per emergency medical services 6.0 hemoglobin, patient on 4 liters nasal cannula per baseline .multiple bedsores. Patient pleasantly confused upon arrival, unable to tell year. Pale but responding to staff. Paperwork from nursing home states hemoglobin 6.3 with history of [CONDITION(S)]. Physical exam - .Skin comments: Large bandaged sacral decubitus with approximately 5cm of surrounding [CONDITION(S)], warm to touch .She remained overall stable through her emergency department course. She had [CONDITION(S)]. On head-to-toe examination the sacral decubitus ulcer with evidence of surrounding [CONDITION(S)] was appreciated, and I believe that this is the mostly likely source. I absolutely believe that she requires hospitalization for continued evaluation and treatment. I discussed all currently available information directly with V22 (hospital physician) who agrees to bring this patient onto their service and agrees to transfer care. Clinical impression: [CONDITION(S)] with acute organ dysfunction due to unspecified organism; [CONDITION(S)] of buttock; pressure injury of skin of sacral region, unspecified injury stage. R3's patient image of the left buttock, dated 3/25/22 at 11:21 PM, captures a very large, black/necrotic, infected area to the entire back side with the right lower back/hip area visible in this scan, also observed as black and necrotic. 3/26/22 HP (history & physical) by V22 (hospital physician) - Active hospital problems and plan: .Severe [CONDITION(S)] likely from necrotic sacral ulcer .please consult su

Based on observation, interview, and record review the facility failed to: 1. Ensure disinfectant used to treat non-porous surfaces for Covid-19 was utilized per manufacturer guidelines to complete the required contact time for effective disinfection. 2. Require N95 grade facemask application for staff working on Covid-19 positive units. 3. Complete sanitization of hands prior to exiting the Covid-19 positive units. 4. Prevent cross contamination between staff working designated Covid-19 positive units versus those working Non Covid-19 positive units. 5. Provide adequate resident supervision to ensure Covid-19 positive residents remain within the designated Covid-19 isolation halls. These systemic failures have resulted in 69 residents testing positive for Covid-19, with death being the result for eleven of those residents (R1, R8, R11, R12, R14, R15, R16, R17, R18, R19, R20) who were confirmed positive. These failures have the potential to affect all 72 residents residing in the facility and resulted in an Immediate Jeopardy (IJ) to their health and safety. The IJ was identified to have begun on [DATE], when the facility first received V31's (Social Service Assistant) confirmation of Covid-19, who had been actively working within the facility, and failed to complete effective facility disinfection practices to kill Covid-19. As of [DATE] the facility has had 69 resident cases of Covid-19 and 11 deaths (R1, R8, R11, R12, R14, R15, R16, R17, R18, R19, R20) associated with Covid-19. The facility was notified of the Immediate Jeopardy on [DATE] at 9:10 AM. The surveyors confirmed by observations, record review and interview that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: 1. On [DATE] at 2:45 PM, V2 (Director of Nursing) stated the facility has had 7 residents expire in the facility, and 1 expired in the hospital due to Covid-19 at the time of this interview. V2 stated prior to the Covid-19 diagnosis, none of the 8 deceased were expected to pass, were receiving end of life services, hospice, or comfort care measures. V2 contributes the 8 deaths to Covid-19. On [DATE] at 1:55 PM, V3 (Assistant Director of Nursing) stated that R21 was the facility's first resident confirmed Covid-19 case after being tested individually at the local hospital. V3 stated R21 was tested for Covid-19 on [DATE]. V3 stated from [DATE] until current, the facility has had 69 positive resident Covid-19 cases and 11 resident deaths due to Covid-19. A timeline provided by the facility on [DATE] documents the following weekly Covid-19 results since all facility staff and resident testing began: First Covid-19 positive date: Staff (V31) tested on [DATE]. Results of positive nature were reported on [DATE] by V31 to the facility. Facility Mass Testing Date Began: [DATE] & [DATE] - # positive residents: 0 - #positive staff: 5 - # residents hospitalized with this week: 0 - #residents ER visit d/t (due to) Covid this week: 0 - #residents expired this week: 0 Facility Mass Testing Date: [DATE] & [DATE] - # positive residents: 16 - # positive staff: 14 - # residents hospitalized with this week: 3 - # residents ER visit d/t Covid this week: 2 - # residents expired this week: 0 Facility Mass Testing Date: [DATE] & [DATE] - # positive residents: 20 - # positive staff: 15 - # residents hospitalized with this week: 1 - # residents ER visit d/t Covid this week: 2 - # residents expired this week: 0 Facility Mass Testing Date: [DATE] & [DATE] - # positive residents: 16 - # positive staff: 7 - # residents hospitalized with this week: 2 - # residents ER visit d/t Covid this week: 1 - # residents expired this week: 5 Facility Mass Testing Date: [DATE] & [DATE] - # positive residents: 13 - # positive staff: 8 - # residents hospitalized with this week: 2 - # residents ER visit d/t Covid this week: 0 - # residents expired this week: 2 Review of R14's Clinical Record documents a positive Covid-19 test date of [DATE]. R14's Clinical Record does not indicate R14 was being treated for [REDACTED]. R14's Clinical Record documents R14 expired in the facility on [DATE]. Review of R14's Certificate of Death Worksheet dated [DATE] confirms the date of death as [DATE] with the sole Cause of Death listed as A. Covid Infection. Review of R15's Clinical Record documents a positive Covid-19 test date of [DATE]. R15's Clinical Record does not indicate R15 was being treated for [REDACTED]. R15's Clinical Record documents R15 expired in the facility on [DATE]. Review of R15's Certificate of Death Worksheet dated [DATE] confirms the date of death as [DATE] with the sole Cause of Death listed as A. Covid. Review of R16's Clinical Record documents a positive Covid-19 test date of [DATE]. R16's Clinical Record does not indicate R16 was being treated for [REDACTED]. R16's Clinical Record documents R16 expired in the facility on [DATE]. Review of R16's Certificate of Death Worksheet dated [DATE] confirms the date of death as [DATE] with the sole Cause of Death listed as A. Novel Corona Covid-19 Virus Infection. On [DATE] review of the not dated article titled List N: Disinfectants for Use Against [DIAGNOSES REDACTED]-CoV-2 (Covid-19) and found at https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-[DIAGNOSES REDACTED]-cov-2-covid-19 stated, When using an EPA (Environmental Protection Agency)-registered disinfectant, follow the label directions for safe, effective use. Make sure to follow the contact time, which is the amount of time the surface should be visibly wet PH7Q Dual product information found at https://www.betco.com/products/ph7q-dual/ on [DATE] stated: FOR USE AS A ONE-STEP GENERAL, HOSPITAL, MEDICAL DISINFECTANT, FUNGICIDE, VIRUCIDE* AND CLEANER: 1. Pre-clean heavily soiled areas. 2. Apply use solution of 0.5 oz. of this product per gal. of water (or equivalent use dilution) to disinfect hard, non-porous surfaces with a sponge, brush, cloth, mop, auto scrubber, mechanical spray device, coarse pump or trigger spray device. For spray applications, spray ,[DATE] inches from surface. Do not breathe spray. 3. Treated surfaces must remain wet for 10 minutes. 4. Allow to air dry. 5. Prepare a fresh solution daily or when visibly dirty. This product is documented as being an effective disinfectant for Covid-19 when a 10-minute contact time occurs. On [DATE] at 2:30 PM, V14 (Customer Service Representative for sanitizing manufacturer) stated that pH7Q Dual is effective against killing Covid-19 with a 10-minute dwell time on the surface being treated. V14 stated without the surface remaining wet for 10 minutes, pH7Q Dual would not be effective in killing Covid-19. V14 stated the company does offer other disinfectant products effective against Covid-19, with one having a 3-minute dwell time. V14 confirmed that the company he works for is the manufacturer of pH7Q. On [DATE] at 8:58 AM, V13 (Medical Director) stated he agrees that Covid-19 is a highly contagious virus that has resulted in death and/or severe illness for some. V13 acknowledged the long-term care facility population are considered high risk for Covid-19. V13 stated he would expect the facility to follow all CDC (Center for Disease Control) guidelines regarding Covid-19 and infection control standards of practice. V13 stated he would expect the facility to be utilizing an approved disinfectant per manufacturer guidelines to provide effective disinfection, in an effort to eradicate the spread of Covid-19. On [DATE] at 10:20 AM, V12 (Maintenance Supervisor) stated that for disinfecting, staff use pH7Q Dual with a 10-minute dwell time, which is approved to kill Covid-19. V12 stated this a premixed solution that a distributor provides to the facility and services the machines that mix the solution. V12 stated there have been no known problems with the solution. V12 stated mop pads are saturated in the solution and used to wipe the floors and the walls if needed. V12 stated a battery-operated sprayer is used to spray the non-porous surfaces of the beds. V12 stated when staff wipe the high touch surface areas, they spray the handrail or doorknob, etc. (etcetera) and then use a rag that has been sprayed with the solution to dab, so it doesn't drip. V12 stated they don't time the solution being wet, but it definitely doesn't dry before 10 minutes. V12 stated he has educated the housekeeping staff along with CNA (Certified Nurse Assistant) staff on how to clean high touch surface areas. On [DATE] at 8:58 AM, V15 (Housekeeping) stated she has worked in housekeeping at the facility for 11 days. V15 stated she has been trained regarding infection control procedures with Covid-19 and effective cleaning methods. V15 stated the facility uses pH7Q Dual to clean surfaces including floors, walls, doorknobs, handrails, counter tops, other high touch surface areas, etcetera. V15 described the process of cleaning a hard surface, with a handrail being used as the example, as spraying pH7Q Dual onto the surface, waiting 5 - 10 minutes then using a dry rag to wipe the disinfectant off. On [DATE] at 9:04 AM, V15 was observed entering an occupied resident room on the Non Covid-19 positive unit with a spray bottle of pH7Q Dual and dry rag. During continuous observation, at 9:05 AM, V15 was observed spraying the bathroom sink and toilet with pH7Q. At 9:06 AM, V15 was observed draping the dry rag over the edge of the sink covering an area that had just been sprayed with pH7Q, and stepping back from the sink area. At 9:07 AM, V15 was observed picking up the dry rag from the sink edge and began wiping the sink surface. At 9:07, AM V15 acknowledged the sink surface is dry and this is her normal disinfecting process. On [DATE] at 9:29 AM, V16 (Housekeeping) stated she has worked in housekeeping at the facility for approximately 3 months. V16 was observed as providing housekeeping services on a Covid-19 positive unit. V16 stated pH7Q Dual disinfectant is used to clean surfaces including doorknobs, handrails, floors, etc. V16 described the process of disinfecting a handrail as spraying a rag with pH7Q Dual, lightly spraying pH7Q Dual onto the rail, then blotting off any that may be run with her sprayed rag. V16 stated she only sprays the handrails lightly as to not mess up the wallpaper. On [DATE] at 9:34 AM, V16 was observed demonstrating this practice with continuous observation. V16 was observed spraying 4 sprays of pH7Q Dual onto a dry rag. V16 then sprayed a portion of the handrail with pH7Q and immediately began blotting the rail with her rag, creating a dry surface within less than a minute. This surveyor touched the rail to ensure the dry status, as well as V16 acknowledging the dry surface. When asked if there was any certain amount of contact time needed for appropriate disinfection, V16 replied 10 minutes, despite the observation not including a 10-minute dwell time. V16 was observed as continuing this same cleaning practice following her interview and demonstration of cleaning. V16 acknowledged this is her normal disinfecting process. On [DATE] at 12:56 PM, V17 (Housekeeping) stated the facility uses pH7Q Dual to disinfect surfaces. V17 was observed spraying handrails within the Covid-19 positive unit with pH7Q Dual and immediately wiping them off with a rag. This was observed as creating a dry surface prior to the required 10-minute contact time. On [DATE] at 9:30 AM, V8 (Housekeeping) stated pH7Q Dual is the disinfectant they use to spray the walls and the high touch surface areas. V8 described dampening a rag with the disinfectant and patting the spray on the high touch surface area. V8 stated the disinfectant is supposed to stay wet 10 minutes on the floor and ,[DATE] minutes on the high touch areas. V8 stated she has worked at the facility for [AGE] years. On [DATE] at 9:36 AM, V18 (Licensed Practical Nurse/LPN) stated she has worked at the facility for 4 years. V18 stated she cannot recall any time when surfaces such as the countertop of the nurse's station have been left wet with disinfectant. V18 stated she recalls observing housekeeping staff spray and wipe surfaces. 2. On [DATE] review of the article titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated [DATE] and found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html state, HCP (Health Care Professionals) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 (Covid-19) infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. On [DATE] review of the article titled Strategies for Optimizing the Supply of Facemasks dated [DATE] and found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html stated, In settings where facemasks are not available, HCP (health care personnel) might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face. The facility policy titled Policy and Procedure for Suspected or Confirmed Coronavirus (Covid-19) with a most recent revision date of [DATE] stated under the section Personal Protective Equipment (PPE) and Supplies .Full PPE should be worn per CDC (Center for Disease Control) guidelines for the care of any resident with known or suspected Covid-19 per CDC guidance on conservation of PPE. On [DATE] at 8:58 AM, V13 (Medical Director) stated he would expect the facility to follow all CDC guidelines regarding Covid-19 and infection control standards of practice. On [DATE] at 11:50 AM, V2 (Director of Nursing) and V3 (Assistant Director of Nursing) both confirmed the facility has experienced no shortage of any type of PPE at any time and verify N95 grade masks are available for staff use. On [DATE] at 9:14 AM, V1 (Administrator) confirmed the facility has always had N95 grade masks available for staff use since Covid-19 began around March. V1 stated staff can choose to wear either a surgical mask with face shield, or N95 grade mask with face shield despite being on or off the Covid-19 positive units. V1 stated most staff prefer the surgical mask with face shield due to the increased ability to breathe. V1 stated some staff did express their desire to wear an N95 grade mask, although they were not comfortable with the ones the facility provided. V1 stated the facility allowed those staff to be fit tested at the local hospital for an N95 grade mask. On [DATE] at 9:25 AM, V19 (Laundry/Housekeeping) stated she normally works in laundry but is helping with housekeeping also currently. V19 was observed providing housekeeping services on the Covid-19 positive unit with a surgical mask, face shield, gown, and gloves in place. V19 acknowledged an N95 grade mask is offered and available at the facility, but stated she chooses to wear a surgical mask because it is easier for her to breathe and cooler. V19 stated mask choices are available daily when screened at the beginning of the shift, but also throughout the day if the mask becomes soiled or an additional one is needed. On [DATE] at 9:29 AM, V16 was observed as providing housekeeping services on the Covid-19 positive unit. V16 was observed as wearing a gown, gloves, face shield, and surgical mask below her nose, exposing her nares. During this interview, V16 was observed as reaching a gloved hand inside her face shield to pull the surgical mask up over her nose. On [DATE] at 9:58 AM, V20 (CNA) was observed wearing a cloth tie-dye face mask, face shield, and gown while working the Covid-19 positive unit in the facility. V20 acknowledged the facility provides surgical and N95 grade face masks for staff use. V20 stated the tie-dye mask was purchased from a boutique in a neighboring state. On [DATE] at 1:29 PM, V21 (Social Services) was observed wearing a gown, surgical mask, and face shield while working on the Covid-19 positive unit. V21 acknowledged N95 masks are available for use, but stated staff choose if they would like to wear the N95 mask or surgical mask. V21 stated there has been no shortage of PPE at the facility. On [DATE] at 1:03 PM, V22 (LPN) was observed working the Covid-19 positive unit wearing a gown, face shield, and surgical mask. V22 stated the facility has an N95 grade mask available for staff to wear if preferred but are not required. V22 stated staff choose if they want to wear a surgical or N95 grade mask. On [DATE] at 12:58 PM, V23 (Activities Assistant) was observed within 1 foot of Covid-19 positive residents while delivering mail, wearing a surgical mask, face shield, and gown. V23 acknowledged an N95 grade mask is available to use, but stated she chooses to wear a surgical mask. V23 stated she works both the positive and non-positive Covid-19 units currently. On [DATE] at 9:00 AM, the facility was observed and V2 reported the facility has a surplus of all types of PPE, including N95 grade masks. N95 grade masks were observed as being available as well as surgical masks at the staff screening checkpoint. 