Every finding on record at Sheridan Village NRSG & RHB

Based on observations interviews and records review, the facility failed to store potentially hazardous foods at or below 41*F to prevent foodborne illnesses temperatures during cold storage in 1 of 1 cooler. This failure has the potential to affect 180 residents receiving meals from the facility kitchen.On 08/01/2026 at 12:35PM during tour of the kitchen surveyor and V5 (Dietary Manager) observed cooler (Fridge) temperature thermometer outside the cooler door reading 51 degrees F. V5 opened the cooler door. Inside thermometer Read 47 degrees F. Observed foods stored in the cooler including cartons different types of milk with an expiration dated 08/12/2026, 08/11/2026. Surveyor and V5 stated in the cooler for approximately six minutes. Inside the cooler felt warm to both surveyor and V5.V5 stated the cooler temperatures are supposed to be maintained between 35 degrees F to 41 degrees F. That's the safe range to prevent food from spoiling. If residents are given spoiled foods, the Residents can get foodborne illness.On 08/01/2026 at 12:48PM, V9 (Cook) stated she checks the cooler temperatures every morning when she gets to work. If the temperature is above 41, I don't chart it. I call and notify V5 or maintenance. The cooler is controlled by a compressor located in the basement. Sometimes it malfunctions. Sometimes when cooler temperatures are high above 41 degrees F, I go down to the basement and listen to the compressor to see if it is working. When it is working it makes loud noise. I have told staff in the kitchen on multiple occasions not to leave the cooler door open. V9 demonstrated how kitchen staff prop the cooler door open to get cool air in kitchen. V9 stated the cooler temperature needs to be maintained at 41 degrees and below to preserve food stored in it. Food can spoil if not stored under proper temperatures. Spoilt food can cause food borne illness to residents.On 08/01/2026 at 1:05PM V10 (maintenance), V5 (dietary manager) and surveyor toured the basement where the compressor is located. Temp on the compressor was observed at 59F. V10 stated the compressor switch was off. V10 turned on the switch. V10 was unable to communicate further due to language barrier.On 08/01/2026 at 2:20PM, V5(dietary manager) stated he notified V6 (Maintenance Director) that the cooler temperature was 51F. V5 said V6 stated he would call the outside vendor to check the cooler compressor located in the basement. V6 stated the outside vendor came and checked the compressor and stated compressor power was off causing the cooler temperature to rise. If the cooler temperatures are not maintained between 35-41 degrees F. This can cause food stored in the cooler to spoil. Residents can get food borne illnesses if served spoiled foods. On 08/02/2026 at 11: 18 AM, V6 (Maintenance Director) via phone stated the compressor for the cooler in the kitchen is in the basement. It is on a timer to give it time to cool down, so it does not blow out. It is for safety. There was a power outage in the area yesterday morning. That could have affected the timer. V6 stated when kitchen staff leave the door of the cooler open for long, the thermometer and cooler temperatures rise. This can cause the food in the cooler to spoil. V6 stated an outside vendor comes to the facility to service the cooler compressor frequently. V6 has called the outside vendor to fix the cooler. Policy titled Cold Food Storage, Preparation and Meal Service dated 06/2026 documents:-Cold foods should be held at a maximum temperature of 41*F.-Cold foods will be held at or below 41*F.Work order sheet from outside vendor dated 8/1/2026 documents:-Checked and found defrost clock off setting from power outage.

Based on interviews and records review the facility failed to permit one resident (R1) of three reviewed to return to the facility following an emergency psychiatric hospitalization facility due to a change in condition.Findings include:R1's medical diagnosis in current face sheet includes but not limited to Unspecified mood [affective] disorder, Autistic disorder, Mild intellectual disabilities, Epilepsy, unspecified, not intractable, without status epilepticus. (MDS Minimum Data Set) section C-Cognitive Patterns dated 07/07/2026 document R1's Brief Interview for Mental Status as 15/15 indicating R1 has intact cognitive abilities. R1's census sheets R1 was re-admitted to the facility on [DATE] and discharged on 07/07/2026.R1 is a closed record and was not residing in the facility during this investigation.Progress notes dated 06/30/2026 09:47 AM, 06/30/2026 12:01 PM, 06/30/2026 09:29 PM, 07/01/2026 07:03 AM, 07/01/2026 09:48 AM, 07/01/2026 01:47 PM, 07/02/2026 02:39 PM, 07/02/2026 09:31 PM document R1 was calm and did not display any behaviors issues towards staff or peers.Facility Assessment tool dated 05/2025 through 04/2026 documents:-The facility accepts residents with physical and cognitive disabilities:Category:-Neurological SystemPsychiatric Mood DisordersSocial services progress note dated 07/07/2026 01:37 PM documents R1 was aggressive towards staff and peers, unable to be redirected. posed a potential risk to the safety of others. R1 was sent to a nearby hospital for psychiatric and medical evaluationR1's census sheet documents R1 was re-admitted to the facility on [DATE]Policy titled Involuntary Transfer and Discharge (IVD) dated 06.26, documents:-The facility must have evidence that the resident's status at the time that the resident seeks to return to the facility (NOT at the time the resident was transferred) meets one of the criteria for transfer or discharge.Progress notes dated 07/15/2026 V4 (Medical Doctor- MD/Facility Medical Director) document R1 needs can no longer be safely or appropriately met in this facility due to ongoing episodes of aggression and unsafe behaviors. Additionally, R1 has demonstrated behaviors that place the risk of harm.On 08/01/2026 at 1:25PM V7(Psychiatric Rehabilitation Service Director-PRSD/Director of Social Services) stated R1 was sent out to the hospital on 7/7/2026 for aggressive behavior. R1 was aggressive with one of his peers (R5). R1 was cursing R5 out, making comments that he was going to hurt her. Staff intervened. R1 got aggressive with staff saying he would hit them if they did not get out of his way. R1 was placed on 1:1. V7 took R1 off the unit to calm R1 down. R1 displayed paranoia and delusional behaviors thinking people were out to get him. R1 felt he had to defend himself.V7 issued R1 with an Involuntary Discharge (IVD) because the facility felt they could no longer meet R1's psychiatric needs. R1 was sent to psychiatric hospital for further evaluation. R1 could not come back to the facility.V7 stated R1 had been in and out of the facility. During previous stays at the facility, V7 had tried to find alternative placements for R1 but had not been successful. V7 after R1 was transferred to the hospital for further evaluation on 7/7/2026, V7 did not work with the hospital to find alternative placement for R1. V7 further stated once a resident is sent to the hospital with an emergency IVD, the hospital must find alternative placement for the resident.On 08/02/2026 at 12:43PM, V2 (Director of Nursing-DON) stated before a resident is admitted to the facility, the facility reviews the resident's information to assess if the resident is a fit for the facility. V2 stated he and V1(administrator) review resident packet. If a resident is aggressive, I assess the resident, redirect the resident. If the resident does not calm down, I look at that resident's physician orders for medications to calm them down. If the resident does not calm down, the nurses call the doctor for further orders. The resident can be placed on 1:1 to prevent harming themselves or other residents. If that does not work, the psychiatrist gives orders for the resident to be sent out to the hospital for further evaluation and treatment. We have a 10-day bed hold policy. The residents can come back to the facility after stabilization at the hospital.On 08.02.2026 at 2:19PM, V1 (Administrator) stated she was informed by different staff at the facility that R1 was aggressive and threatening to staff. V1 stated she personally did not have issues with R1. Staff called code yellow for assistance to calm R1 down. V7(PRSD/Director of Social Services) went and took R1 out of the unit and placed R1 on 1:1 to deescalate the situation. R1 was sent to the hospital for further evaluation. V1 stated later she received a call from her staff (does not remember date or staff who called her) asking if R1 can return to the facility from the hospital. V1 stated R1 cannot return to the facility because he was discharged with an IVD for aggressive behavior. V1 stated the facility admitted R1 back on previous occasions because the facility could manage R1's health needs.V1 stated on a previous occasion, R left the faciity on after leaving the facility on a community pass and did not return to the facility. R1 was later found in the hospital. R1 was admitted back to the facility on 6/30/2026 after almost a month of being out of the facility. During this stay R1's aggressive behavior could not be managed at the facility. V1 stated Social Services did not assist with R1's discharge planning at the hospital because R1 was sent out on an IVD. V1 stated once a resident is discharged to the hospital on an IVD, the hospital finds placement for the resident.

Based on interview and record review, the facility failed to maintain complete medical records that were readily accessible, containing complete and accurately documented diagnosis for one (R1) of seven (R2, R3, R4, R5, R6, R7) residents reviewed.Findings Include:R1 has diagnosis not limited to Quadriplegia, Acute Neurologic, Mood disorder due to known physiological condition, Neuromuscular dysfunction of bladder, Major depressive disorder, single episode, Elevated prostate specific antigen and Aphasia. Wound Management Detail Report document in part: Wound Observation History: Date/Time Observed Rash 12/31/25 09:11 PM Rash distribution: Distributed. Rash color: Red. Rash Texture: Firm. Rash Shape: Scattered. Rash Details: Itchy. Comments: weekly skin observation skin rashes present treatment ongoing, resident continue to complain of itching, treatment will continue until next appointment. Date/Time Observed Rash 01/14/26 09:17 PM Rash distribution: Distributed. Rash color: Red. Rash Shape: Scattered. Rash Details: Itchy Comments: weekly skin observation skin rashes present treatment ongoing, resident continue to complain of itching, treatment will continue until next appointment. Wound Type: Rash. Wound Location: Right lower back. Date/Time Identified 01/20/26 01:25 PM Dermatology Office Visit dated 01/20/26 document in part: Chief complaint one month history itchy body eruption upper, lower extremities, abdomen, chest, back wakes him up at night. Review of systems, positive for itchiness significant and wakes him up at night. Examination of chest, back, abdomen, upper/lower extremities reveal excoriated papules. Assessment and plan: #1 scabies recommend apply permethrin to total body from neck down, wash off in 8 hours repeat once a week for 4 weeks, take ivermectin 200 mcg/kg once a week for 4 weeks, recommend take 12 mg ivermectin tablet once a week for 4 weeks. R1's Physician order dated Permethrin cream; 5 %; amount: as directed; topical Special Instructions: Apply to the total body from the neck down and wash off in 8 hours. repeat once a week for 4 weeks. Once A Day on Tue 11:00 PM start dated 01/20/26. Ivermectin tablet; 3 mg (milligrams); amount: 1 tablet; oral Special Instructions: Take 1 tablet per week x4 weeks. Once A Day on Wednesday 06:00 AM start date 01/21/26 - end date 02/11/26. R1's Progress note dated 01/20/26 09:14 PM edited by V8 (Registered Nurse) on 01/21/26 03:35 PM Reason: More data available: document in part: The resident returned from his scheduled dermatology appointment in stable condition with a dx: scabies, a new order for permethrin 5% cream to be applied to the entire body from the neck down and washed off in 8 hours once a week for 4 weeks, take ivermectin 3 mg tablet once a week for 4 weeks, and then 12 mg ivermectin tablet once a week for 4 weeks.R1's edited Progress note dated 01/20/26 09:14 PM now reads: The resident returned from his scheduled dermatology appointment in stable condition with a dx: skin rash, a new order for permethrin 5% cream to be applied to the entire body from the neck down and washed off in 8 hours once a week for 4 weeks, take ivermectin 3 mg tablet once a week for 4 weeks, and then 12 mg ivermectin tablet once a week for 4 weeks.R1's Progress noted dated 01/21/26 01:52 PM document in part: Resident assessed due to skin rash. Resident noted with scattered erythematous papular rash to affected areas on body. R1's Progress noted dated 01/21/26 10:40 PM document in part: The resident is alert and oriented x 3, no complaints of pain, but has some itching.R1's Progress noted dated 01/23/26 12:35 PM document in part: generalized rash still present.R1's Progress noted dated 01/25/26 09:34 AM document in part: monitor skin rash. The resident is on contact isolation for skin rash. The resident had some itching.R1's Progress noted dated 01/26/2026 05:49 AM document in part: Residents skin rash is subsiding. The resident had some itching.Progress noted dated 02/12/26 11:37 AM document in part: Resident has completed course of topical ointment for treatment of skin rash. Contact isolation precautions have been discontinued at this time.On 05/15/26 at 11:03 AM R1 communicated using a communication board. R1 communicated that he had rashes in January 2026. He had scabies and was in the room by himself. Staff used creams and gave him a shower. After he came back from the dermatologist, they told him that he had scabies. The itching was worse at night when he was trying to sleep. He was itching a little pass November 2025. On 05/13/26 at 02:29 PM V8 (Registered Nurse) stated R1 had a skin rash a few months ago. R1 was getting worst when he was receiving hydrocortisone and triamcinolone. R1 told me and the certified nurse assistant told me R1 was getting worse. The Certified Nurse Assistant told me that I needed to look at R1's skin when he started breaking his skin. I said let's send R1 to the dermatologist. R1 went to the dermatologist for the skin rash and had an order for cream for 4 weeks and medication. R1 was diagnosed with scabies when he went to the dermatologist. Surveyor asked V8 why she documented R1's dermatology appointment diagnosis as a skin rash. V8 stated I was told to do that by V2 (Director of Nursing) and V3 (Assistant Director of Nursing). I don't know why because I originally documented R1's diagnosis as scabies. In October there was a concern on another floor with scabies. The scabies started on the 7th floor. On 05/15/26 at 08:59 AM V2 (Director of Nursing) stated When R1's rash developed his treatment was ongoing and was prescribed by the nurse practitioner. We are not great with documentation. We were looking for symptoms for the documentation.On 05/18/26 at 03:24 PM V5 (Former Infection Control Coordinator) stated There was nothing reported to me about R1's skin rashes until 01/20/26. R1 was itching and scratching. The Nurse Practitioner ordered for R1 to have a dermatology consultation and oral ivermectin. The nurse consultant, V2 (Director of Nursing) and myself were reading over R1's paperwork for 3 hours and there was no diagnosis. There was an order for a biopsy of the skin but no diagnosis. I don't remember seeing the word scabies and I never saw that documentation. I wrote what I read, and I wrote skin rash because that is what we came to the conclusion of. R1's rash was red and on his arms. I did not know R1 had scabies, but he said he felt biting at night. There was nothing that I read in R1's records that said scabies. Permethrin is used for scabies. On 05/15/26 at 12:30 Per telephone interview V17 (Medical Doctor Internal Medicine) stated There should be clinical observation until symptoms have been resolved. Document as a skin rash due to scabies.Policy:Titled Charting and Documentation revised 01/09/26 document in part: Policy Statement: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. 3. All incidents, accidents, or changes in the residents' condition must be recorded. 6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: c. The assessment data and/or any unusual findings obtained during the procedure/treatment.