3. Review of an article on [DATE] titled, Hand Hygiene Recommendations dated [DATE] and found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html stated, Hand hygiene is an important part of the U.S. (United Stated) response to the international emergence of COVID-19. [MEDICATION NAME] hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. On [DATE] at 10:03 AM, V24 (CNA) was observed working the Covid-19 positive unit. During continuous observation prior to V24 exiting the Covid-19 unit, V24 was observed as not wearing gloves, doffing her PPE gown and exiting the Covid unit without completing any hand sanitization. Observation was continued through a window in the door separating the Covid-19 positive and non Covid positive units in which V24 was seen utilizing the facility exit door in which all staff working the Covid-19 and non Covid-19 units use. Alcohol based hand sanitizer was observed as being available at the entrance and exit of both doorways used. On [DATE] at 9:50 AM, V11 (CNA) was observed working the Covid-19 positive unit. During continuous observation prior to V11 exiting the Covid-19 unit, V11 was observed removing her gloves, placing them in the trash, then doffing her gown and exit the door without completing hand sanitization. Observation was continued through a window in the door separating the Covid-19 positive and non Covid positive units in which V11 was seen utilizing the facility exit door all staff working the Covid-19 and non Covid-19 units use, with non-sanitized hands. On [DATE] at 12:48 PM, V25 (LPN) was observed working the Covid-19 positive unit. During continuous observation prior to V25 exiting the Covid-19 unit, V25 was observed as not wearing gloves, doffing her PPE gown and exiting the Covid unit without completing hand sanitization. Observation was continued through a window in the door separating the Covid-19 positive and non Covid positive units in which V25 was seen utilizing the facility exit door all staff working the Covid-19 and non Covid-19 units use, with non-sanitized hands. On [DATE] at 1:45 PM, V1 stated her expectation would be that staff either wash their hands with soap and water or use alcohol-based hand sanitizer after doffing their gown and exiting the Covid-19 positive unit. V1 acknowledged the door in which staff are exiting the Covid-19 positive unit without washing and/or sanitizing is a door that is utilized by all staff within the facility as they enter that door for Covid-19 screening prior to beginning their shift. 4. On [DATE] at 1:10 PM, V20 (CNA) was observed in an open doorway separating the Covid-19 positive from negative hallway of the building. V20 was observed donned in a gown, surgical face mask, and face shield as she was working the Covid-19 positive hallway. V26 (CNA) was observed as being in the same doorway as V20 and donned only in a surgical mask and face shield, as he was working the Non-Covid positive hallway. V20 was observed coming in direct contact with V26, including his clothing during an episode that can be described as horse play where V20 playfully hit V26 in the upper arm and was pushing V26 with her hands. V26 and V20 then returned to their assigned halls and closed the door. On [DATE] at 9:14 AM, V1 stated she spoke with V20 and the facility has re-educated her on infection control practices and cross contamination prevention. 5. On [DATE] at 9:00 AM, R13 was observed exiting the Covid-19 positive unit through the closed double doors and entered the Non Covid-19 positive side of the facility. R13 was observed as being guided back to the Covid-19 unit by V22 after ambulating for a period of less than 5 minutes down the Non Covid-19 positive unit. R13's Clinical Record documents R13 was tested for Covid-19 on [DATE], with a positive test result received on [DATE]. R13 was placed on the facility Covid-19 positive isolation unit at that time. R13's Clinical Record documents a Minimum (MDS) data set [DATE] indicating R13's cognitive level as moderately impaired. On [DATE] at 9:40 AM, V10 (LPN) stated that they do have residents that wander. V10 stated there is no alarm on the interior door, but some residents have a personal wandering device that would sound if they would try to go out the exit doors to the outside. V10 stated they just try to watch the doors to keep Covid-19 positive residents residing on the Covid-19 positive unit from entering the Non Covid-19 side of the facility. On [DATE] at 9:30 AM, V9 (LPN) stated that no doors are alarmed for when a confused resident would possibly pass through the doors from Covid-19 positive unit to the non Covid-19 positive unit. The facility census sheet provided on [DATE] documents 72 residents reside in the facility at this time. An Immediate Jeopardy was identified to have begun on [DATE], when the facility first received V31's confirmation of Covid-19, who had been actively working within the facility and failed to complete effective facility disinfection practices to kill Covid-19. As of [DATE] the facility has had 69 resident cases of Covid-19 and 11 deaths (R1, R8, R11, R12, R14, R15, R16, R17, R18, R19, R20) associated with Covid-19. V1 was notified of the Immediate Jeopardy on [DATE] at 9:10 AM. On [DATE] the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediacy: - Re-education and implementation of the deep cleaning regimen: Completed [DATE] by Maintenance Director, DON, ADON with Housekeeping and Nursing staff - Re-education of housekeeping staff to ensure disinfectant products are utilized per manufacturer guidelines for effective disinfection of COVID-19: Completed [DATE] by Maintenance Director, DON, ADON with Housekeeping and Nursing - Ordered N95 grade face masks to be implemented immediately and provided inservice to staff on the CDC requirements on COVID-19 positive residents: Completed [DATE] by Administrator, DON, ADON - Administrator went to EMA (Emergency Management Agency) in Marion Illinois and picked up 120 - N95 masks. The N95 masks were immediately given to all staff working the Covid unit. - Re-education of staff on the requirements of hand-hygiene associated with COVID-19: Completed [DATE] by DON and ADON with all staff - Re-education of staff on infection control measures to prevent cross-contamination: Completed [DATE] by DON and ADON with all staff - Re-education of staff on the requirements for resident supervision to prevent cross contamination between COVID-19 positive and negative units. One resident who wanders exited the positive unit. This resident is now kept in an area within staff sight; 1:1 activities are being provided as well as ongoing redirection. Completed [DATE] by DON and ADON with all staff - Twice weekly testing is being done (Sunday/Wednesday for residents; Monday/Thursday for staff). All residents tested Negative on [DATE]). Date of Final Completion - [DATE]. Ongoing: Beginning [DATE] at 9:30 AM, the infection control preventionist, and/or designee will monitor the following daily for at least 4 weeks, then weekly until pandemic has ended to ensure compliance is maintained: Observation of deep cleaning for proper procedure. - Observation of use of approved disinfectant products to ensure utilized correctly - Observation of proper use of N95 masks - Observation of proper hand hygiene - Observation of resident care to ensure prevention of cross contamination - Observation of residents who wander to ensure adequate supervision is maintained to prevent cross-contamination between COVI,[DATE] positive and negative units.

Based on interview and record review, the facility failed to assess a confused, agitated resident at high risk for falls and failed to restrict a resident's access to potentially hazardous chemicals for 1 resident of 3 residents (R5) reviewed for accidents and hazards in the sample of 10. This failure resulted in R5, while agitated and confused, falling out of bed and fracturing his pelvis. Findings include: R5's Face Sheet documented an admission date of [DATE] and a discharge date of [DATE]. R5's Admission [DIAGNOSES REDACTED]. R5's Fall Risk assessment dated [DATE] documented a score of 13, indicating R5 was at high risk for falls. R5's Care Plan dated 06/29/20 documented a problem area of (R5 is at) Risk for falls due to impaired mobility and having a history of falls, and (R5) is at risk for constipation due to decreased mobility, medication side effects, and pain. A 06/30/20 Brief Interview for Mental Status documented a score of 4, indicating R5 experienced severe impairment in cognition. R5's July 2020 Medication Administration Record [REDACTED]. 1. A Nursing Progress Note dated 07/04/20 at 9:45pm, authored by V9 (Registered Nurse) stated (R5) rolled out of bed this night . Transferred to hospital for further evaluation. A Fall Report dated 07/04/20 stated, (R5) was laying on the floor, confused at intervals, unable to explain why he was getting out of bed. A 07/04/20 Emergency Department Note stated, (R5 was) Brought to emergency room for evaluation of a fall and lethargy. Patient has been more lethargic all day today. Patient rolled out of bed and landed on the left side. A CT (Computed Tomography) (of the) Abdomen (and) Pelvis dated 07/05/20 documented, There is a large quantity of stool within the rectum .Fecal impaction is not excluded .A jagged fracture is present at the right inferior pubic ramus which is new as compared to 10/02/19. On 08/04/20 at 8:30am, V19 (R5's family member) stated R5 was admitted to the facility in late June 2020. V19 stated that a few days after R5's admission, extended family members reported to V19 that they saw R5 during a window visit (Covid-19 precautions) and R5 looked sick and told them They're killing me here without further explanation. V19 stated on 07/05/20 she was contacted by the facility that R5 fell out of bed and was sent to the emergency room , where it was discovered that R5 had fractured his pelvis in this fall. On 08/06/20 at 2:35pm, V13 (Certified Nursing Assistant/CNA) stated she was working evening shift (2:00pm-10:00pm) with R5 on 07/04/20 at the time of the fall. V13 stated V14 (CNA) was working the hall with her. V13 stated during the evening, R5 was very confused, shaky, and agitated, and this was not his baseline behavior. V13 stated R5 historically had difficulty communicating and was not able to tell them what was going on with him. V13 stated it was the Fourth of July holiday, R5 was a veteran with a history of [MEDICAL CONDITIONS], and V13 had wondered if hearing fireworks had anything to do with his presentation that evening. V13 stated from 6pm on, she and V14 asked V9 several times to assess R5, and V13 and V14 told V9 they thought perhaps R5 needed to go to the hospital. V13 stated V9 said she was aware R5 had [MEDICAL CONDITION] and maybe the fireworks were upsetting him, and she was not sure what reason we would have to send him out. V13 stated she believed V9 would have briefly seen R5 during medication pass that evening, but she does not know if V9 assessed R5 or called the physician about him, as V9 did not communicate that to her. V13 stated about an hour before shift change, she and V14 repositioned R5 toward the wall and tried to comfort him. V13 stated R5 was upset, agitated, and more confused. They then put the bed in the lowest position and left the room. V13 stated R5 did not have a fall mat listed as an intervention. About 30 minutes before shift change, V13 was doing rounds and saw R5 lying on the floor, bleeding from his left elbow. V13 stated R5 was unable to state what had happened. V13 stated she called for help, V9 responded, assessed R5 and called the ambulance, and R5 was transported to the emergency room . On 08/07/20 at 4:00pm, V14 corroborated V13's account of the events of 07/04/20 as outlined above. V14 stated by the time she and V13 put R5 to bed, R5 was, Shaking and incoherent. On 08/06/20 at 1:45pm, V9 stated she was working with R5 from 6pm on 07/04/20 but does not remember any of the related details. V9 stated she cannot remember if R5 had any fall precautions in place. V9 stated she cannot remember if R5 was a high risk for falls but Most of our residents are. V9 stated she could not remember any details about what R5's status was that evening. On 08/07/20 at 9:50am, V17 (Medical Doctor/R5's Physician) stated R5 was a newly admitted resident and he had not yet seen him but his Nurse Practitioner, V18, had done a new patient evaluation on R5. On 08/07/20 at 1:15pm, V18 stated she saw R5 as a new patient on 06/29/20 at the facility. V18 stated R5 had multiple serious medical problems including [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] Disorder, [MEDICAL CONDITION] secondary to Pneumonia. R5's Nursing Progress Notes for the day of 7/4/20 fail to document any of the confusion, agitation, or any other behaviors R5 was experiencing that night before he fell . On 08/11/20 at 9:00am, V2 (Director of Nursing) acknowledged R5's confusion, [MEDICAL CONDITION], and bowel impaction could have been contributing factors in his fall. V2 stated that on 07/04/20 when V13 and V14 realized R5 needed assessment by V9, they should have completed an ALERT form on the computer system which prompts the nurse to assess the resident. V2 confirmed this had not been done and R5 was therefore not assessed. V2 verified R5 had not had a bowel movement in six days at the time of the fall. V2 stated when a resident does not have a bowel movement in three days time, the computer system flags an alert for staff to assess the resident. V2 stated this did not occur in R5's case and she is unsure why. An undated Notification of Resident Change in Condition Policy stated, It is the policy of this facility to promptly notify the resident, their legal representatives, and attending physicians of changes in the residents health condition (including)a significant change in the residents physical, mental, or psychosocial status.i.e. deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complication .Clinical change in condition is determined by resident visualization, medical record review, clinical assessment findings, and care plan review. 2. On 08/04/20 at 8:30am, V19 stated she obtained R5's medical records from the facility and in reviewing them found that on 06/29/20, R5 had accidentally ingested wound cleanser. R5 stated the documentation stated the facility tried to contact her about this incident without success, which V19 stated was possible. V19 stated considering R5's confused mental status, V19 was surprised R5 had access to wound cleanser. R5's Nursing Progress Note authored by V16 (Licensed Practical Nurse), dated 06/29/20 at 9:52am documented, .(R5) was drinking (trade name) wound cleanser, notified (V18), attempted to call (V19), unable to contact, called poison control (who stated) solution is basically benign. A corresponding Incident Report stated, Nursing Description: (R5) was drinking roommates cleaning solution. Resident Description: 'I thought it was my water'. On 08/05/20 at 5:30pm, V16 stated R5 was a new resident and she wasn't very familiar with him when the above referenced incident occurred. V16 stated R5's roommate had activated the call light and reported R5 was drinking wound cleanser. V16 stated R5 had gotten into a supply cart on his roommates side of room which had peritoneal [MEDICAL TREATMENT] supplies on it including sealed bottles of solution used to cleanse the [MEDICAL TREATMENT] port site. V16 stated R5 told her he thought it was bottled water. V16 stated she didn't realize R5 was confused enough to do something like this. V16 stated staff then immediately removed the supplies from the room and stored them in a locked area. On 08/07/20 at 1:15pm, V18 stated she was still at the facility on 06/29/20 when she was informed by staff that R5 had accidentally ingested wound cleanser. V18 stated poison control was called, she again evaluated R5, and there were no sequelae to this incident. V18 stated R5 drank the wound cleanser as due to his confused mental state he believed it to be a bottle of water.

Based on record review, and interview, the facility failed to safely transfer from the bed to a wheeled chair 1 of 3 residents (R4) reviewed for safe transfer in the sample of 8. This failure resulted in R4 sustaining comminuted fractures of the right distal fibular and tibial diaphyseal and fifth metatarsal head fracture requiring hospitalization and surgery to repair the fractures. The facility also failed to follow its own policy and procedure for transfers/gait belt use. Findings include: 1. R4 a [AGE] year old woman was admitted to this facility on 12/16/2013 according to facility admission records of that date. R4's Physician order [REDACTED]. According to the facility's Incident/Accident log of 12/26/2013, R4 was transferred by E7 (Certified Nurse Assistant/CNA) from the bed to her wheeled chair, R4 sustained an injury to her right leg. Review of R4's record notes, the Minimum Data Set/MDS dated [DATE] identifies R4 to require extensive assistance of two staff for transfers. R4's Care Plan with an initiation date of 12/16/2013 indicates a Focus of "requires ext. assist of 2 for all transfers, with an intervention to provide 2 assist with all transfers". The MDS Kardex Report (undated) notes transfers, extensive assistance, two person physical assist. Review of E7's Clinical Staff Orientation Checklist and Sign Off document fails to note date/time or signature of E7 for topics completed. Review of the facility training records titled Transfer and Reviewing CNA kardex dated 12/28/2013 notes by signature that E7 was in attendance and did receive this training, this training was provided after the incident of 12/26/2013. Review of facility policy/procedure titled Gait Belt, dated 5/26/2009 notes "gait belts are utilized on all residents requiring assistance with transfers". During an interview on 1/15/2013 at 3:00 P.M. with E7, when asked about the incident on 12/26/2013 when R4 was injured, E7 stated, "I was working with another aide E8 (CNA) and she told me to go and get R4 up for dinner. I went to move her from the bed to the wheeled chair, not using a gait belt, I first moved her legs off the bed and put her feet on the floor, I used a bear hug to pivot her into the chair, as I pushed the chair back I noticed blood dripping onto the floor, I immediately called for help. I don't know how she got injured, I did not do anything wrong, I used the transfer technique I was taught by E8. She (R4) never yelled out in pain, I did not hear a pop. When asked if she knew that R4 required extensive assist of 2 person for all transfers E7 stated, "No one told me that, I never saw her care plan, and I was never shown how to read the CNA kardex." When asked about transfer training, E7 stated, "I received training during orientation but the first day of orientation I missed all the nursing stuff because of a family emergency. I had to leave work early that day." E7 stated, "After the incident on 12/26/2013 (Thursday), and after giving her statement to administration she was sent home and stayed off work the next day (Friday), adding she was off on Saturday and Sunday, and she was allowed to return to work the following Monday after being told the incident was unsubstantiated." E7 stated, "She began her employment at this facility on 12/3/2013." On 1/15/2013 at 2:30 P.M. E8 (CNA) was interviewed regarding R4 and the incident on 12/26/2013. E8 stated, "She has worked at this facility 7 months prior to the incident of 12/26/2013. E8 stated, "Staff were getting residents up and ready for dinner, and she asked E7 to "get R4 ready for dinner". E8 denied asking E7 to get R4 up. Shortly afterwards she heard E7 yell for help and E8 responded. When E8 entered the room R4 was sitting in her chair in the middle of the floor, her foot was dangling, blood was on the floor and the bandage on her right leg was soaked in blood, there was no blood in the bed, there was no blood on the chair or wheels on the chair." E8 stated, "She called for the nurse and applied towels and pressure to control the bleeding. E8 stated, "The nurse responded and provided care to the leg and 911 was called. When the ambulance arrived R4 was taken to the local hospital. E8 stated, "She then asked E7 what happened, and E7 said, "I don't know what happened, I did not do anything to hurt her (R4)." When E8 was asked if she had trained E7 on transfers, E8 stated, "Yes, but only on the residents we had worked on together. E9 (CNA Supervisor) was interviewed on 1/15/2013 at 1:00 P.M.. When asked about R4, and the incident of 12/26/2013, E9 stated, "He was working in another area of the building and was notified of the incident after it happened. E9 stated, "He asked E7 how the injury occurred, and E7 stated, "I don't know how it happened I did not do anything to hurt her." E14 (CNA) was interviewed by telephone (this was her day off), on 1/15/2013 at 12:40 P.M. When asked about R4, and the incident of 12/26/2013, E14 denied working on that date stating "I was on vacation for 5 days". When asked about training E7 on transfers, E14 denied training E7 on transfers. Z1 (Physician) was interviewed by telephone at 2:00 P.M. on 1/15/2013 and was asked about possible causes for the injury to R4. Z1 stated, "She had reoccurring falls at home, I was told by the Hospitalist, that she was being transferred from the bed to the wheeled chair and I cannot say what caused the fractures. I don't know what happened, don't know if there was any abuse, there are new staff there and I hope they will be able to make sure everyone receives the care they deserve."

Based on observation, record review and interview the facility failed to collect accurate data regarding falls, identify trends and risk factors regarding the circumstances surrounding falls, failed to implement fall interventions, and monitor and modify the effectiveness of interventions that are established for residents who continued to experience multiple falls for 2 of 6 residents (R3 and R4) reviewed for falls in the sample of 6. These failures resulted in R3, who receives Coumadin and Aspirin daily, falling 8 times from 08/9/13 to 10/6/13 with two of the falls resulting in an Intracranial Bleed. On 10/06/13, R3 fell out of a chair and was hospitalized in the Intensive Care Unit with an Intracranial Bleed. At the time of this survey, R3 remains hospitalized under the care of Hospice and is not expected to live, according to an interview with Z2, (Hospitalist/ Registered Nurse) on 10/17/13 at 8:50 AM. These failure resulted in an Immediate Jeopardy for R3. On 10/09/13 at 4:15 PM , E3 (Registered Nurse) provided a Resident Census Sheet dated 10/08/13 that indicated the facility has 87 of 122 residents who are considered to be at high risk to fall. E3 stated residents are considered to be at a high risk for falling if they score 10 points or higher on the facility fall risk assessment form. The Incident Logs for October 2013, September 2013 and August 2013, note R3 and R4 are the only residents who sustained multiple falls with injuries. While the Immediacy was removed on 10/09/13 at 5:45 PM, the facility remains out of compliance at a Severity Level 2 as the facility continues to educate staff daily regarding proper interventions to follow for residents who have fallen and continue to monitor and evaluate the effectiveness of the interventions. Findings include: 1. R3's Physicians Order Sheet (POS) dated 10/01/13, note R3 was admitted to the facility from home on 07/26/13 with the following Diagnoses: [REDACTED]. R3's October, 2013, physician's orders [REDACTED]. A Progress Report dated 09/26/13 notes R3 scored a 17 on the Fall Risk Assessment. The facility Fall Assessment form documents a score of 10 or above is considered to be at high risk for falls to occur. According to R3's Incident/Accident Reports, R3 has fallen eight times between 08/09/13 and 10/5/13, with six of those falls occurring between 4:30 PM and 9:30 PM and R3 fell from a chair during five of these six falls. All of the falls have been unwitnessed according to these Incident/Accident Reports. There is no evidence in the facility fall investigations, that the facility analyzed R3's falls for patterns and trends when developing interventions to prevent reoccurrence of falls. E1 (Administrator) stated on 10-10-13 at 2 PM that falls are looked at each morning for those occurring the day before and they only look at that fall and interventions to be added to the care plan. The falls are as follows. A. The Fall reports document on 08/09/13 at 1:45 PM , R3 fell from a wheel chair in his room. The fall was unwitnessed. R3's Care Plan notes on 08/09 /13 a new intervention that staff will not leave R3 unattended while up in the wheel chair. B. An Incident and Accident Report dated 08/14/13 at 4:30 PM documents R3 fell from a wheel chair in his room and the fall was unwitnessed. A pressure pad alarm was sounding and alerted staff of this fall. The Fall Report contradicts the Incident and Accident Report regarding this same fall. This report notes R3 fell on [DATE] at 4:30 PM , this report does not specify if R3 was in bed or in a chair. The Fall Report notes E12 (Certified Nurse Aide) and E13 (Certified Nurse Aide) witnessed the fall. An undated Investigation Conclusion relating to the 08/14/13 fall notes, R3 was in a wheel chair in his room and staff found him laying on the floor with the pressure alarm sounding, The plan of Action notes R3 will be toileted before and after meals. C. The Incident/Accident Report dated 08/14/13 at 5:40 PM documents R3 was alone in his room in a wheel chair. Staff heard the pressure pad alarm sound and found R3 standing in the doorway. Fall Report notes dated 08-14-13 at 5:40 PM indicate as staff approached R3 he fell before E11 could reach him. R3 was laying on the floor unresponsive. R3 was sent to the hospital and admitted with Intracranial Bleeding. The Fall report contradicts the Incident and Accident Report regarding this same fall. This report dated 08/14/13 at 5:40 PM notes E12 (Certified Nurse Aide) heard an alarm going off, saw R3 in the doorway of his room and he fell over onto floor in the hallway and was unresponsive. The Post Fall Investigation for R3's 08/14/13 fall at 5:40 PM indicates R3 tripped while ambulating in the hall way. Page two of this report notes R3 was laying in bed watching television at 5:30 PM when staff last saw R3. The Investigation Summary dated 08/14/13 notes R3 was sitting in his room watching television when a CNA (not specified who) last saw R3. The recommended interventions noted, on the undated , Post Fall Management form regarding the fall R3 sustained on 08/14/13 at 5:40 PM, is to increase activities with supervision,. The Care Plan initiated on 08/02/13 that was revised on 10/07/13 does not include an intervention to increase activities with supervision. The undated MDS Kardex Report, that hangs on R3's closet door, does not include an intervention to increase activities with supervision for R3, D. According to the facility Incident/Accident Report dated 09/06/13 at 6:45 PM, R3 fell from bed. E3 walked past the room and saw R3 on the floor. R3 was not injured according to this incident report. R3's Care Plan dated 08-02-13 does not address a plan with interventions to keep R3 from self-transferring nor is there an assessment to determine if there are common factors with R3's falls. No new interventions were added to this Care Plan. E. According to the facility Incident/Accident Report dated 09/12/13 at 6:00 PM, R3 fell from the wheel chair in the dining room. Staff heard the alarm sound and saw R3 stand up and fall backwards. R3 was not injured according to this incident report. R3's Care Plan dated 08-02-13 does not address a plan with interventions to keep R3 from self-transferring nor is there an assessment to determine if there are common factors with R3's falls. No new interventions were added to this Care Plan F. According to the facility Incident/Accident Report dated 09/24/13 at 9:30 PM, R3 was alone in his room and fell out of a reclining chair, and the pressure alarm was sounding. R3 was not injured according to this incident report. R3's Care Plan dated 08-02-13 does not address a plan with interventions to keep R3 from self-transferring nor is there an assessment to determine if there are common factors with R3's falls. No new interventions were added to this Care Plan G. According to the facility Incident/Accident Report dated 09/27/13 R3 fell from bed at 5:30 AM. R3 was not injured according to this incident report. R3's Care Plan dated 08-02-13 does not address a plan with interventions to keep R3 from falling out of bed nor is there an assessment to determine if there are common factors with R3's falls. No new interventions were added to this Care Plan. H. An Incident and Accident report dated 10/05/13 at 7:00 PM notes R3 fell from a chair, hit his head and was admitted to the hospital's Intensive Care Unit with Intracranial Bleeding. The 10/05/13 Fall Report notes the fall was unwitnessed and occurred in the Activity Room. The same report also notes that the fall occurred in R3's room. During an interview with E6 ( Licensed Practical Nurse) at 2:30 PM on 10/09/13 , E6 confirmed R3 was sitting in a high backed chair in the Activity room asleep after supper. E6 said she could not see R3 from where she was sitting, working on a computer ,at the nurses station. E6 said she heard the pressure alarm sound, when she got to where R3 was, in the Activity Room , R3 was on his hands and knees,on the floor, trying to stand up. E6 stated no other staff were present in the activity room at this time. E6 said two residents with Dementia (No recall of identify of residents) were sitting on the couch, beside R3's chair, when the fall occurred. E6 stated she noticed a red area to the back of R3's head. E6 said she and E7 (Licensed Practical Nurse) began to evaluate R3's Neurological Responses and when R3's Blood Pressure rose and they noticed one of R3's eyes was blood shot they sent R3 to the hospital. E6 said R3 was admitted to the hospital's intensive care unit, with a [DIAGNOSES REDACTED]. E6 said the chair R3 was sitting in was facing the hallway and staff could see R3 when they walked by. E6 also said R3 was on 15 minute checks. A Preliminary Report History and Physical dated 10/06/13, notes R3 had Intracranial bleeding causing significant mass effect in the range of 10 millimeters. Supertheraputic anticoagulation was corrected due to the Intracranial Bleed, with Vitamin K. An Operative Report dated 10/06/13 notes R3 had a large chronic Subdural Hematoma causing midline shift. A Bur Hole Craniotomy for evacuation of chronic Subdural Hematoma and a Titanium