Based on observation, interviews and records review, the facility failed to follow proper sanitation and food handling practices. This failure has the potential to affect all 178 residents receiving food from the kitchen. Findings include: On 05/27/2025, at 9:39 AM, during tour of the kitchen with V4 (Dietary Manager), observed two silver baking pans wrapped with foil paper on top in the cooler, placed on top of a food cart. V4 stated inside the pans were meat loaf which was being thawed for next day's meal. Observed a pool of a white liquid spilled on top of one of the pans. V4 identified the liquid as milk. V4 stated the milk should not be spilt on the foil wrapping the meat loaf because it can drip inside the meat loaf. This could cause contamination and some residents could be allergic to milk. On one of the shelves in the cooler was observed two big cartoons, one containing cabbage and another containing oranges. Three cabbages were observed to be yellowing/brownish in color with brownish stuff dripping out. V4 stated the cabbages should have been thrown out because they were no longer good for resident consumption and can cause illnesses if cooked for residents. Observed the carton of oranges with some oranges having a grayish substance on them. The oranges were very squishy and broke open when V4 touched them. V4 stated the oranges were rotten and the grayish substance on the oranges was mold which can cause cross contamination and cause residents to become ill. V4 stated kitchen staff should be checking for spoiled food in the cooler and dispose of it to prevent cross contamination which can cause residents to become ill. The cooler temperature was observed at 51 degrees F. V4 stated the cooler temperature should be below 41 degrees F. In the freezer was a box of open waffles with no date when opened. V4 stated food should be labeled with date opened so that staff can know when the food is expired to prevent food borne illnesses. There were two black food carts, one the in cooler and one in the kitchen near a countertop were with whitish substances and black stains on the shelves of the carts. V4 stated the whitish substance was from spills from food and the carts were dirty. V4 further stated the staff who was responsible for cleaning all the food carts and checking the cooler for spoiled food quit over a week ago. V4 was trying to keep up with completing the staff who quit responsibilities and was not able to complete them all because he was also supervising the kitchen. V4 stated unsanitary or dirty food carts can contaminate residents' food and cause illnesses. On 05/27/2025, at 10:13 AM, V4 and surveyor observed V7 (dietary Aide) Rinsing dirty dishes and loading them into the dishwasher. V7 was observed walking over to the other side of the machine to take out the cleaned dishes. V7 did not wash her hands or wear gloves before touching the clean dishes. V4 stated V7 should wash her hands and/or wear gloves before touching the clean dishes and loading them on the clean rack. V4 stated R7 was contaminating the clean dishes by not following sanitary dish washing procedure and V7's actions can cause residents to become ill due to cross contamination. On 05/27/2025, at 11:35 AM, V6 (cook) was observed preparing puree and mechanical soft foods in the puree machine. V6 put cream style corn in the puree machine, pureed it and emptied it in a small baking pan. V6 walked over to the sink and rinsed the puree bowl. V6 came back and put the country style steak in the puree machine and pureed it. V6 stated as long as he was using the puree machine constantly without stopping for more than five minutes. V6 stated he does not need to sanitize or wash it, rinsing is enough. V6 stated there is only one puree machine and this is how he has been pureeing the foods. Facility policy titled Blender, no date documents: -Thoroughly wash unit and remove all food particles from blade. Check cleanliness of top of unit. -Rinse and Sanitize -Air dry Facility polity titled Storage of Refrigerated foods dated 08/24 documents: - Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality -Refrigerated foods are stores at 41* or below. Facility polity titled Dishroom Sanitation, dated 08/24 documents: -Hands must be washed after handling dirty dishes before handling clean dishes.

Based on interview and record review, the facility failed to initiate a new Level I screen for residents with a known mental illness for four (R76, R110, R116, R152) residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35 residents reviewed. Findings include: R76's Facesheet documents that R76 was admitted to the facility on [DATE], with diagnoses not limited to: Schizoaffective disorder and bipolar disorder. R76's Interagency Certification of Screening Results dated [DATE], does not indicate if there is a reasonable basis for suspecting DD (Developmental Delay) or MI (mental illness). R76's Minimum Data Set (MDS) Section I dated [DATE], indicates active diagnoses of anxiety disorder and bipolar disorder. There is no documentation to show that R76 has a Level II PASARR screening. R110's Facesheet documents that R110 was admitted to the facility on [DATE], with diagnoses not limited to: Schizophrenia, major depressive disorder, manic episodes, and suicidal ideations. R110's Interagency Certification of Screening Results OBRA-I Initial Screen dated [DATE], indicates that R110 has no reasonable basis for suspecting DD (Developmental Delay) or MI (mental illness). There is no documentation to show that R110 has a Level II PASARR screening. R116's Facesheet documents that R116 was admitted to the facility on [DATE], with diagnoses not limited to: Schizoaffective disorder, delusional disorders, major depressive disorder. R116's Level II PASARR/Preadmission Screening and Resident Review screening dated [DATE], documents that R116 is excluded from a Level II PASARR because R116 has No diagnosis- no LOC. R152's Facesheet documents that R152 was admitted to the facility on [DATE], with a diagnosis of schizophrenia. R152's Level I PASARR/Preadmission Screening and Resident Review screening dated [DATE], documents that R152 does not require a Level II PASARR because R152 does not have a SMI/severe mental illness, ID/intellectual disability, or RC/related concern. On [DATE], at 9:37 AM, V21 (Social Services Director) states V22 (Admissions Director) is responsible for inputting residents' PASARR/Preadmission Screening and Resident Review information into the screening agency website. V21 states V22 is also responsible for ensuring that a resident's PASARR screening is accurate. V21 states he is responsible for inputting resident's information and referring residents for a new PASARR screening once it expires. V21 states to his understanding, residents who have been admitted to the facility prior to 2022, do not need a new PASARR screening in the new screening system. V21 states any resident admitted to the facility after 2022, should have a PASARR screening in the new screening system. V21 states the PASARR screenings should be completed at the hospital before a resident is admitted to the facility. V21 states he checks the screening agency system daily for expired PASARR screenings and there should not be any PASARR screenings that are outdated. V21 states if a resident experiences any psychiatric mental health issues while residing in the facility, then the nursing home is responsible for ensuring that the resident is still suitable to live in the nursing home setting. On [DATE], at 11:14 AM, V22 (Admissions Director) states he has been working at the facility for 2 months and he is responsible for making sure PASARR screening are valid upon resident admission. V22 states a resident's PASARR screening is considered valid if all pertinent information is entered correctly. V22 states V21 (Social Services Director) is responsible for making sure the PASARR screenings are updated. V22 states a PASARR is a screening that needs to be done by the transferring facility prior to a resident being admitted to the facility. V22 states the transferring facility is usually the hospital or another nursing home. V22 states residents who have been admitted to the facility prior to [DATE] has been grand-fathered in and do not require a PASARR screening through the new screening system. Facility policy dated 12/2023 titled Preadmission Screening and Residential Review (PASRR) documents in part, Policy: 1. Comply with Federal, State, and the appointed screening agency in standards addressing the PASARR assessment/screening process. 2. Request full and complete PASRR materials (Level 1 and 2) from each referral source prior to or soon following admission. 3. Review the PASRR documents to help assess/ascertain what type of problems, needs and issues need to be addressed to help the resident function at his/her maximum level of well-being. Procedure: 3. The hospital/screening agency/referral source may be contacted, as indicated and asked to provide any missing or incomplete documents. The screenings are now expected to be located in the screening agency's system and accessible by the facility. 4. As indicated, the screening material should be reviewed as a component of the assessment process and treatment, suggestions/recommendations should be identified and appropriately addressed.

Based on observation, interview, and record review the facility failed to a.) remove and discard expired medications that had been open in one of five medication carts reviewed, b.) remove and discard expired enteral feedings located in one of four medication storage rooms reviewed, and c.) ensure medications were locked and secured while unattended. These failures have the potential to affect 59 residents residing in the facility reviewed for medication labeling and storage. Findings Include: On 05/27/2025, at 11:07 AM, surveyor and V11 (Licensed Practical Nurse/LPN) located on the 3rd floor of the facility at the medication cart. Surveyor observes the following: one open house stock medication bottle labeled Meclizine 12. 5mg inside of the medication cart. Meclizine medication observed with an expiration date labeled 02/2025. V11 states the Meclizine medication should not be stored in the medication cart and should have been discarded once it expired on 02/2025. V11 states it is not safe to administer expired medications to residents and they could experience adverse reactions if given expired medications. On 05/27/2025, at 11:13 AM, surveyor located inside of the third-floor medication storage room with V11 (LPN). Surveyor observes the following: four house stock enteral feeding containers labeled Glucerna with Carbsteady 1.5 CAL 33.8 ounces with an expiration date labeled 04/01/2025. V11 states the enteral feeding containers should not be stored in the medication storage room for resident use and should have been discarded once it expired on 04/01/2025. V11 states residents receiving enteral feedings could potentially get sick if expired enteral feedings are administered to them. On 05/27/2025, at 11:16 AM, surveyor located on the second floor of the facility. Surveyor observes a medication cart (identified as Cart B) unlocked and unattended. V10 (Registered Nurse/RN) observed exiting a resident's room and locks the Cart B medication cart. On 05/27/2025, at 11:18 AM, V10 states she normally locks the medications cart when she leaves it unattended. V10 states she must have been rushing this time when she left the medication cart unlocked and unattended. V10 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. V10 states then residents could potentially self-administer the medications and overdose or have an adverse reaction. Facility census dated 05/27/2025, documents a total of 30 residents resides on the third floor of the facility and 29 residents reside on the second floor of the facility. Facility document titled Residents on Tube Feeding lists a total of 4 residents residing in the facility who have gastronomy tubes for enteral feedings. Facility policy dated 10/25/2014, titled Storage of Medications documents in part, Procedures: B. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Expiration Dating: H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

Based on interview and record review, facility failed to follow their policy to offer, educate and receive consent for COVID-19 (corona virus) vaccination for 1 (R66) out of 5 residents reviewed for immunizations, in a total sample of 35. Findings include: On 05/28/2025, at 12:00 PM, R66 stated she doesn't remember the facility offering COVID-19 vaccination or educating her about it. On 05/28/2025, surveyor reviewed R66's immunizations with V19 (Infection Preventionist). On 05/28/2025, at 12:37 PM, V19 stated that she cannot find R66's consent for COVID-19 vaccine. V19 stated she is pretty sure she offered it. V19 stated that she is not sure if R66 received her COVID-19 vaccine nor does she have education documented. V19 stated that she does not know what happened and why R66 did not receive her COVID-19 vaccine. V19 stated that it is important for these residents to be educated and have their vaccination to protect them from COVID-19 infection. On 05/29/2025, at 2:05 PM, V3 (Director of Nursing) stated that upon admission, residents' immunizations are reviewed. V3 stated that if a resident did receive the COVID vaccination, we educate them the importance and benefits of the vaccine. V3 stated that then they can make an informed decision to give consent for the administration of the COVID-19 vaccine. V3 stated that we document every time we educate residents on the benefits of the immunization. If it is not documented, then it was not done. R66's immunization record documents in part: There was no COVID-19 vaccine offered nor administration history. No documentation of education or consent for COVID-19 vaccination. Facility's COVID-19 Immunization Policy (01/2021) documents in part: The facility shall notify all residents of the COVID-19 vaccination and shall provide or arrange for vaccination for all residents. The facility shall provide all residents with education about the benefits of COVID-19 vaccine and potential consequences of COVID-19 illness. The facility shall include documentation of each person either accepted the offer or declined the offer.

Based on interview and record review, facility failed to follow their policy to offer, educate and receive consent for influenza and pneumococcal vaccination for 1 (R66) out of 5 residents reviewed for immunizations, in a total sample of 35. Findings include: On 05/28/2025, at 12:00 PM, R66 stated she doesn't remember the facility offering her influenza and pneumococcal vaccination. On 05/28/2025, surveyor reviewed R66's immunizations with V19 (Infection Preventionist). On 05/28/2025, at 12:37 PM, V19 stated that she cannot find R66's consent for influenza or pneumococcal vaccine. V19 stated she is pretty sure she offered it. V19 stated that R66 did not receive her influenza or pneumococcal vaccine, nor does she have education or consent. V19 stated that she does not know what happened and why R66 does not have her pneumococcal or influenza vaccine or was educated on the benefits of these vaccines. V19 stated that it is important for these residents to have their vaccination to protect them from influenza and pneumonia related infections. On 05/29/2025, at 2:05 PM, V3 (Director of Nursing) stated that upon admission, residents' immunizations are reviewed. V3 stated that if a resident did not receive the influenza or pneumococcal vaccination, we educate them the importance and benefits of the vaccine. V3 stated that then they can make an informed decision to give consent for the administration of the influenza or pneumococcal vaccine. V3 stated that we document every time we educate residents on the benefits of the immunization. If it is not documented, then it was not done. R66's immunization record documents in part: There was no influenza or pneumococcal vaccine offered in 2024. No pneumococcal or influenza vaccine administered. No documentation of education or consent for influenza or pneumococcal vaccination. Facility's Influenza and Pneumococcal Immunization Policy (undated) documents in part: Each resident or when appropriate resident representative, will be educated regarding the benefits and potential side effects of both influenza and pneumococcal immunizations and will be provided the opportunity to accept or refuse them. The facility will document both the education provided and the resident's decision in the resident's clinical record.

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for one (R1) out of four residents reviewed for medication administration in a total sample of 35 residents reviewed, resulting in a 7.69% error rate. Findings Include: On 05/28/2025, at 9:22 AM, surveyor located on the 4th floor of the facility with V11 (Licensed Practical Nurse/LPN) during a medication administration pass. V11 administers Acetaminophen 500 mg: 2 tablets by mouth to R1. R1's medication administration record (MAR) dated 05/01/2025 - 05/28/2025 documents: Acetaminophen 325 mg- 2 tablets by mouth every 6 hours as needed. R1's medication administration record (MAR) dated 05/01/2025 - 05/28/2025 documents: Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg: 1 tablet by mouth twice a day scheduled at 9:00 AM and 5:00 PM. On 05/28/2025, at 9:22 AM, surveyor observes that this medication was not given to R1 during the 9:00 AM medication administration pass with V11 (LPN). V11 states she is finished administering all of R1's scheduled morning medications. On 05/28/2025, at 2:52 PM, V11 (LPN) states she did not administer R1's Bactrim medication during the morning medication pass while surveyor was present because she did not see the order in R1's MAR. V11 states she checked the facility's 24-hour communication report and saw that R1 was prescribed antibiotics. V11 states she then checked R1's MAR again and saw the Bactrim order on R1's MAR. V11 states she then administered R1's Bactrim medication to him at approximately 10:30 AM, after the surveyor had already left the 4th floor. V11 states she is aware that she should triple check the resident's MAR to check medications orders. V11 states it is important to read and re-check resident's MARs to prevent medication errors from occurring. Facility policy dated 10/25/2014, titled Medication Administration documents in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures: 4.) FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. b. Check #2: Prepare the dose- The dose is removed from the container and verified against the label and the MAR by reviewing the five rights. 5.) Prior to administration, the medication and dosage schedule on the on the resident's medication administration record (MAR) are compared with the medication label. 2) Medications are administered in accordance with written orders of the prescriber. 5) When PRN medications are administered, the following documentation is provided: a.) Date and time of administration, dose, route of administration.