Cranioplasty. During an interview with Z2 (Hospitalist Registered Nurse) at 8:50 AM on 10/17/13, Z2 said R3 sustained a severe Intracranial Bleed that is expected to cause death. Z2 said R3 was admitted to the Hospice Care program on 10/07/13, and is currently in the hospital on the medical floor. Z2 said R3 was anticipated to die within one week of the Injury. R3's Care Plan with fall interventions initiated on 08/02/13 and revised 10/07/13 do not identify 15 minute checks as an intervention for R3's falls. The Care Plan does indicate that R3 should not be unattended while in a wheel chair. During an interview on 10/09/13 at 12:45 PM E8 (Certified Nurse Aide) stated R3 needed some one to watch him at all times 24/7 and that R3 needs one on one care. E8 said her partner had gone to lunch when R3 fell on [DATE] and she was helping E7,(Licensed Practical Nurse), they were in the process of sending another resident to the hospital. E8 stated they heard the chair alarm sound around 7:00 PM. E8 said she saw R3 kneeling on the floor and E 6 was assisting him. During an interview with E7 (Licensed Practical Nurse) at 12:45 PM on 10/09/13 she stated they kept R3 out where some one could see him at all times. E7 said R3 needed to be redirected, assisted to walk or occupied in some way at all times unless he was asleep. E7 said R3 has a very unsteady gait and is unbalanced. E7 stated on 10/05/13, R3 had been in the wheel chair but he wanted to sit in the high back chair and read the newspaper. E7 said they put him in the chair and put the pad alarm in place. E7 said the last time she saw him it was around 6:45 PM and he was looking at a newspaper. When asked what interventions are to be used with R3, E9 (Certified Nurse Aide) at 9:00 AM on 10/10/13, stated R3 needed to be in view of staff at all times. E9 said R3 required staff to assist him to walk, offer snacks, books, newspapers and busy boxes. E9 said they would try to wear him out by walking him in the evenings. E9 said she has worked at the facility for six months and when working with R3 the longer the day goes on the more active R3 gets. During an interview with E2 (Director of Nursing) at 3:00 PM on 10/09/13 she stated R3 is very impulsive, and not steady on his feet. R3 is not safe to to walk without assistance from staff. E2 stated if R3 is in a chair or wheel chair he should be in view at all times unless he was in bed asleep. On 10/10/13 at 2:55 PM, E1 (Administrator) and E2 (DON) stated the nurse on duty at the time the fall occurs completes an assessment of the resident and the circumstances surrounding the fall. The nurse fills out a post fall assessment. The Inter-Disciplinary Team comprised of the Director of Nursing , Administrator, Social Service Designee, Activity Director, Physical Therapist, and Restorative Aide, review the assessments for patterns and root cause analysis. The Inter Disciplinary Team determines what interventions to put in place after the fall occurs and they convey it to the Nurse Aides by updating the Kardex in residents rooms. During an interview with E14 ( Licensed Practical Nurse) on 10/08/13 at 12:40 PM E14 said fall interventions are posted on the inside of resident closet doors so all staff can have easy access to the current fall interventions used to prevent falls for residents who are in the Falling Star Program. The MDS Kardex Report that was hanging on R3's closet door listed the following fall interventions; 08/10/13 staff are not to leave R3 unattended in the wheel chair. On 08/14/13 Resident will be toileted after meals and as needed. 09/06/13 fifteen minute checks. 09/12/13 leg rest to be removed while resident is self propelling to avoid tripping. 09/24/13 pressure pad alarm to reclining chair place resident in bed when drowsy. 09/26/13 up and dressed in wheel chair upon awakening to prevent resident from getting up unassisted. 10/05/13 resident must be in view at all times due to impulsiveness/safety. R3's Care Plan initiated on 08/02/13 and revised on 10/07/13 notes R3 is at high risk for falls due to impaired safety awareness, unsteady gait, impaired balance and daily use of medications that could cause dizziness. The 10/01/13 Physician order [REDACTED]. According to the Drug Information Handbook for Nursing, 8th Edition from Lexi-Comp, these medications can cause weakness and dizziness. The only interventions noted on R3's Care Plan are; 08/02/13 offer and assist to the toilet frequently and as needed, 08/02/13 assist of 1 for transfers, 08/02/13 keep call light in reach, 08/02/13 monitor for side effects of medication that could cause dizziness, drowsiness, 08/09/13 remind staff not to leave resident unattended while in wheel chair, 08/13/13 elevate foot pedals while in wheel chair and alarming pressure pad to wheel chair, 08/14/13 resident will be taken to the toilet before and after meals and as needed, 09/13/13 remove wheel chair pedals while resident self propels to avoid tripping , 09/24/13 pressure pad alarm to reclining chair, place resident in bed when drowsy, 09/24/13, pressure pad to bed, 09/26/13 up and dressed in wheel chair upon awakening, 09/26/13 monitor neuro checks, 10/05/13 resident must be in view at all times due to impulsiveness/ safety. The Care Plan also notes R3 is on Anticoagulant (blood thinning) therapy due to the [DIAGNOSES REDACTED]with interventions in place for staff to monitor for signs of complications of Anticoagulant therapy. The facilities fall post fall assessment do not identify R3's Anticoagulant therapy. 2. R4's Care Plan for falls dated 04-30-13 document that R4 is high risk for falls, has balance problems while standing and walking, utilizes assistive device, has decreased muscle coordination, has change in gait pattern, has vertigo, and uses narcotics and psychotropic medications. The physician's orders [REDACTED]. R4 has been assessed as high risk for falls since 04-30-13 according to the facility fall risk assessment. According to R4's Care Plan dated 07-01-13, R4 had falls on 04-26-13 (2 falls), 06-22-13, 08-14-13 and on 09-09-13 (2 falls). The falls are as follows. A. The facility Incident/Accident Report for 04-26-13 documents, that at 7:15 PM on 04-26-13, R4 tried to get up from her wheel chair in the front lobby, the wheel chair rolled and R4 was found on the floor. The Post Fall Investigation documents that the brakes were unlocked, the chair alarm sounded during this incident, no injuries noted, and R4 could not indicate what had happened. R4's Care Plan for falls dated 04-30-13 was not updated to include a plan with interventions on the Care Plan to address R3's self transfer from her wheel chair. B. The second fall for R4 on 04-26-13 with no time given, indicates on the facility Investigation Conclusion documents that R4 was taken to her room by staff, the staff left the room and R4 attempted to self transfer from wheel chair to bed after the supper meal. The facility Post Fall Management Form dated 04-26-13 with no time given documents the root cause as attempted to self transfer and wanted to lie down after the supper meal. The intervention was to offer to lay R4 down after the supper meal. R4's Care Plan for falls dated 04-30-13 was not updated after this fall to include a plan with interventions to address how soon after the supper meal R3 is to be put to bed and R3's unsafe self- transfers after the evening meal on 04-26-13. C. The Investigation Conclusion to the Incident Report for R4's fall at 7:15 PM on 06-22-13 documents R4 was in her room and found to have slid out of R4's wheel chair to the floor in her room. This report documents that the root cause was that R4 slid out of the wheel chair. The intervention given was to put a non-skid fabric in her chair. There was no evaluation of what R4 was doing before the fall and/or if R4 was trying to transfer herself. R4's Care Plan for falls dated 04-30-13 does not include interventions to increase supervision after having another unobserved fall nor is there any indication that R4's medications were reviewed at that time. D. The facility Investigation Conclusion dated 08-14-13 documents that at 9:35 am on 08-14-13, R4 was found by staff laying on the floor after attempting to self ambulate. This report lists weakness/fainted as a predisposing physiological factor and again documents that R4 had an unobserved fall. Review of R4's X-ray report dated 08-14-13 documents that R4 sustained an "Acute nondisplaced fracture of medial malleolus with adjacent soft tissue swelling. In comparison to prior study, findings are new." The facility Post Fall Management Form for the 08-14-13 at 9:35 am fall documents a root cause determination as "Res (Resident) attempted to get self up for either toilet/bed." New interventions to be implemented were to toilet R4 every 2 hours and to lay R4 down for naps when fatigued. R4's Care Plan dated 07-01-13 has a problem of "Resident is High risk for falls r/t (related to) Paralysis, Poor communication/comprehension, balance problems. Interventions on this Care Plan up-dated due to the 08-14-13 fall are toilet frequently, and lay down for naps when fatigued. There is no plan to increase supervision to prevent R4 from self transferring nor is there any comprehensive assessment of these falls to determine if there are common factors. E. The facility Incident Investigation report documents a fall on 09-09-13 at 6:45 am. This report documents that R4 was found on the floor mat next to bed on the right side of the bed. No injuries were noted and R4's brace was in place to the right lower extremity according to this report. The Investigation Conclusion for this 09-09-13 fall stated, "It is believed due to the weight on the leg with the brace, she put her leg over the bed and by gravity kept moving until she landed on the mat." There is no assessment of the leg brace used since the 08-14-13 fall as an environmental hazard for R4 or any measures put in place to keep the leg in bed to prevent a reoccurrence nor is there any comprehensive assessment of these falls to determine if there are common factors. F. The facility Incident Investigation report dated 09-09-13 at 5:35 PM documents that R4 was found lying flat on her back in the short hall and R4's right leg was bent in toward her body. The root cause was determined to be that R4 was self propelling wheel chair down a slight incline. An X-ray dated 09-09-13 has findings of "A complete oblique fracture is identified involving the distal third of the right femur. Posterior medial displacement of the distal fracture fragment is noted." R4's Care Plan dated 07-01-13 has a problem of being high risk for falls. The interventions added after the 09-09-13 falls were to encourage to attend activities, offer assistance to and from meals, provide for resident needs. There is no comprehensive assessment of R4's falls to determine if there are common factors and/ issues/changes in condition that might contribute to falls nor was there a plan initiated to address R4's non-compliance with not self transferring. R4's physician's orders [REDACTED]. According to the Drug Information Handbook for Nursing, 8th Edition from Lexi-Comp, Sonata can have the side effect of Dizziness, Vertigo, Light Headedness; Celexa can have the side effect of Dizziness; and Xanax can have the side effect and "has been associated with falls and traumatic injury and should be used with extreme caution in patients who are at risk of these events (especially the elderly)". The facility failed to take this information into consideration as a possible contributing factor in R4's falls. E2 on 10-10-13 at 10:30 PM stated that she did not know if there were any pharmacy recommendations on these specific medications pertaining to R4's falls. E2, Director of Nurses, verified on 10-15-13 at 8:30 am that R4 had falls on 04-26-13, 06-22-13, 08-14-13, and 09-09-13. E2 also stated during this interview that all interventions are listed on the care plan. 3. E1 (Administrator), E2 (Director of Nursing), E3 (Registered Nurse Clinical Nurse), and E5 (Regional Director of Operations) were notified of the Immediate Jeopardy on 10/09/13 at 3:14 PM. The Immediate Jeopardy was determined to have begun on 10/05/13 at 7:40 PM when R3 fell out of a chair and hit his head. R3's blood pressure became elevated and the white area of R3's eye became red. R3 was admitted to the hospital in the intensive care unit with a [DIAGNOSES REDACTED]. On 10/09/13 between 4:35 PM and 5:35 PM , the surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: (A) During an interview with E3 (Registered Nurse Clinical Nurse) at 5:00 PM, on 10/09/13, E3 said the records and residents R1 , R2, R4 and R6 were reassessed by E2, E3 and E5 to validate the accuracy of incident records, modify the interventions and review for trends related to falls. (B) During an interview with E3 at 5:00 PM on 10/09/13, The residents Care Plans were updated, as well as the Kardex files in the residents rooms. E3 said , E1, E2 , E3, E4, and E5 determined after reassessing the residents fall risks that 87 residents were assessed to be at high risk for falling. On 10/10/13 at 9:20 AM, E3 said they reviewed incident reports and determined that a large number of falls do occur in the evening. They implemented a plan, to engage residents who are at risk to fall , in an organized group activity that will begin after the residents eat supper. (C) The re-education was started on 10/10/13. Staff are required to attend The re-education programs before they can begin work. The content of the re-education program was a review of the facilities Falling Star Protocol, Fall Prevention Program and the importance of following individual residents fall interventions. Re-education will be completed by 10/10/13 (D) Staff will also be required to attend re education programs daily at 6:30 AM , 1:00 PM and 3:00 PM for the next few weeks to review information regarding residents who fall and to assess the appropriateness of the interventions. (E) The inter-disciplinary team is reviewing incidents daily to establish trends, root cause, and validate the accuracy of incident/accident reports. (F) The Quality Assurance Committee will review the incidents and accidents reports monthly and as needed to determine the effectiveness of the process and revise them as needed. (G) The facility will conduct audits to ensure that residents who are at risk for falls have interventions in place as per the plan of care. Audits will be conducted by the Director of Nursing/designee daily for 4 weeks, then 3 times a week until the facility has sustained compliance. Findings will be presented to the Quality Assurance Committee for 3 months for review and recommendations.