Based on observations, interview and records review, the facility failed to discontinue or get an order to continue as needed psychotropic medications and failed to get psychotropic consent from Power of Attorney (POA) for one (R52) resident of seven reviewed in a total sample of 35 Findings include: R52's current face sheet documents R52 is a [AGE] year-old individual with medical diagnosis that include but not limited to Major depressive disorder, recurrent severe without psychotic features, Schizophrenia, unspecified, schizoaffective disorder, bipolar type, other psychotic disorder not due to a substance or known physiological condition, anxiety disorder, unspecified. Minimum Data Set (MDS) section C-Cognitive Patterns dates 05/14/2025, document R52's BIMS as 3/15, indicating R52 has severe cognitive impairment. R52's BIM scores dated 05/08/2025, 05/01/2025. BIMS dated 04/23/2025 is 3/15. On 05/27/25, 12:28 PM, R52 was observed sitting in the dining room with staff supervising him. R52 was observed with stacks of papers with pens. R52 stated he likes to write a lot. R52 was observed oriented to person/place and was confused about situation or time. R52 was not able to answer most of the questions that were asked. Review of R52's psychotropic consent forms document R52 consented for psychotropic medications on 05/08/2025: -Clonazepam - Schedule IV tablet; 1 mg; 1 tablet; oral Twice A Day As needed (PRN). -Zolpidem 5mg 1 tablet at bedtime -Olanzapine 10 Mg 1 Tablet PO(Oral) BID (two times day) Review of R52's psychotropic consent forms document R52 consented for psychotropic medications on 05/11/2025: -Lorazepam, 2mg/mL 1 mL Q6hrs PRN (As needed) Review of R52's face sheet and electronic Health Records document R52 has a POA for health. On 05/29/2025, V3 (Director of Nursing) stated although R52 has a BIMS score of 3/15 which means he is severely cognitively impaired, he can still sign for his psychotropic medications. The nurses document in progress notes that R52 is alert and oriented times two, which means R52 is alert and oriented to name and place. V3 stated he did not know if R52 can make decisions based on understanding. V3 stated the nurse on duty on 5/82025, notified R52's Power of Attorney (POA) that R52 was back in the facility, but there is not documentation that the POA was notified of R52's psychotropic medications. V3 stated if it's not documented it is not done. Reviewed of R52's progress notes dated 5/8/2025, document R52's POA was notified of R52's return to the facility but no documentation R52's POA was notified R52 was started on psychotropic medications and psychotropic consent was signed by R52. V3 stated as needed (PRN) psychotropic medication orders are active for only 14 days and should be discontinued after the 14 days or an order for medication continuation should be given by the physician. R52's Physician Order Sheet (POS) dated 5/11/2025 documents: Prescription Lorazepam - Schedule IV solution; 2 mg/mL; amt (Amount) 2 mg; injection Every 6 Hours -05/11/2025, Open Ended PRN Medications Prescription Lorazepam - Schedule IV tablet; 2 mg; : 1 Tab; oral Every 6 Hours -05/11/2025, Open Ended PRN Medications Policy titled MAC Rx Pharmacy Policies and Procedures Manual dated 10/25/2014, documents: -Effective 11/28/2017, CMS (Centers for Medicare & Medicaid Services) redefined the class definition of psychotropic medications to include the below listed drug classes. The PRN (as needed) psychotropic are time limited to a maximum day supply of 14-day duration for SNF (Skilled Nursing Facility). A continuation Psychotropic Medication Policy dated February 2014, documents: -Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian or other authorized representative. R52's Physician Order Sheet dated 05/08/2025, document: Prescription benztropine tablet; 1 mg; amt (amount) 1 tablet; oral. Twice A Day 9:00 AM, 5:00 PM. 05/08/2025, Open Ended Medications. Prescription Clonazepam - Schedule IV tablet; 1 mg; amt: 1 tablet; oral Twice A Day 9:00 AM, 5:00 PM. 05/08/2025, Open Ended Medications. Prescription Olanzapine tablet; 10 mg; amt: 1; oral Twice A Day 9:00 AM, 5:00 PM, 05/08/2025, Open Ended Medications Prescription Zolpidem - Schedule IV tablet; 5 mg; amt: 1; oral At Bedtime 9:00 PM, 05/08/2025, Open Ended Medications

Based on observations, interviews and record reviews, the facility failed to ensure that medications were refilled and readily available for 2 residents (R60, R96) out of 8 residents reviewed for controlled substance medications in a sample of 35. The facility also failed to b.) keep an accurate count of all narcotic medications for two (R55, R118) residents, c.) ensure controlled substances were counted, and documented, at the beginning and end of each shift for 12 out of 237 shifts. These failures have the potential to affect 61 residents residing in the facility. Findings Include: R60's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Lymphedema, hypertensive heart disease without heart failure, chronic obstructive pulmonary disease, unspecified, Muscle wasting and atrophy, not elsewhere classified, unspecified site, abnormalities of gait and mobility. Minimum Data Set Section (MDS) section C (dated 03/24/2025) documents that R60 has an Interview for Mental Status (BIMS) score of 15, indicating that R60's cognition is intact. Care plan (dated 03/24/2025) documents that R60 has complaints of chronic pain. Care plan documents that R60 has a diagnosis of lymphedema and is at risk for circulatory complications, swelling, pain, cardiac distress and decreased mobility. R96's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hemiplegia, unspecified affecting right dominant side, schizoaffective disorder, Bipolar disorder, Major depressive disorder, anxiety disorder. Minimum Data Set Section (MDS) section C (dated 03/19/2025) documents that R96 has an Interview for Mental Status (BIMS) score of 15, indicating that R96's cognition is intact. Care plan (dated 01/02/2025) documents that R96 is at risk for alteration in sleep patterns related to insomnia. On 05/27/2025, surveyor was conducting resident interviews during an annual licensure and recertification survey. At 1:22 PM, R60 stated, I am in a lot of pain. They did not give me my pain medication for a few days now because they ran out and did not reorder my pain medications. I take Tylenol with Codeine. The last time that they gave me my pain medication was two days ago. My pain is really bad. My pain is 10 out of 10. They said that they ran out of my medication because it was not ordered fast enough. They let my pain medication run out, and they did not re-order the pain medication before it ran out. They let my medications run out, and they are supposed to refill the medications before they run out. Now they want to give me regular Tylenol for my pain, but I told them that the regular Tylenol is not strong enough to manage my pain. I am in pain, and I am not comfortable without my Tylenol with Codeine. On 05/27/2025, at 1:38 PM, surveyor interviewed R96. R96 stated, I have a concern. They keep running out of my Lunesta sleeping medication. They continuously run out and they don't refill it before it runs out. I get the Lunesta at nighttime to aide me with sleep. Last night the nurse did not give it to me because she said they were out. I did not sleep the entire night without the Lunesta. This happened many times and I am so frustrated that they continue to run out of my sleeping medication. I am tired because without the Lunesta, I cannot sleep. On 05/27/2025, at 1:56 PM, surveyor inspected the 3rd floor nursing cart with V11 (licensed Practical Nurse) to determine if R60's Tylenol with Codeine pain medication and R96's Lunesta medication for sleep aide were stocked in the medication cart. Based on the inspection, surveyor observed that the two medications were not in the cart. V11 stated, I am the nurse for R60 and R96. R60's Tylenol with Codeine is not in the medication cart, because they ran out of the resident's pain medications. R60 told me that he is in pain and all I was able to give R60 is regular Tylenol. According to the controlled substance ledger, the last time that R60 got his Tylenol with Codeine was on 05/25/2025 at 9:00 PM. I faxed over the order for the pain medication to the pharmacy. Hopefully they will deliver it. R96's Lunesta medication is out of stock. R96 told me that last night she did not receive her scheduled Lunesta medications because the facility ran out. R96 told me that she did not sleep all night because she did not receive the Lunesta medications. They reordered the medication for R96. We are waiting for the pharmacy to bring it. On 05/28/2025, at 10:46 AM, V3 (director of nursing) stated, The expectation is that when there are 3 or 4 pills left in the resident's bingo card, the nurses are supposed to reorder the medications. Nurses are not supposed to wait to the last minute to reorder resident's medications. All medications are supposed to be reordered before they run out. Controlled Substance Disposition Form indicated that that last time that R60 received Tylenol with Codeine 15mg for pain management was on 05/25/2025, at 9:00 PM. R60's Progress Note (dated 05/27/2025) documents, Resident complained of pain to the nurse and requested for his codeine. The medication was not available at this time. Doctor was notified immediately that we have tramadol in the convenient box. Doctor insisted we give Tylenol 1000mg PO and have pharmacy contact him for script. The order was noted and carried out. Pharmacist was called and medication will be delivered STAT (immediately). Resident was made aware. His emergency contact was notified. Resident was assessed for pain, complained of pain to the lower back rated 3/10. Tylenol 1000mg PO was given, well tolerated. Staff will continue to monitor. R60's Physician Order (dated 05/28/2025) documents: Acetaminophen-codeine - Schedule III tablet; 300-15 mg; amount: 1 tablet; oral Special Instructions: Give at 8:00 AM, 2:00 PM, 8:00 PM, as scheduled. R96's Physician Order (dated 11/06/2024) states: Lunesta (eszopiclone) - Schedule IV tablet; 1 mg; amount: 3 mg; oral tablet. Controlled Substance Prescriptions Policy (dated 10/25/2014) documents in part: Refill requests for CIII-CV, and partial fill quantity (CIIs) remains and medications are not automatically refilled by the pharmacy, refills are: Written on a medication order form or ordered by peeling the reorder tab from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy four (4) days in advance of need to assure an adequate supply is on hand. Findings include: On 05/27/2025, at 10:25 AM, surveyor and V14 (Licensed Practical Nurse/LPN) located on the 5th floor of the facility performing a controlled substance count and record review. Surveyor observed the following: A medication bingo card labeled R118's name, Lorazepam 0.5mg. Surveyor observed there were 15 pills inside of the medication bingo card. R118's controlled drug receipt record documents a count of 16 pills. A medication bingo card labeled R55's name, Lorazepam 1mg, surveyor observed there were 4 pills inside of the medication bingo card. R55's controlled drug receipt record documents a count of 5 pills. V14 states he administered the medications to R55 and R118 this morning and forgot to document that he administered them. On 05/27/2025, at approximately 11:00 AM, review of the Controlled Substances Check Form for the month of May 2025 for the third-floor medication cart indicated for 2 shifts in May 2025, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 05/13/25, 2nd shift (3:00 PM-11:00 PM) On 05/17/25, 2nd shift (3:00 PM-11:00 PM) On 05/27/2025, at approximately 11:00 AM, V16 (LPN/Wound Care Coordinator) states it is important to count and document all controlled substances to prevent drug diversions in the facility. V16 states if controlled substances are not documented, then it means that the control substances were not counted. On 05/27/2025, at approximately 11:20 AM, review of the Controlled Substances Check Form for the month of May 2025 for the second floor Cart B medication cart indicated for 4 shifts in May 2025, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 05/18/25, 3rd shift (11:00 PM-7:00 AM) On 05/19/25, 1st shift (7:00 AM-3:00 PM) On 05/23/25, 1st shift (7:00 AM-3:00 PM), 2nd shift (3:00 PM-11:00 PM) On 05/27/2025, at approximately 11:40 AM, review of the Controlled Substances Check Form for the month of May 2025 for the second floor Cart A medication cart indicated for 6 shifts in May 2025, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 05/01/25, 3rd shift (11:00 PM-7:00 AM) On 05/03/25, 3rd shift (11:00 PM-7:00 AM) On 05/04/25, 1st shift (7:00 AM-3:00 PM) On 05/19/25, 2nd shift (3:00 PM-11:00 PM) On 05/24/25, 3rd shift (11:00 PM-7:00 AM) On 05/25/25, 2nd shift (3:00 PM-11:00 PM) Facility policy dated 10/25/2014 titled Controlled Substance Storage documents in part, E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses. F4. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and Form: Controlled Substance Count Record.

Based on observation, interview, and record review, facility failed to follow their policy to ensure call light is within reach for 1 (R86) out of 3 residents reviewed for call lights in a total sample of 35. Findings Include: On 05/27/2025, at 11:30 AM, surveyor observed R86's foot of the bed is by the call light switch. R86's call light string was hanging on the floor. R86 was unable to reach her call light. R86 stated she cannot find her call light. R86 stated that she asked the staff multiple times to place the call light switch by her head. On 05/27/2025, at 11:35 AM, surveyor asked V18 (Registered Nurse) to come to R86's room. V18 stated R86 is totally dependent and needs help getting out of bed out of bed. V18 stated that R86 needs help transferring to the wheelchair. Surveyor asked V18 if she could locate R86's call light. V18 found R86's call light on the floor at the foot of R86's bed. V18 then picked up the call light and clipped it to R86's gown. V18 stated that she will call someone to better locate R86's call light. V18 stated that it is important for residents to have their call lights within reach so they can voice their needs. V18 stated that if call lights are not within reach, residents are unable to voice their needs. On 05/28/2025, at 2:00 PM, V3 (Director of Nursing) stated that all call lights are to be within reach of the residents. It should be within reach so the residents can voice their needs. V3 stated that if call lights are not within reach, residents are unable to voice their needs. R86's fall care plan documents in part: Keep call light within reach of the resident. R86's care policy documents in part: Place call lights within the reach of the resident. Facility's Answering the call lights policy (08/2008) documents in part: When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interviews and records review, the facility failed to assess and conduct investigations for allegations of physical abuse for one (R1) resident in a sample of three reviewed. Findings include: R1's medical diagnosis includes but not limited to: Cerebral Palsy, unspecified, Schizoaffective disorder, unspecified, Morbid (severe) obesity, Unspecified Psychosis not due to a substance or known physiological condition, Bipolar disorder, unspecified. R1's MDS (Minimum Data Set) section C dated 01/06/2023 documents R1's Brief Interview for Mental Status (BIMS) as 13/15, indicating R1 has intact cognitive functional abilities. MDS section GG-Functional Abilities documents R1 needs Substantial/maximal assistance, dependent on staff for Activities of Daily Living (ADL) care, uses a mechanical lift for transfer and uses a manual wheelchair for mobility. On 02/01/2025, at 1:33 PM, R1 stated that last year (no date provided) during a mechanical lift transfer, staff hurt her knee and she thought staff did it intentionally, therefore R1 called emergency services because she was in pain, and she also informed V7(Registered Nurse-RN) but nothing was done. Nursing progress noted dated 10/07/2024, document R1 reported to V7 (Registered Nurse-RN) that R1 called emergency services stating staff hurt her during mechanical lift transfer. On 02/01/2025, at 12:44 PM, V7 (Registered Nurse-RN) stated he was R1's nurse on 10/07/2024, when R1 reported to him that during mechanical transfer, staff had injured her knee. V7 stated he did not assess R1, and he did not notify R1's physician because R1 has behavioral health issues and V7 did not think R1 was injured during transfer, therefore V7 notified Social Services instead. V7 stated he should have assessed R1 for any injuries and based on his findings, notify R1's physician and V1 (Administrator), so that R1's allegation of being hurt by staff during mechanical lift transfer can be investigated. On 02/01/2025, at 3:03 PM, V2 (Director of Nursing-DON)stated when R1 reported to V7 that during mechanical lift transfer, R1's knee was hurt by staff, V7 should have assessed R1 to make sure there were no injuries, notified R1's physician, V1 and V2 so that the physician can give orders for R1 and allegation of physical abuse can be investigated to determine if R1 was hurt intentionally or if it was an accident. V2 stated assessing and investigating allegations of abuse helps prevent resident abuse. V2 stated if V7 did not document his findings, then it was not done. On 02/01/2025, at 3:26 PM, V1(Administrator) stated that when R1 notified V7 that R1 was hurt during mechanical transfer on 10/07/2024, and that R1 had called emergency services, V7 should have notified R1's physician, V1 and V2 so that the allegation can be investigated to determine if R1 needed to be sent to the hospital for further assessments and possible treatment. V1 stated not reporting an allegation of abuse or incident can put a resident in danger. V2 stated she does in-services for reporting incident report to staff once a year and as needed. Policy titled: Abuse Prevention Policy dated 10/2022 documents: -Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Policy titled Hoyer (Mechanical) Lift documents: A Hoyer (Mechanical) lift assists staff to lift and move a resident as safely and as easily as possible.