A. Based on interview and record review, the facility failed to implement interventions put in place for falls, identify effective interventions, include new interventions added with falls to the care plan and failed to include each fall on the care plan, to prevent recurrent falls for one of ten residents (R1) reviewed for falls in the sample of 24. These failures resulted in R1 being sent to the emergency room and diagnosed with [REDACTED]. The findings include: R1's Minimum Data Set, ((MDS) dated [DATE], notes 2 falls with no injury since the last review. According to the facility Accident/Incident Tracking logs for 2013, R1 had a total of eleven falls from 01/01/2013 through 05/31/2013 as follows: 01/04/2013 at 11:30am, R1 tripped over the floor mat R1 was carrying. The intervention for this fall is for the floor mat to be secured to the floor with tape. 1/30/13 at 5:55 a.m., R1 was found sitting in the floor in the hallway. R1 received an abrasion to her forehead. R1 received a dose of ativan at 5:00am on this date so the intervention for this fall is to ask the MD for a dose reduction of ativan. Review of the Physicians Orders for January 2013 - July 2013 shows the same dosage of Ativan that R1 was on at the time of this fall. 02/03/2013 at 5:00pm. R1 was found sitting in the floor in the dining room. No injuries noted. The only intervention is to keep resident in view as much as possible. 02/04/2013 at 2:10am. R1 attempted to stand up from sitting on the bed. R1 obtained an abrasion under the right eye and a "goose egg" on forehead. The interventions for this fall are to use alarm in bed, check batteries and use seat belt. 02/05/2013 at 6:08am. R1 was found in the floor in the doorway of her room. Injuries were a hematoma to the right side of the forehead and bruising to right side of the face. R1 was evaluated in the emergency room and returned to the facility .The intervention for this fall is to educate the staff about having the alarm in place. The Incident / Accident Report dated 02/05/2013 shows that the intervention to use an alarm did not happen at this time and a fall did occur. The immediate intervention implemented to prevent re-occurrence is for the alarm to be in place. On 7-18-13 at 1:00 p.m., E6 stated that she was not sure why the alarm was not used but the staff has been inserviced to use it. 02/27/2013 at 3:40am. R1 was sitting in the floor. No injuries noted. The intervention for this fall is to use a body pillow when R1 is in the bed. 03/07/2013 at 9:45am. R1 was in the hallway and turned over the wheel chair. R1 obtained a knot on the right side of the forehead. Antitipper bars were attached to the wheel chair. 03/25/2013 at 3:20am. During transfer with assist of a Certified Nurse Aide, R1 became combative and was lowered to the ground. No noted injuries. The only interventions are to provide calm, quiet environment with reassurance and train staff. 04/15/2013 at 12:45 a.m. R1 was found beside her bed. No injuries noted. The only intervention is to do hourly checks on R1 and a bladder wheel (a three day voiding diary). 04/18/2013 at 11:00 p.m. R1 fell in her room. R1 obtained a knot on the right side of the forehead. The only interventions are to do fifteen minute checks and a bladder wheel. 05/14/2013 at 1:00am R1 fell resulting in an emergency room visit. R1 had a hematoma on the right side of the forehead, red area on the left knee and red area on the right shoulder. R1 had a large amount of bleeding from her nares. R1's nose was edematous. R1 was diagnosed with [REDACTED]. The room number on the incident/accident reports are the same as R1's current room number as observed on 7-17-13 at 9:00 a.m. Review of R1's Care Plan last dated 05/14/13 showed the falls for R1 were not always included as part of R1's Care Plan, the falls for 01/30/2013 and 02/27/2013 are not listed on the Care Plan. The interventions that were put into place as indicated on the incident/accident reports were not always included as part of R1's Care Plan. The following interventions that are listed on the Incident / Accident Reports but are not on the Care Plan are to use a body pillow, ask about reducing Ativan, keep resident in view, and staff education for alarm in place. Review of the Occurrence and Event Policy with revision date of 05/14/2013 states it is policy of Christian Homes, Inc. to provide a safe environment that strives to eliminate hazards and to provide adequate care, supervision and assistive devices to prevent accidents. E6, (LPN, Care Plan Coordinator) was interviewed on 07/18/2013 at 1:00pm. E6 said that she thought all of the incident dates and interventions were listed on the Care Plan. E6 said she had recently updated the care plans and must have removed them. E8 (Assistant Director of Nurses) on 7-19-13 at 10:00 a.m. when asked if the facility had reviewed R1's medications in relation to the falls, E8 presented 3 separate documents, with fax to: the facility pharmacy name listed (each with it's own date-one dated 12-30-12, one dated 1-4-13 and one dated 4-18-13) titled "Medication Review Facsimile Cover Sheet". The only information contained on these Medication Review Facsimile Cover Sheet documents, is a check mark under the category of patient experiencing the following condition(s), falls,dizziness or evidence if impaired coordination. A document dated 3-11-13, with the facility pharmacy name at the top and the category of Medications That May Cause/Contribute to Falls, with R1's name on it, includes the following medications that R1 receives that are indicated as may cause/contribute to falls: Amiodipine, Donepezil,Levothyroxine,Lorazepam,Pantoprazole,Buspirone,Phenytoin,Quetiapine,and Sertraline, Hydralazine.This document also indicates to please advise the physician of these medications and whether it would be appropriate to discontinue or make a change to the residents medication. E8 stated on 7-19-13 at 10:00 a.m., this is all of the information we have regarding the medication in relation to R1's falls. There was no information presented to indicate the physician had addressed the concern.

Based on interview and record review, the facility failed to develop and implement an abuse prohibition policy that complied with federal regulations by requiring the immediate reporting to the state agency of all allegations of abuse, neglect, mistreatment, or misappropriation of resident property and failed to implement its abuse prohibition policy to ensure that all allegations of abuse were reported immediately to the Administrator and investigated. In addition, the facility failed to ensure that all staff, including supervisory staff and Administration were effectively trained in abuse investigation and reporting requirements. On 1/14/2013, facility staff had knowledge of a situation which would have required a reasonable suspicion to immediately report and initiate an investigation of an alleged sexual assault, as a result of a statement made to staff by 1 resident (R2). In addition, the facility failed to notify local law enforcement and the state agency of an allegation of sexual abuse in the required time frame for 1 resident (R1). These failures resulted in 127 in-house residents being put at risk of potential abuse as a result of the failure to investigate and report a suspicion of sexual abuse immediately to the Administrator, local law enforcement and the state agency as required. This failure resulted in an Immediate Jeopardy. On 2/12/2013, the facility indicated an in-house census of 127 residents on the Facility Data Sheet. While the immediacy was removed on 2/22/2013 , the facility remains out of compliance at a Severity Level 2 while the facility continues to re-educate all staff on the revised abuse prohibition policy. Findings include: 1. Review of the facility policy titled "Resident Abuse Investigation" with a "revision" date of 2/11/2010 revealed "that all allegations of resident abuse, regardless of the source of abuse, will be fully investigated to prevent further incidents...The Abuse Prevention Coordinator or his/her designee will initiate the investigation of the allegation...ALL allegations of abuse will be reported to the state authorities as soon as practical, local law enforcement...in accordance with current state and/or federal regulations...The Abuse Prevention Coordinator or his/her designee will notify the State regulatory agency...of the alleged abuse within 24 hours of the receipt of the allegation. E1, Administrator stated on 2/21/2013 at 9:45am that she was told by E21, Evening Supervisor-Registered Nurse, on the morning of 1/22/13 (exact time unknown) of R2 having said something during incontinence care to E18, Certified Nurse Aide (CNA) about "a man being down there". E1 stated that when she was first told, on 1/22/13, it was unknown exactly when R2 had made the statement to E18. E1 stated that E21 was made aware of R2's statement on the evening of 1/21/2013 when E18 had reported it to E21. E1 stated on 2/21/2013 at 9:45am that she did not do an investigation of R2's statement nor report it as an allegation of abuse to the state agency or police. E1 stated " It just didn't occur to me that it was needed, R2 just does stuff". E1 stated that she was now doing an investigation. E18, Certified Nurse Aide, (CNA) stated when interviewed by phone on 2/21/2013 at 8:00am that on or about 1/14/2013 during the midnight shift, she did a bed check on R2 and found her to be incontinent of urine. E18 stated that as she was cleaning R2, R2 said "Ow or Ouch" and when E18 asked her what was wrong, R2 said that she was "sore down there". E18 stated that she asked R2 why she was sore and that R2 stated "oh from those men poking around down there". E18 stated that she reported it to the nurse on the wing when she had finished with R2's care but could not recall who she had reported it to, but thought that it was either E20 or E21, both of whom are a Licensed Practical Nurse (LPN). E18 stated that she then documented what R2 stated in the behavior book on the comment papers. E18 was asked what the nurse's response was and E18 stated that she did not recall them saying anything but that they did not rush "in there" (To R2's room). E18 stated that she could not recall exactly but that a week or maybe two weeks later, another nurse was telling her and other staff to only go into another resident's room (R1) with two staff present because of an allegation of sexual abuse when "it triggered my memory". E18 stated that she grabbed the behavior book and showed E21 and E22, LPN, what she had documented. E18 stated that E22 told her to report it to E23, RN, Assistant Director of Nurses (ADON), which she stated she did the next morning. E18 said that E23 took the paper out of the book and put it on the desk. E18 stated that E23 seemed concerned by the look on his face. E21, RN stated on 2/19/2013 at 4:10pm that E18 made her aware of the statements made by R2 "roughly a month ago". (Unsure of date and time). E21 stated that E18 had told her that "the other night" (unknown date) R2 had complained of hurting while being given incontinence care and when questioned further by E18, R2 had said "that man been messing with me down there". E21 stated that E18 told her that she had reported it that night to the charge nurse, E19, LPN. E21 verified that she saw the documentation of the incident written by E18 in the behavior book. E21 stated that she did a physical assessment of R2 with E22 present but noted nothing more than R2's normal redness. E21 stated that she did not document any of this but reported it to E2, DON the next morning .and was told that she would investigate it. E19, LPN stated on 2/21/13 at 2:55pm that she did not recall being told anything in relation to R2 making a statement referencing having been inappropriately touched. E23, ADON stated on 2/21/2013 at 9:55am that he had "no clue as to the date" but that it was early am that he was told by E18 about R2's statement and was showed the documentation in the behavior book. E23 stated he pulled the documentation that E18 had written from the behavior book and copied and laid it on the desk. E23 stated that when he reported the incident to E2, DON that morning, he was unable to find the documentation and did not know what happened to it. E2 stated on 2/20/2013 at 4:40pm that the first time she became aware of the statements made by R2 was during the R1 investigation (which occurred the week of 1/21/2013), and was told by either E18 or E21 but could not remember. Review of R2's Nurses Notes from 1/1/2013 thru 2/15/2013 found no documentation mentioning any statement being made by R2 in reference to being touched or "messed with" inappropriately by a man. The facility did not have an abuse investigation involving R2 available for review when asked on 2/15/2013 for all abuse allegations and investigations for the past 6 months. R2 has a [DIAGNOSES REDACTED]. The Facility Admission Sheet of 4/20/2010 documents a [DIAGNOSES REDACTED]. R2 was observed in bed at 10:00am on 2/19/2013 sleeping. At 1:30pm on 2/19/2013 R2 was observed in bed, calling out "help" frequently. When asked what she needed, R2 did not reply. R2 did not respond when asked if she had ever been touched inappropriately or hurt by staff. R2's cognitive level is assessed as severely impaired on the 12/31/12 Resident Assessment Instrument. 2. An "Initial Report To Public Health of Alleged Abuse" for R1 was received by the state agency's regional office, by fax, from the facility on January 22, 2013 at 5:38 pm, as noted by the time and date stamp on the report. On 2/15/2013, the facility was asked to provide all allegations of abuse and investigations for the past 6 months. An investigation was reviewed with a date of 1/21/2013 that indicated that during a Care Plan meeting on 1/21/2013 (no time given), Z5 alleged that R1 had stated on January 14, 2013 that R1 had been raped. E24, Social Service Designee, stated on 2/15/2013 at 4:05 pm that the Care Plan meeting occurred in the afternoon, sometime between 1-2 pm on 1/21/2013. E1, Administrator stated on 2/15/2013 at 4:00 pm that she was present during the Care Plan meeting for R1 on 1/21/2013 when Z5 made the allegation of R1 stating she had been raped. E1 stated that an investigation was initiated immediately but that she did not notify the local police until 9 am on 1/22/2013. E1 stated that she did not notify the state agency until 1//22/2013 at 5:30pm, at which time she faxed the initial report of the investigation to the state agency's regional office. E1, Administrator and E2, Director of Nursing (DON), were notified of the Immediate Jeopardy on 2/21/2013 at 11:50am . The Immediate Jeopardy was determined to have begun on 1/14/2013 during the 11pm-7 am shift when staff failed to follow the facility policies and procedures regarding abuse allegations, failed to immediately notify the Administrator of an allegation of abuse and failed to initiate an investigation after R2 stated to E18, Certified Nurse Aide "Ouch, I'm sore there" during incontinence care and then said that a "man had been down there" referring to her vaginal/peri area . The surveyor confirmed by record review and interview that the facility took the following action to remove the Immediate Jeopardy: A. An investigation was initiated on 2/20/2013 regarding the January 14, 2013 statements made by R2 to E18. B. The facility revised their abuse prohibition policies to include the required time frame for reporting allegations of abuse. All staff will be re-educated on the facility's abuse policy and reporting requirements as per state and federal regulations. Inservice records beginning on 2/20/2013 regarding abuse policies were reviewed. Staff not currently working at the time the re-education was started were not allowed to work until receiving re-education .Re-education includes: The facility will ensure that all allegations of abuse will be reported to the Administrator and the Department of Public Health immediatelty, and local law enforcement as required. C. Cognitively intact residents were interviewed to assure no other residents had been affected.Completion date 2-22-13. D. Resident Grievances were reviewed for the past 90 days to assure that issues of abuse mistreatment or neglect have been reported timely to the Department of Public Health. Completion date 2-22-13. E. As part of the facility's Quality Review Process, E1 stated that all allegations of abuse will be reviewed at the morning meeting to determine if allegations have been properly reported. Random interviews of cognitively intact residents will be done to assure that allegations of abuse have been properly investigated and reported. Completion Date: 2/22/2013