Based on interview and record review the facility failed to report alleged abuse allegations to the proper authorities within the prescribed time frame for one [R1] of three [R3, R4] residents reviewed for abuse. Findings Include: R1 clinical record indicate the following: R1 is a thirty-nine-year-old admitted with medical diagnosis including but not limited to cerebral palsy, schizoaffective disorder, chronic obstructive pulmonary disease, morbid obesity, hypertensive heart disease, sleep apnea, psychosis, bipolar disorder, and mood affective disorder. R1's minimum data set brief interview indicates R1 is cognitive intact. R1's care plan: 12/23/24, R1 has persistent mental illness. R1 experienced psychosis in the form of both auditory hallucinations [hearing voices, information in her head often of a negative nature] and delusional [falsely believing things that never happened, not true nor valid]. R1 made an allegation against staff member that may be the result of a disordered thinking R1 told a staff member certified nurse assistant, broke her legs while receiving patient care. R1 psychosis, hallucinations, and delusions will not interfere with R1's participation in ADL care. R1 will work with staff to reality test her thoughts and beliefs. 11/27/23, R1 is at risk due to verbal aggression, poor symptom management and treatment noncompliance. R1 made an allegation of abuse against staff, history of refusing care despite encouragement. 12/10/24, R1 has dysregulated behavior. Display multiple behavior symptoms. R1 has chronic mental illness and thinking, and judgement are compromised. R1 becomes angry, agitated, and impulsive. R1 has limited ability to manage distress. 12/10/23, R1 grabbed and hit a certified nurse assistant that came into my room to provide assistance. R1's progress notes: V7 [Registered Nurse]: 11/15/2024, 1:25 PM, The CNA [V8 Certified Nurse Assistant] taking care of R1 called me to R1's room. R1 is being verbally rude and aggressive and not wanting V8 to care for her. Writer went and asked R1 if she wanted V8 to continue the care and R1 said 'yes it's her job, V8 should change me and get me up so I can call the police and tell them V8 hit me. Writer said that is fine and the CNA [V8] completed her work and writer helped get R1 up in her wheelchair. R1 then proceeded to call the police. Social service was called and informed of the situation. V7 [Registered Nurse]: 11/19/2024, 1:49 PM, R1 made false accusations towards a CNA who was not assigned to her, that the CNA was digging his hands into his pants while standing in front of the nursing station, with other resident and staff around. Interviews: On 2/1/25, at 10:20 AM, R1 stated, All the staff members have fondled my breast all time every day. I do not know their name or what they look like. I have very large breasts and the staff like to play with them while washing me up and changing my clothes. The staff be lifting up my breast and moving them around washing underneath them, but I don't like them touching my breast. I could hold up my breast while the staff wash me, but I will not hold up my breast, they are heavy. The staff is getting paid to wash me up, I should not have to help them. When I got clean up today and dressed, my breast was not fondled. The president of the United States told me I can run any marathon I want to be in. I called the police, because I heard the current president is sending people back to where they belong. It is a lot of Africans here and I will call the police today so they can come and round up all the Africans and send them back to [NAME], before they touch my breast again. I be wet all the time the nurse assistants don't want to clean me up, because they do not like me. I have a menstrual cycle every month. My menstrual cycle came in November, December, and January. I do not have any concerns regarding my monthly cycle. I like being here in this facility. I have not been abused and I feel safe here. No one has called me any names, because I would have called the police. On 2/1/25, at 1:30 PM, V7 [Registered Nurse] stated, On 11/15/24, Certified Nurse Assistant [V8] asked me to speak to R1 because she was being verbally abusive to her [V8]. I asked R1 did she want V8 to continue given her [R1] ADL care and to get her dressed. R1 told me it was okay because it was V8's job to provide care. R1 also said, once I get dressed and, in my wheelchair, I'm going to call the police and tell them that V8 hit me. I told her that was fine and V8 continued to get R1 cleaned, dressed and I assisted V8 placing R1 into her wheelchair. R1 did in fact call the police. I did not report the allegation of abuse to the administrator, because R1 makes false allegations often. I documented the incident as a behavior note. I did not notify the administrator, director of nursing nor nursing supervisor, because I felt it was a behavior. On 11/19/24, R1 said the male certified nurse assistant put his hands inside of his pants at the nursing station facing her [R1]. I was at the nursing station typing. I could not see everything and everyone was moving around the nursing station. I did not report the allegation to the administrator or director of nursing because I felt the allegation was not true. I completed abuse training a few months ago. The abuse coordinator is the administrator. I know when to report abuse. For R1, her allegations are behavioral and delusional. On 2/1/25, at 2:15 PM, V8 [Certified Nurse Assistant] stated, On 11/15/24, R1 started to yell and swear at me during the ADL care process. R1 sometimes would be in a different mood and start yelling for no apparent reason. R1 was easily agitated, and tried to hit me, but a moved out the way. I left the room and got the nurse [V7] to assist me. I told V7 that R1 tried to hit me while I was providing care. V7 came into the room and spoke with her and calmed R1 down and asked was it alright if I proceeded to get her [R1] dressed and washed up. R1 said it was okay and that it was my job to do so anyway. R1 also reported to the nurse [V7] that I hit her after she knew that she tried to hit me. Also, R1 told me and V7 that once she gets up, she was going to report me to the police. V7 and I got her up in the wheelchair and R1 called and reported me to the police. I did not report the incident to the administrator nor director of nursing because I thought V7 was going to report the incident. On 11/19/24, I was not present at the nursing station to witness any male staff placing their hands in their pants. I received abuse training around December. The abuse coordinator is the administrator. On 2/2/25, at 8:52 AM, V16 [Licensed Practical Nurse] stated, R1 is smart, manipulative, and likes attention. R1 also has a lot of delusions with everyone. I hear her on her cell phone all the time having delusional conversations with the president of the United States and other people, but no one is on the other end of the phone. R1 likes to control everything, refuses care all the time. On all three shifts from time to time I work all three shifts and I'm very familiar with R1. There is a two person assist at all times with R1, due to so many accusations of abuse and delusions. However, if R1 tells me of any allegations I will report the allegation to the abuse coordinator. It is not up to me if the allegation is false or not. R1 has not reported staff calling her names. R1 receives care and supervision appropriately, from two person assist. On 2/2/25, at 9:30 AM, V17 [Licensed Practical Nurse] stated, R1 makes frequent allegations in the past, but R1 has two person assist at all times, which has slowed down the allegations. One day R1 told me that my hair was ugly and rough, that I need to be deported back to [NAME] and R1 called the police to come pick me up and deport me back to [NAME]. Even if I am having a conversation with another staff or resident R1 would join the conversation and think we were talking about her [R1]. Often R1 refuses ADL care, even if she is wet. Until she feels like being changed. R1 has not reported to me that staff or other residents has called her names. If R1 reported an allegation of abuse to me, I would immediately report it to the administration. If it involved a staff member, I would separate the two. The administrator is the abuse coordinator, I received abuse training about four months ago. On 2/1/25, at 3:15 PM, V1 [Administrator] stated, I was the assistant administrator here for five years, and the administrator for two weeks. If there were any abuse allegations while I was the assistant administrator, I would have been involved and made aware. I was not made aware of the reported allegations to V7 on 11/15/24, and 11/19/24 involving R1. I was not made aware on any recent allegation from R1 alleging staff members had fondled her [R1] breast, until today. I will submit the initial report to IDPH (Illinois Department of Public Health) today and start an investigation. All new hires receive abuse training and a test during orientation. All staff receives abuse training annually and as needed. I make rounds and talk with R1 often at least a few times per week. R1 has not reported any allegations of abuse. R1 does have delusions, psychosis, and bipolar disorder. Due to R1's delusions, R1 requires at all times two person assist. All staff received abuse training and know to notify the administrator of all alleged abuse allegations for proper investigations. V7 should have reported all allegations from R1 to me, immediately. It is not his responsible to determine if the allegations were true or not. V7 will be educated today. On 2/1/25, at 3:35 PM, V15 [Nurse Consultant] stated, I been working with this facility for three years. I am familiar with R1. All staff knows to report all allegations to administrator. If is not up for staff to determine if the allegation was substantiated or not. Licensed Practical Nurses [V10, V11, V14] and Certified Nurse Assistants [V8, V12, V13] all said they received abuse training, and the abuse coordinator is the administrator. They all said they report any allegations of abuse immediately to the administrator. Policy documents in part: Facility affirms the right of our residents to be free from abuse. Employees are required to report any incident, allegation or suspicion of potential abuse. Staff to observe, hear about, or suspect to the administrator. When an allegation of abuse has been made, the administrator shall notify IDPH, local law enforcement within two hours.

Based on observation, interview and record review the facility failed to ensure food in the walk-in cooler/freezer was labeled with a date indicating when the item was placed into the walk-in cooler/freezer. This failure has the potential to affect all 174 residents in the facility who are receiving an oral diet. The findings include: On [DATE] at 9:50am while inside the walk-in cooler, observed one 48-ounce package of chopped spinach not in a case and not labeled with the date it was placed in the walk-in cooler and one opened box (10 cans in the box) of non-diary whipped topping not labeled with a date it was placed in the walk-in cooler. On [DATE] at 2:15pm V5 (Dietary Supervisor) stated the purpose of labeling/dating the food containers in the walk-in cooler and freezer is so that staff can monitor when to use the foods that are put into the walk-in cooler and freezer. V5 stated the staff has 30 days to keep the food items in the walk-in cooler and freezer once the food items have been dated with an in- date. V5 stated the cooks and dietary aids are responsible for labeling food items when the food items are placed in the walk-in cooler and freezer. V5 stated it is my expectation that the kitchen staff label food items when the food items are initially placed into the walk-in cooler and freezer. V8 stated if a food item is not labeled with a date it was placed into the walk-in cooler or freezer, the food item is at risk for expiring. V5 stated if a resident consumes expired food, the resident can get sick. V5 stated there are no residents in the facility who are NPO (nothing by mouth). Reviewed the Facility's Policy Labeling and Dating Foods (Date Marking) from the Health Technologies, Inc. Guideline & Procedure Manual, 2016 Edition which documents in part, Guideline: All foods stored will be properly labeled according to the following guidelines. Procedure 3. Date marking for freezer storage food items. Unopened cases of frozen food items will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Frozen food packages removed from the case will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Reviewed the facility's undated Dietary Aid Job Description which documents in part, Ensure that safe food handling procedures are being consistently maintained. Follow all dietary policies and procedures. This includes, but is not limited to, Proper sanitation procedures, proper food, and chemical storage procedures.