Based on record review and interview the facility failed to implement its abuse prohibition policy regarding thoroughly investigating and reporting to the State agency immediately, as required all allegations of abuse for 2 of 3 residents (R2, R8) who reported an allegation of abuse, in the sample of 10. The findings are: 1. On 4/2/2013, the facility was asked to provide all investigations related to allegations of abuse, neglect and theft which had occurred since 3/18/2013. An investigation was reviewed which involved R2. A form titled "Resident Concern Form" indicated that R2 had reported, during a care plan meeting on 3/26/2013, (later determined to have the wrong date as the meeting actually occurred on 3/27/2013 ) that R2 felt that E3, Licensed Practical Nurse (LPN) had been "short" with her, "snapped" at her and had come into her room "yelling at her". R2 could not tell those present an exact date of occurrence. The form did not include a time for when this information was reported by R2. E4, Minimum Data Set Coordinator, stated on 4/4/2013 at 9:15 a.m. that the care plan meeting was held sometime in the afternoon on 3/27/2013. E4 stated that she was present at the 3/27/2013, care plan meeting and provided E1, Administrator, with documentation right after the meeting, telling her what R2 had stated. E1 stated on 4/4/2013 at 9:10 a.m. that she interviewed R2 at 4:45 p.m. on 3/27/2013 with R2 again stating that she felt that E3 had yelled at her and that E3 had also told her "you are being stupid" when R2 told E3 that she was making her nervous. E1 indicated that E3 was not working at the time of the allegation and was contacted on 3/28/2013 some time in the 'am' by phone and notified of the allegation and investigation. E1 stated that E3 was told that she was suspended and not to return to work until contacted. E1 stated that she interviewed E3 by telephone. A yellow piece of lined tablet paper dated 3/28/2013 (no time documented) was reviewed from the investigation file. There was no signature on the paper. E1 stated that it was her notes from her phone conversation with E3. The information was not written with complete sentences and was difficult to follow. It did not indicate if E1 was asked if she had yelled at R2 and called her stupid. The initial report notifying the state agency was faxed and noted to have a date and time stamp of 3/28/2013 11:59 a.m. which was approximately 20 hours after E1 was made aware of an allegation of abuse. This was verified by E1 on 4/4/2013 at 9:10 a.m. E1 stated that because of the lateness of the day and being busy with other things, she did not get the initial report faxed immediately as required. E1 stated on 4/4/2013 during the 9:10 a.m. interview that she instructed E5, Certified Nurse Aide, on 3/28/2013 to interview some other residents regarding any concerns they might have. There were 4 resident interviews written up by E5 on 3/28/2013 beginning at 9:40 (no indication of a.m. or p.m.). None of the 4 residents interviewed had any concerns as written in the interview notes by E5. The facility's completed investigation did not include interviews with other staff who work with E3 nor any indication that an interview was attempted with R2's room mate to determine whether she had witnessed or heard any yelling by E3 .This was verified with E1 on 4/4/2013 at 9:10 a.m. The "Resident Abuse Investigation Final Report" signed by E1 and dated 3/28/2013 indicated "no findings, staff brought back to work." 2. On 4/2/2013, the facility was asked to provide all investigations related to allegations of abuse, neglect and theft which had occurred since 3/18/2013. An investigation was reviewed which involved R8. The "Initial Report to Public Health of Alleged Abuse" dated 3/21/2013 and signed by E1, indicated that it was reported to E1 that R8 had stated that E6, Certified Nurse Aide, had told R8 that he "turns his light on too much." This initial report was faxed to the state agency on 3/21/2013 at 7:11 pm as noted by the date and time stamp. The report did not indicate at what time this had been reported to the Administrator. E1 stated on 4/4/2013 at 2:50 pm that she thought that this had been reported to her by someone in therapy. E1 stated that she could not recall what time of the day it was reported to her but it was on 3/21/2013. After some thought, E1 stated that E7, Certified Occupational Therapy Assistant, had reported it. E7 stated on 4/4/2013 at 3:30 pm that on 3/21/2013 she was working with R8 sometime after lunch and that he had told her of an incident which had occurred the night before that had bothered him. E7 stated that R8 told her that a bald guy on nights had been "mean to him" and had given him his urinal and told him to keep it in place all night. R8 further stated to E7 that this staff (E6) had later scolded him when he had turned his call light on after spilling the urinal. E7 stated that she wrote up this information and took it to E1 shortly after R8 had told her. Review of this written information included the reference to "being mean" and being "scolded." The facility investigation included 2 resident interviews conducted on 3/22/2013 by E5. E6 was interviewed by E1 on 3/22/2013 (no time indicated) as noted on a written statement signed by E1. The statement indicated that E6 denied having made any statement to R8 that he was using the call light to much. E1 stated on 4/4/2013 at 2:50 pm that she had determined that the only male working the night of 3/20/2013 who was bald was E6 and that she spoke with E6 by phone on 3/22/2013 and informed him of allegation and suspension pending outcome of investigation. There were no other staff interviewed as part of the investigation and this was confirmed by E1 on 4/4/2013 at 2:50 pm. The "Resident Abuse Investigation Final Report" signed by E1 and dated 3/26/2013 indicated that the allegation could not be substantiated and that E6 was brought back to work. The facility policy on abuse, mistreatment and neglect states on page AA-5 (2 of 5) under "Reporting" indicates that "as soon as possible without delay an initial report will be made to the appropriate state department." On page 5 of 5 under Reporting and Responding to Allegations of Abuse " it states that " Reports will be made immediately" (as soon as possible) but ought not exceed 24 hours after discovery of the incident... AA-4 pages (1 of 5) under " Resident Abuse Investigation" states that all allegations of resident abuse will be thoroughly investigated... "

Based on interview, observation, and record review, the facility failed to investigate one allegation of sexual abuse, after becoming aware of such allegation for 1 resident (R2), and failed to ensure that all allegations of sexual abuse are immediately reported to the Administrator, local law enforcement and/or the state agency for 2 of 2 residents, (R1, R2) reviewed for reporting and investigations of alleged sexual abuse, in the sample of 18. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 2/22/2013, the facility remains out of compliance at a Severity Level 2 due to its' failure to report an allegation of sexual abuse to the state agency and police as required and as the facility continues to educate staff on the reporting and investigation requirements for allegations of abuse. Findings include: 1. E1, Administrator stated on 2/21/2013 at 9:45am that she was told by E21, Evening Supervisor-Registered Nurse, on the morning of 1/22/13 (exact time unknown) of R2 having said something during incontinence care to E18, Certified Nurse Aide (CNA) about "a man being down there". E1 stated that when she was first told, on 1/22/13, it was unknown exactly when R2 had made the statement to E18. E1 stated that E21 was made aware of R2's statement on the evening of 1/21/2013 when E18 had reported it to E21. E1 stated on 2/21/2013 at 9:45am that she did not do an investigation of R2's statement nor report it as an allegation of abuse to the state agency or police. E1 stated " It just didn't occur to me that it was needed, R2 just does stuff". E1 stated that she was now doing an investigation. E18, Certified Nurse Aide, (CNA) stated when interviewed by phone on 2/21/2013 at 8:00am that on or about 1/14/2013 during the midnight shift, she did a bed check on R2 and found her to be incontinent of urine. E18 stated that as she was cleaning R2, R2 said "Ow or Ouch" and when E18 asked her what was wrong, R2 said that she was "sore down there". E18 stated that she asked R2 why she was sore and that R2 stated "oh from those men poking around down there". E18 stated that she reported it to the nurse on the wing when she had finished with R2's care but could not recall who she had reported it to, but thought that it was either E20 or E21, both of whom are a Licensed Practical Nurse (LPN). E18 stated that she then documented what R2 stated in the behavior book on the comment papers. E18 was asked what the nurse's response was and E18 stated that she did not recall them saying anything but that they did not rush "in there" (To R2's room). E18 stated that she could not recall exactly but that a week or maybe two weeks later, another nurse was telling her and other staff to only go into another resident's room (R1) with two staff present because of an allegation of sexual abuse when "it triggered my memory". E18 stated that she grabbed the behavior book and showed E21 and E22, LPN, what she had documented. E18 stated that E22 told her to report it to E23, RN, Assistant Director of Nurses (ADON), which she stated she did the next morning. E18 said that E23 took the paper out of the book and put it on the desk. E18 stated that E23 seemed concerned by the look on his face. E21, RN stated on 2/19/2013 at 4:10pm that E18 made her aware of the statements made by R2 "roughly a month ago". (Unsure of date and time). E21 stated that E18 had told her that "the other night" (unknown date) R2 had complained of hurting while being given incontinence care and when questioned further by E18, R2 had said "that man been messing with me down there". E21 stated that E18 told her that she had reported it that night to the charge nurse, E19, LPN. E21 verified that she saw the documentation of the incident written by E18 in the behavior book. E21 stated that she did a physical assessment of R2 with E22 present but noted nothing more than R2's normal redness. E21 stated that she did not document any of this but reported it to E2, DON the next morning .and was told that she would investigate it. E19, LPN stated on 2/21/13 at 2:55pm that she did not recall being told anything in relation to R2 making a statement referencing having been inappropriately touched. E23, ADON stated on 2/21/2013 at 9:55am that he had "no clue as to the date" but that it was early am that he was told by E18 about R2's statement and was showed the documentation in the behavior book. E23 stated he pulled the documentation that E18 had written from the behavior book and copied and laid it on the desk. E23 stated that when he reported the incident to E2, DON that morning, he was unable to find the documentation and did not know what happened to it. E2 stated on 2/20/2013 at 4:40pm that the first time she became aware of the statements made by R2 was during the R1 investigation (which occurred the week of 1/21/2013), and was told by either E18 or E21 but could not remember. Review of R2's Nurses Notes from 1/1/2013 thru 2/15/2013 found no documentation mentioning any statement being made by R2 in reference to being touched or "messed with" inappropriately by a man. The facility did not have an abuse investigation involving R2 available for review when asked on 2/15/2013 for all abuse allegations and investigations for the past 6 months. R2 has a [DIAGNOSES REDACTED]. The Facility Admission Sheet of 4/20/2010 documents a [DIAGNOSES REDACTED]. R2 was observed in bed at 10:00am on 2/19/2013 sleeping. At 1:30pm on 2/19/2013 R2 was observed in bed, calling out "help" frequently. When asked what she needed, R2 did not reply. R2 did not respond when asked if she had ever been touched inappropriately or hurt by staff. R2's cognitive level is assessed as severely impaired on the 12/31/12 Resident Assessment Instrument. 2. An "Initial Report To Public Health of Alleged Abuse" for R1 was received by the state agency's regional office, by fax, from the facility on January 22, 2013 at 5:38 pm, as noted by the time and date stamp on the report. On 2/15/2013, the facility was asked to provide all allegations of abuse and investigations for the past 6 months. An investigation was reviewed with a date of 1/21/2013 that indicated that during a Care Plan meeting on 1/21/2013 (no time given), Z5 alleged that R1 had stated on January 14, 2013 that R1 had been raped. E24, Social Service Designee, stated on 2/15/2013 at 4:05 pm that the Care Plan meeting occurred in the afternoon, sometime between 1-2 pm on 1/21/2013. E1, Administrator stated on 2/15/2013 at 4:00 pm that she was present during the Care Plan meeting for R1 on 1/21/2013 when Z5 made the allegation of R1 stating she had been raped. E1 stated that an investigation was initiated immediately but that she did not notify the local police until 9 am on 1/22/2013. E1 stated that she did not notify the state agency until 1//22/2013 at 5:30pm, at which time she faxed the initial report of the investigation to the state agency's regional office. E1, Administrator and E2, Director of Nursing (DON), were notified of the Immediate Jeopardy on 2/21/2013 at 11:50am . The Immediate Jeopardy was determined to have begun on 1/14/2013 during the 11pm-7 am shift when staff did not immediately notify the Administrator and an investigation was not initiated after R2 stated to E18, Certified Nurse Aide "Ouch, I'm sore there" during incontinence care and then said that a "man had been down there" referring to her vaginal/peri area . The surveyor confirmed by record review and interview that the facility took the following action to remove the Immediate Jeopardy: A. An investigation was initiated on 2/20/2013 regarding the January 14, 2013 statements made by R2 to E18. B. Cognitively intact residents were interviewed to assure no other residents had been affected.Completion date 2-22-13. C. Resident Grievances were reviewed for the past 90 days to assure that issues of abuse mistreatment or neglect have been reported timely to the Department of Public Health. Completion date 2-22-13. D. All staff will be re-educated on the facility's abuse policy and reporting requirements as per state and federal regulations. Inservice records beginning on 2/20/2013 regarding abuse policies were reviewed. Staff not currently working at the time the re-education was started were not allowed to work until receiving re-education. Re-education includes: The facility will ensure that all allegations of abuse will be reported to the Administrator immediately, and to the Department of Public Health and local law enforcement. As part of the facility's Quality Review Process, E1 stated that all allegations of abuse will be reviewed at the morning meeting to determine if allegations have been properly reported. Random interviews of cognitively intact residents will be done to assure that allegations of abuse have been properly investigated and reported. Completion Date: 2/22/2013

Based on record review, observation and interview the facility failed to develop individualized hydration plans based on assessed needs, assess for signs/symptoms of dehydration, ensure the estimated 24 hour fluid requirements were met, and monitor intake and output for residents at risk of dehydration for 8 of 8 residents (R3, R4, R6, R8, R9, R11, R12 and R13) reviewed for hydration needs due to [MEDICAL CONDITIONS], loose stools, infections and/or abnormal lab values possibly indicative of Dehydration from the sample of 18. This failure resulted in R8 developing an elevated Potassium, Blood Urea Nitrogen (BUN), Creatinine, and White Blood Count on 2-5-13 (lab report of 2-5-13). Interviews indicate R8 was experiencing episodes of dizziness, abdominal pain, nausea, and an increase in loose stools the first week in February 2013. R8 was diagnosed with [REDACTED]. R8's Medical Certificate of Death dated 2-9-13 lists immediate cause of death as [MEDICAL CONDITION] due to or as a consequence of Septic Shock, due to or as a consequence of Acute [MEDICAL CONDITION], which the physician indicated all began with Dehydration. This failure resulted in an Immediate Jeopardy. On 2-26-13, the facility identified on a document titled "Shawnee Christian Nursing Center", that 40 of the 127 residents in the facility currently have either a [DIAGNOSES REDACTED].>25 and/or Creatinine > 1.3) indicative of possible Dehydration (35 residents). While the Immediacy was removed on 2-22-13, the facility remains out of compliance at a Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of their interventions to ensure resident hydration needs are being met. Findings include: 1. R8 was admitted to this facility on 1-14-13, according to the Admission Record face sheet. R8's [DIAGNOSES REDACTED]. R8's January 2013 physician's orders [REDACTED]. E7 (Certified Occupational Therapist Assistant) stated on 2-20-13 at 2:00 p.m. that "I cared for R8 from admission until she went into the hospital. R8 had been admitted to the facility for rehabilitation with the intention of returning home. R8 had made great progress. R8 had dizziness during her first week at the facility but it had dissipated. R8 was doing well with self care and learning to care for her [MEDICAL CONDITION]. During the first week of February 2013, R8's dizziness came back and R8 was complaining of nausea and not feeling well. R8 said she was having a lot of stool coming into the [MEDICAL CONDITION] bag, so she was checked for [MEDICAL CONDITION]. We were trying to do her home assessment, on 3 different occasions, on Monday and Wednesday, that last week she was here, but she was not feeling well enough to do it. R8 was getting weaker toward the end of that week." E6 (Certified Nurse Aide) stated on 2-20-13 at 1:10 p.m. "I had R8 in my group quite a bit while she was here. R8 was always asking for ice water. R8 started complaining of nausea and belly pain on 2-3-13, a couple of days later she was diagnosed with [REDACTED]. One of the evenings R8 had bloody stool in the [MEDICAL CONDITION] bag and 2-3 days later she passed away. The last evening I had her she was very pale in the face, rubbing her stomach, saying I am so sick and don't feel good. R8 was having more stools in the [MEDICAL CONDITION] bag, where we would empty it every time she went to the bathroom. Previously we would only empty it once a shift." E5 (Registered Nurse) stated on 2-20-13 at 10:41 a.m. "R8 was doing pretty good for the first couple of days in February. we were teaching on [MEDICAL CONDITION] care because R8 planned to go home. On 2-5-13 R8 complained of a little dizziness overnight. I checked her orthostatic blood pressure and glucose and called the doctor. Orders for labs and a Urinalysis were obtained, which were all completed. On 2-6-13 R8 said she was having more output in her [MEDICAL CONDITION] bag than usual. I got a stool sample for [MEDICAL CONDITION] since R8's previous roommate had tested positive for [MEDICAL CONDITION]. I looked at lab results on 2-6-13. Routine lab results we fax to the doctor. With critical lab results we call the doctor. With R8's labs I would have expected the doctor to be called since they weren't considered routine. We didn't put anything different in place for R8 based on the lab results. In report on 2-6-13, they had said the doctor had been contacted and [MEDICATION NAME] was ordered. R8 drank quite a bit, but I don't know if it was a sufficient quantity. A document titled "SBAR Communication Form" dated 2-5-13 indicates at 1 p.m. that Z1 (Physician) was notified regarding R8's emesis and dizziness. Orders were obtained for Complete Blood Count (CBC), Basic Metabolic Profile (BMP) and Urinalysis. At 6 p.m. an order for [REDACTED]. The document titled "Patient Report" dated 2-5-13 and reported 2-5-13 at 19:24 documents in part Potassium 5.5 H (3.5-5.1), BUN 27 H (7-22), Creatinine 1.23 H (0.67-1.17), Blood Calcium 10.8 H (8.5-10.1), Sodium 128 L (136-145), Chloride 88 L (98-107), Glomerular Filtration Rate 56 L (60), White Blood Count 16.3 H (4.8-10.8). The document titled "MEDLAB" and dated 1-22-13 indicates these same values were all normal at that time with the exception of the White Blood Count which was only slightly elevated at 11.2. The document titled "MEDLAB" and dated 2-6-13 (specimen collected) and 2-7-13 (reported) Positive for the [DIAGNOSES REDACTED]icile [MEDICATION NAME] and the [DIAGNOSES REDACTED]icile Toxin A and B. According to the February 2013 ADL Flow Record , which has inconsistent documentation, on the days it is documented (2-1 through 2-4-13) they have zeros for the number of bowel movements in the [MEDICAL CONDITION] bag. There is no documentation regarding bowel movements from 2-5 through 2-8-13 .The Skilled Daily Nurses Notes regarding bowel movements for 2-2 through 2-8-13 ( the day R8 was admitted to the hospital, SBAR Communication form dated 2-8-13) only indicates under the section titled Bowel and Bladder, by the word diarrhea, there is one checkmark for evenings on 2-6-13,one checkmark for days and one for evenings on 2-7-13. On these same Skilled Daily Nurses Notes under the section titled Skin it is always marked normal. The SBAR Communication Form dated 2-8-13 at 8:00 a.m. indicates that R8's physician (Z1) was notified of pain, increased lethargy, bloody drainage liquid form in [MEDICAL CONDITION] bag. Z1 ordered to send to ER. R8 admitted with [MEDICAL CONDITION] and Dehydration. R8's Initial Plan of Care ( no date) with goal date of 5-2-13 lists under the heading of Problem "Potential for weight loss and dehydration related to [MEDICAL CONDITION] with recent surgery, possible med effects, etc...", under the heading Goal"Will have no weight loss or signs/symptoms of dehydration during the next 90 days", Under the heading Approach in part "Monitor and record intake; Enc adequate intake of food/fluids at meals, snacks, med pass, food related activities and social events, etc...; monitor labs as ordered." Also under the heading Problem, with no start date "[DIAGNOSES REDACTED]. heading Approach, in part "Observe for watery diarrhea, fever, loss of appetite, nausea, cramps, etc...; any increase/decrease in watery stools or other signs/symptoms/complications and report for follow up." There is no specific plan in place to ensure R8's assessed fluid needs are met. The Registered Dietitian assessment dated [DATE] and marked as admission has R8's fluid needs calculated as 1710 total cc in a 24 hour period. The only documentation of R8's fluid consumption during her stay at this facility from 1-14-13 through 2-8-13 (Admission Record) was on the January and February 2013 Food Intake Records. There is a section on these records for mL's of fluid consumed at each meal. The only day there is any documentation for fluid consumption at breakfast and lunch is on 1-19-13, all other dates for these 2 meals are blank. The fluid consumption at supper meals is documented and ranges from 240 - 300 mL's at each of those meals. E2 (Director of Nurses) stated on 2-20-13 at 4:30 p.m. "We do not have a specific plan in place to meet the 24 hour fluid requirements for resident's assessed needs. We do encourage fluids. R8 was not on intake and output." R8's History and Physical with admission date of [DATE] to the local hospital states in part under the heading Chief Complaint/History of Present Illness "This is an [AGE] year old white female who has not been feeling well for the past weak. She stated she lost her appetite, has not really eaten anything. She had a lot of liquid stool coming out of the [MEDICAL CONDITION]. Patient's lab tests show findings suggesting she is hypovolemic....The workup showed the hemoglobin was 17.6; this is probably due to dehydration and hypovolemia. BUN is 80, creatinine 3.7. Patient's potassium was 6.3, sodium 124... Amylase was noted to be elevated at 388...Patient is admitted for further evaluation and treatment." Under the heading "Physical Examination: General: She is weak, pale, looks dry/dehydrated, but alert. Head and Neck: Mouth dry...Abdomen:... Bright red blood noted in the ostomy bag...Skin: Very dry. Neurological: She is alert and oriented...Impression: 1. Hypovolemia 2. [MEDICAL CONDITION] 3. Acute [MEDICAL CONDITION] 4. History of [MEDICAL CONDITION] 5. Recent [MEDICAL CONDITION] was positive."The emergency room Report of 2-8-13 lists Dehydration as a diagnosis The hematology reports in comparison from the 2-5-13 report to the 2-8-13 report are as follows: BUN on 2-5-13 was 27 and on 2-8-13 had increased to 80; Potassium on 2-5-13 was 5.5 and had increased to 6.3 on 2-8-13; Creatinine on 2-5-13 was 1.23 and on 2-8-13 it was 3.7; Chloride on 2-5-13 was 88 and on 2-8-13 it was 91; White Blood Count on 2-5-13 was 16.3 and on 2-8-13 it was 17.4. R8's Medical Certificate of Death dated 2-9-13 lists Immediate cause of death as [MEDICAL CONDITION], due to or as a consequence of Septic Shock, due to or as a consequence of Acute [MEDICAL CONDITION]. Z1 (Physician) stated on 2-19-13 at 10:40 a.m. that the Acute [MEDICAL CONDITION] started with the Dehydration. Z1 also stated that he was not notified of the abnormal lab values from the 2-5-13 results until 2-7-13, when the facility called on the [MEDICAL CONDITION] results. Z1 also stated that the facility should have picked up on R8's condition at least 12 hours sooner than they did. 2. R13 was admitted to the facility on [DATE], according to the Admission Record face sheet. The February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The February 2013 CNA Care Record indicates that R13 began experiencing loose stools as follows: 2-6-13, 3 loose stools on day shift; 2-7-13, large loose on nights and 2 loose on days. A lab report dated 2-7-13 indicates a specimen was obtained to be tested for [MEDICAL CONDITION] and the results were positive and reported on 2-9-13. The February 2013 MAR indicated [REDACTED]. The February 2013 CNA Care Record continues to include loose stools on 2-9 through 2-12-13 and 2-16 through 2-20-13. R13 stated on 2-20-13 at 2:15 p.m. that he didn't feel well enough to talk. A strong fecal odor was noted. R13 was holding head in both hands. R13 requested that surveyor get help to change his diaper, at which time surveyor summoned help for R13. E25 (Licensed Practical Nurse) on 2-20-13 at 3:20 p.m. stated " R13 had vomited this morning and had 4 loose stools today. R13 just got off antibiotic for [MEDICAL CONDITION]. R13 may have what is going around" On 2-20-13 at 3:45 p.m. E25 showed the surveyor on R13's MAR indicated [REDACTED]. Surveyor then asked E25 what the plan for R13 was, since the [MEDICATION NAME] had been completed 5 days ago and R13 was continuing to have multiple loose stools daily. E25's response was well I could call the doctor. E25 contacted Z6 (Physician) at that time and according to E25, orders were obtained for Complete Blood Count, Basic Metabolic Profile, Kidney Ureters and Bladder Xray for the morning, [MEDICATION NAME] 250 mg three times daily for 7 days and consult with the [MEDICATION NAME]. R13 stated on 2-21-13 at 11:25 a.m. "I am weak and not feeling well. I have had 3 loose stools this morning." R13's laboratory report dated 2-20-13 indicates the following: White Blood Count 12.1 H (4.8 - 10.8); Blood Urea Nitrogen 27 H (7-22); Creatinine 1.31 H (0.67-1.17); Hemoglobin 12.8 L (14 - 18) and Hematocrit 39.4 L (42 - 52). The Registered Dietitian (RD) assessment dated [DATE] calculates a 24 hour fluid need of 2289 cc's, for R13. R13's Initial Plan of Care with a date of 2-7-13 by the problem of Dehydration potential related to fever/antibiotic therapy, there is no individualized plan to meet the assessed fluid requirements as calculated by the RD. The Care Plan also includes a problem/need of Foley catheter with an intervention of Intake and Output. E2 (Director of Nurses) verified on 2-28-13 at 4:14 p.m. that R13's intake and output was not started until 2-21-13. E2 (Director of Nurses) stated on 2-20-13 at 4:30 p.m. "We do not have a specific plan in place to meet the 24 hour fluid requirements for resident's assessed needs. We do encourage fluids." 3. R6 was admitted to the facility on [DATE], according to the Admission Record face sheet. According to the CNA Care Record for February 2013, R6 began experiencing loose stools on 2-5-13. A lab report indicates a specimen for [MEDICAL CONDITION] was obtained on 2-5-13 with the results being positive and reported on 2-6-13. R6's Nurses Notes indicate that on 2-5-13 R6 was admitted to the hospital for Dehydration, Altered Mental Status and Acute Diverticulitis. The Nurses Notes indicate that R6 was returned to the facility on [DATE]. The February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Registered Dietitian (RD) assessment dated [DATE] calculates a 24 hour fluid need of 2580cc's, for R6. R6's Resident Care Plan with a date of 1-10-13 by the problem of Dehydration potential related to fever/antibiotic therapy, with dates updated of 1-21-13 and 2-8-13, there is no individualized plan to meet the assessed fluid requirements as calculated by the RD. 4. R9 was admitted to the facility on [DATE]. R9's January 2013 physician's orders [REDACTED]. R9's Bowel Movement Record for January 2013 indicates that R9 had 2 loose stools on 1-27-13, 6 loose stools on 1-28-13, 4 loose stools on 1-29-13, 5 loose stools on 1-30-13 and one loose stool on 1-31-13. A lab report for [MEDICAL CONDITION] indicates that a specimen was collected on 1-29-13 and reported on 1-30-13 as positive for [MEDICAL CONDITION]. R9's January 2013 MAR indicated [REDACTED]. This same MAR indicated [REDACTED]. R9's Nutritional assessment dated [DATE] calculates her 24 hour fluid requirements at 1470 cc's. R9's Initial Plan of Care (no date) does not identify dehydration as a potential problem. [MEDICAL CONDITION] is identified as a problem with a date of 1-30-13. There is no individualized plan in place to meet R9's fluid needs. R9's Food Intake Records for January and February 2013 have a line for fluid in mL's for each meal. The only meal/fluid recorded on these forms from the date of admission on 1-21-13 until the date of discharge on 2-14-13 was for the supper meal. The amount of fluids consumed at the supper meals ranged from 120-480 cc's. E2 (Director of Nurses) stated on 2-20-13 at 4:30 p.m. "We do not have a specific plan in place to meet the 24 hour fluid requirements for resident's assessed needs. We do encourage fluids." 5. R12 was admitted to the facility on [DATE], according to the Admission Face sheet. R12 stated on 2-15-13 at 3:45 p.m. "I had a [MEDICAL CONDITION] reversal about 2 weeks ago. I have a lot of loose stools. My surgeon said that is quite normal until my body gets readjusted and caught up." R12's Bowel Movement Records for January and February 2013 indicate that R12 has multiple loose stools on most days. R12's RD assessment dated [DATE] calculates the 24 hour fluid requirements at 1950 cc's. R12's Resident Care Plan dated 12-26-12 does not identify dehydration as a potential problem. The care plan does identify VRE in the urine (no date) and history of UTI's (no date) as problems. There is no individualized fluid plan in place to ensure that R12 meets the 24 hour fluid requirements. E2 (Director of Nurses) stated on 2-20-13 at 4:30 p.m. "We do not have a specific plan in place to meet the 24 hour fluid requirements for resident's assessed needs. We do encourage fluids." 6. R11 was admitted to the facility on [DATE], according to the Admission Face sheet. Z6 (Physician) stated on 2-15-13 at 4:45 p.m. that R11 has Functional Bowel Disease and will sway from constipation to loose stools. The facility keeps me well informed of R11's condition." R11's Bowel Movement Record for January and February 2013 document multiple loose stools almost daily. R11's Nutritional Assessment completed by the RD and dated 2-29-12 calculates R11's fluid requirements at 2385 cc's in 24 hours. R11's Resident Care Plan dated 11-7-12 and 2-19-13 have a goal of will have no signs/symptoms of [MEDICAL CONDITION] or Dehydration thru next review. There is no individualized plan in place to ensure that R11's 24 hour fluid requirements are met. E2 (Director of Nurses) stated on 2-20-13 at 4:30 p.m. "We do not have a specific plan in place to meet the 24 hour fluid requirements for resident's assessed needs. We do encourage fluids." 7. R3 was admitted to the facility on [DATE] according to the Admission Face Sheet. R3 has a history of Urinary Tract Infections [MEDICAL CONDITION] according to the [DIAGNOSES REDACTED]. R3 was treated for [REDACTED]. A goal on the current Care Plan is for R3 to not have any signs or symptoms of [MEDICAL CONDITION] or dehydration. Approaches are for staff to monitor and record amount of intake. An approach listed for "potential for skin breakdown" related to "recent UTI" is to encourage fluid. There is not a specific plan in place to ensure that R3 is consuming a sufficient amount of fluids. The annual RD assessment dated [DATE] indicated a fluid need of 2040 cc's per day. Review of the January and February 2013 Food Intake Records indicate daily fluid intake at meals ranging from 510 cc's to 880 cc's. No other fluid tracking was noted being used to monitor fluid intake. 8. R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The History and Physical dated 10/12/2012 from the hospital indicates that R3 was admitted at that time with dehydration, Acute [MEDICAL CONDITION] and a possible UTI. The current Care Plan dated 12/7/2012 indicates that R4 has a history of UTI's and to encourage fluids to 1500 cc's daily and to encourage juice at meals, "(preferably cranberry)". There is no specific plan in place to ensure that R4 is being offered and encouraged to drink the 1500 cc's. The only tracking of fluids was noted on the Food Intake Records. January and February 2013 Food intake Records indicate daily fluid intake at meals to range from 460 to 940 cc's. Treatment with an antibiotic, "Cipro" for a UTI was started on 12/14/2013 as noted on the December 2012 Physician order [REDACTED]. E1 (Administrator) and E2 (Director of Nurses) were notified of the Immediate Jeopardy on 2-21-13 at 11:50 a.m. The Immediate Jeopardy was determined to have begun on 2-5-13 when R8 developed an increase in loose stools and abnormal lab values indicative of Dehydration and Infection. The facility failed to develop an individualized fluid plan based on assessed needs, assess the resident for signs/symptoms of dehydration, ensure the estimated 24 hour fluid requirements were met and failed to develop a plan for monitoring intake/output regarding these changes in the resident's condition. The surveyor confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy. A. Residents # R8, R9, R6, R11, R12, R13, R4, and R3 have been assessed by the Assistant Directors of Nursing for signs and symptoms of dehydration. The physicians brave been notified when appropriate. Care plans have been updated to reflect their current status to ensure they are meeting the 24 hour total fluid intake as recommended by dietician. Correction Date: Feb. 22, 2013 B. Residents residing in the facility with GI symptoms and on antibiotics for treatment of [REDACTED]. Residents with GI symptoms and on antibiotics for treatment of [REDACTED]. Vital signs will be monitored while symptomatic every shift. Care plans of residents deemed at risk for dehydration will be reviewed and updated as based on resident assessment. Physicians will be notified if the resident does not meet the dietician recommended fluid intake in a 24 hour period. Completion date: Feb. 22, 2013. C. Licensed staff will be re-educated on signs and symptoms of dehydration, indicators that place residents at risk for dehydration, and facility protocol for residents with GI symptoms and residents on antibiotics for treatment of [REDACTED]. Licensed staff and CNA's will be re-educated on monitoring residents' fluid intake and proper recording methods. Re-education will be completed by February 22, 2013. Staff not currently working will not be permitted to work until after receiving re-education. Completion Date: Feb. 22, 2013 D. Residents with GI symptoms and residents on antibiotics for treatment of [REDACTED]. Residents currently being treated for [REDACTED]. Completion Date: Feb. 22, 2013

Based on interview and review of records, the facility failed to provide safe transfer and positioning for one of two residents (R3) reviewed for injuries in the sample of three. This failure resulted in a comminuted fracture of the distal humerus to R3, accompanied by significant and continuous pain and decreased ability to participate in her activities of daily living. Findings include: According to an Incident/Accident Report dated 8/18/11 at 7:30 p.m., R3 experienced "pain in L (left) arm after pop," which occurred while R3 was being transferred to bed. The Incident/Accident Report states R3 has a [DIAGNOSES REDACTED]. The report was signed as completed by E7, Licensed Practical Nurse (LPN). On 9/15/11 at 2:50 p.m., E4, LPN, stated that the incident occurred "after the dinner med pass, between 6 and 7 p.m. CNAs (Certified Nurse Aids, E3 and E5) were putting (R3) to bed. (E5) came out and said, 'Come here right now.' I went down to the room. E3 said, 'I think I broke her arm. I was transferring her and I heard a loud pop.' E4 continued, "(R3) said her arm hurt. I checked her arm and it was painful to touch. As soon as I left the room, about 5 minutes later, I told (E7) that CNAs think they may have broken (R3's) arm." E4 explained to the surveyor that she (E4) was not the nurse on R3's unit, and that she needed to pass this information to the unit nurse, who was E7. "About 20 minutes later, (E5) came to me and stated (R3) was still hurting. I went to tell (E7), and she had not done anything yet." On 9/16/11 at 12:00 p.m., E5 described the accident scenario, which she described as occurring "at 25 or 20 minutes to 7:00 p.m." E5 stated, "She's (R3) on the bed but she's a little on the edge because she's so short her feet don't touch the floor," and "When we went to boost her onto bed it didn't help. She was still partly on the bed and partly off." According to the Minimum Data Set ((MDS) dated [DATE], R3's height is 4 feet and 10 inches. E5 continued, "(E3) had her top half and I had her feet. I took her shoes and her pants off and told (E3) to tell me when she was ready. As soon as I got her feet on the bed, (E3) screamed and said, 'Oh my God I think her arm is broken!'" E5 stated that she did not see the position of R3's arm, and did not know if it had hit or gotten caught in the rail on R3's bed. E5 added that "her arm should have been secure before turning her. She is not able to move it herself." At 12:30 p.m. on 9/16/11, E5 showed the surveyor the grab bar and the bed that R3 had used. The grab bar on the bed was made from heavy steel tubing approximately 2 inches in diameter. According to R3's Care Plan, dated 6/6/11, R3 was able to use her right hand to assist in positioning and transfers. On 9/15/11 at 3:20 p.m., E3 stated, "When we put her into bed, I had her by shoulders and (E5) by the feet. When we put her into bed her left arm hit the grab bar. She was so short that we had to help her, lift her, into the bed." E3 stated that R3 did not seem to understand what happened at first, adding, "When I got really freaked out and said, 'what was that? Oh my God!' that's when she was crying in pain." E3 described coming back to check on R3 after her evaluation by E4 and E7, Licensed Practical Nurses, and finding her in pain at approximately 8:00 p.m. and again at 9:30 p.m. According to a mobile x-ray Patient Report dated 8/19/11, R3 sustained a comminuted fracture involving the distal humerus. According to nursing notes dated 8/19/11 at 2:10 a.m., she was subsequently transferred to the hospital by ambulance. According to the hospital discharge summary, R3 was admitted on [DATE] with a Left Humerus Fracture, and discharged on [DATE] to follow up with an Orthopedist an an outpatient. On 9/16/11 at 4:00 p.m., Z5, R3's family member, stated that R3 was not returned to the facility and instead taken to a different facility in another town. On 9/20/11 at 9:00 a.m., in her room at the facility where R3 now resides, R3 stated that she continues to have pain in her injured arm. She stated that she feels better when she uses her right hand to pull her left arm up to her chest and hold, looping 2 fingers of her right hand around a part of her brace. R3 was wearing a hinged brace on her arm and was visibly apprehensive and protective of her left arm. R3 stated that she didn't know exactly how her arm broke, whether it hit or got caught on the grab bar, because it happened too fast. She stated that the aids seemed like they were in a hurry, and didn't seem to be paying attention to her. R3 became emotional discussing the incident and stated that she didn't want to think about it. On 9/20/11 at 9:15 a.m., Z2, a CNA at the facility where R3 currently resides, stated, "(R3) only lets me dress her. She won't raise her arm above her hip. She holds her left arm tight against her belly with her right hand. She says she's afraid that it's going to get hurt again." Z2 stated that R3 would be able to assist more in her activities of daily living if she were not in so much pain: she might be able to participate more in her dressing and transfers. Z2 stated that R3 usually requests pain medication before or after her transfers.

Based on record review, interview and observation, the facility failed to provide supervision to prevent falls for two residents (R2, R3) which resulted in a fractured hip for R2 and R3 of the three residents reviewed with falls/fractures and failed to do a thorough investigation of the falls. Findings include: 1. R2 has [DIAGNOSES REDACTED]. Review of the facility's incident log, R2 had a fall from bed on 08/01/10 with no injuries. On 09/13/10 nurse note, R2 was "found on the floor of room r/t (related to) a fall/slip from w/c (wheelchair)to the floor.....resident c/o (complains of) pain in R (right) hip upon movement". Interview with E2 (Director of Nurses) on 09/23/10 at 11:20 A.M., E2 indicated on 09/13/10, R2 was brought back to the facility following an outpatient procedure. Interview with E6 (CNA) on 09/23/10 at 2:05 P.M., E6 indicated on 09/13/10 she was taking residents from the dining room to their rooms when she walked by R2's room. R2 was yelling "I'm hurting". R2 was found on the floor. This fall resulted in R2 receiving a fractured right hip. The Accident/Incident Report of 09/13/10 indicated "res (resident) was left in room by self and attempted to transfer self to bed". R2's current care plan indicated an intervention was added on 08/01/10 for R2 to wear a "tag alarm at all times to bed and chair". Interview with E6 indicated when she found R2 on the floor on 09/13/10, R2 was not wearing an alarm. No alarm was sounding. Interview with E7 (CNA) on 09/23/10 at 2:20 P.M., E7 stated R2 did not have an alarm on. E7 stated "(R2) was suppose to have one on (alarm)". The "Post Fall Investigation" form dated 09/13/10, indicated and alarm was present, chair alarm did not sound. There was no investigation to determine if R2 was wearing the alarm or if the alarm malfunctioned. This was verified with E2 on 09/27/10 at 11:50 A.M. R2 was observed on 09/23/10 in the dining room in a high back wheelchair with an alarm attached. 2. R3 has [DIAGNOSES REDACTED]. R3's cognition is assessed as moderately impaired. Review of the facility's incident log indicated R3 had a fall on 08/26/10 that resulted in a fractured right hip. The nurse note of 08/26/10 stated, "6:45 A.M., Res (resident) observed laying on R (right) side in memory dining room". R3's care plan of 08/25/10 indicated R3 was to have a self release seat belt while in the wheelchair. Interview with E5 (Licensed Practical Nurse) on 09/23/10 at 1:00 P.M., E5 stated she was walking by the dining room and observed R3 on the floor. E5 could not confirm if R3 was wearing a self release seat belt. E5 was unable to confirm any facility staff present in the dining room at the time R3 fell . Interview with E2 (Director of Nurses) on 09/23/10 at 1:10 P.M., E2 stated staff was to be in the dining room for supervision. R2's fall was at 6:45 A.M. and E2 stated breakfast is served at 7:15 A.M. E2 was unable to state if staff was present to supervise the dining room at the time R3 fell . E2 could not confirm if R3 was wearing the self release seat belt or if the alarm was sounding when R3 fell . E2 stated R3 can self release the seat belt and the alarm should sound when released. The "Post Fall Investigation" form indicated no alarm was present and no chair alarm sounded. R3's fall risk assessment of 07/10/10 indicated R3 is at high risk for falls. R3 was observed on 09/23/10 at 11:00 A.M. in bed. This was confirmed with E1 (Administrator) and E2 on 09/27/10 at 1:00 P.M.