Based on observation, interviews and records reviewed, the facility failed to ensure residents on enhanced barrier precautions (EBP) had EBP signs posted at their rooms, that staff were using Personal Protective Equipment (PPE) when providing care for residents and that the residents' PPE bins were available and stocked. These failures affected 4 (R24, R43, R83, R165) residents and has the potential to affect all 174 residents in the facility. Findings include: On 06/23/2024 at 11:14 am, observed V12, Certified Nursing Assistant (CNA) with no gloves or gown on, adjusting R43's diaper, under pad and sheets. R43 observed with indwelling foley catheter. There was no Enhanced Barrier Precaution sign on the door of R43's room. The was no Personal Protective Equipment (PPE) bin outside R43's room. On 06/23/2024 at 11:20 am, V12 (CNA) stated Enhanced barrier isolation is pretty much when you gown and glove up. We use isolation when there is a sign on the door, or the nurses will let us know who to use isolation on. The resident R43, that I was just caring for is not on isolation. Normally we have in-services on infection control, or we would ask the nurse or treatment nurse. On 06/23/2024 at 11:27 am, V11 (Licensed Practical Nurse/LPN) stated, I am supposed to use EBP when hands on care to the resident is being done. We use EBP for everybody that has a sign on the door, for residents with wounds and foleys to protect them (residents) from us (staff). R43's room does not have a sign on the door. R43 should have an EBP sign on R43's door because he has a foley. On 06/23/2024 at 12:13 pm, V11 placed EBP sign to R43's door. R43's diagnosis includes but are not limited to Benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, presence of urogenital implants: indwelling urinary catheter. R43 has a pressure ulcer to left ear, last documented assessment 06/20/2024. Current wound care orders to left posterior ear, cleanse with normal saline pat dry and apply dry dressing 3 times a week and prn. R43's Care plan dated 05/01/2024, in part R43 is on enhance barrier precautions r/t indwelling catheter, wound. Place sign on door. Wear gown and glove for: dressing, grooming, bathing, showering, transfers, changing of linens and briefs, hygiene care, toileting. Wear gown and gloves for care of indwelling catheter. R43's active physician order dated 06/01/2024 include but not limited: Enhanced Barrier Precaution R/T wound and Foley. The facility's Infection Control Policy dated June 2020 in part 5. The facility provides personnel protective equipment (PPE) which refer to barriers used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. PPE used is based upon the nature of the interaction with the resident and/or the likely mode of transmission. During times when PPE is not sufficient in supply the facility will utilize CDC guidance for Optimizing PPE. Types of PPE include a. Glove, b. Gowns, c. Masks, d. Eye Protection Goggles and/or Face Shields. 9. Systems for monitoring resident care areas, such as urinary catheters, incontinence, wound care, skin care, infusion therapy, dialysis, mechanical ventilation and associated risks. The facility's Enhanced Barrier Precautions Policy dated 04/28/24, in part: 8. Post clear signage on the door/wall outside resident room. 9. Personal Protective equipment is required for all staff providing high-contact resident care activities to include: iv. Providing hygiene, v. changing linen, vi. Changing briefs or assisting with toileting. 19. Enhanced Barrier Precautions are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device. 43351 On 06/23/24 at 10:42 AM, there was an 'Enhanced Barrier Precaution' sign posted by R83's door. There was no PPE bin outside of the room. This observation was pointed out to V13 (Restorative Nurse/LPN) and V13 stated there is no PPE bin outside of his (R83) room. I (V13) think he (R83) is on extra barrier precaution due to his (R83) wound. This surveyor and V13 went inside R83's room to check for PPE bin. V13 stated there is no PPE bin inside his (R83) room. On 06/23/24 at 10:52 AM, V4 (Director of Nursing) stated EBP (Enhanced Barrier Precautions) are for residents with g-tube, foley catheter, colostomy, and wounds. The purpose of placing residents on enhanced barrier precaution is for infection control; to prevent splashes of infection. The sign should be up and there should be a PPE bin outside the resident's room. On 06/23/2024 at 10: 53am, V4 went inside R83's room and stated I (V4) don't see a PPE bin inside the room and there is none outside the room too. R83's (04/18/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R83's mental status as cognitively intact. R83's Census documented that R83 was moved to a new room on 04/08/2024. R83's (05/24/2024-06/24/2024) Physician Order Report documented, in part Diagnoses: peripheral vascular disease. General: Start date: 05/30/2024 - Open Ended. Enhance Barrier Caution r/t (related to) wound. Treatment Flow sheet. General: Start date: 05/15/2024. End Date: 06/23/2024 (DC- discontinued Date) Description: Site: BKA (below knee amputation) cleanse wound with normal saline o wound cleanser. Pat periwound dry. Collagen and xeroform every 3 days and PRN (as needed) if loose/solid (soiled). General. Start Date: 06/23/2024. End Date: Open Ended. Description. Site: _ BKA cleanse wound with normal saline or wound cleanser. Pat peri wound dry. Foam (dressing) three times a week and PRN if loose /solid (soiled). The (06/19/2024) Resident Extra Barrier Precaution list included R83 (for wound). The (undated) Enhance Barrier Precautions policy documented, in part Policy. Enhanced Barrier Precautions is designed to reduce transmission of multi drug resistant Organism (MDRO) and extensive drug resistant Organism (XDRO) in nursing homes. It is the policy of this facility that Enhance Barrier Precautions, in addition to standard and contact precautions will be implemented during high contact resident care activities when caring for residents that have an increased risk for acquiring a multi drug resistant Organism such as a resident with wounds. Overview. The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDROs (multidrug resistant Organism) to employee's hands and clothing during cares beyond situations in which staff anticipate exposure to blood or body fluids. Pathogen-based approach will be used in the facility which will involve the use of gown and gloves during high contact activities for resident. A risk based approach will be used when residents have increased risk for acquiring MDRO or XDRO such as residents with wounds. Procedure 9. Personal protective equipment is required for all staff providing high contact resident care activities to include: viii. Wound care: any skin opening or requiring a dressing. 45644 R165's admission diagnoses include but not limited to malignant neoplasm of colon, colorectal cancer, malignant neoplasm of rectosigmoid, and diabetes. On 6/23/24 at 10:38 am, R165 had an Enhance Barrier Precaution (EBP) sign on R165's door with a PPE (Protective Precaution Equipment) bin outside of R165's door with no gowns in the bin. R165's Physician Order Report documents in part, Enhance Barrier precaution r/t (related to) indwelling catheter. R165's care plan documents in part, Problem: R165 is on enhance barrier precautions r/t indwelling catheter, colostomy . Approach: .Keep bin place outside of R165's door stocked with PPE. R24's admission diagnoses include but not limited to diabetes, mellitus, hypertension, benign prostatic hyperplasia, gastro-esophageal reflux disease, and urogenital implants. On 6/23/24 at 10:45 am, R24 had an Enhance Barrier Precaution sign on R24's door, with no PPE bin outside of R24's door. R24's Physician Order Report documents in part, Enhance Barrier precaution r/t (related to) indwelling catheter/ G-tube (Gastrostomy-tube). R24's care plan documents in part, Problem: R24 is on enhance barrier precautions r/t peg tube, stoma site. Approach: Wear gown and gloves for care of g-tube and feedings. On 6/25/24 at 10:00am, V4 DON (Director of Nursing) stated that the supply person should restock the PPE bins. The nurse and CNA (Certified Nursing Assistant should notify the supply person when supplies are needed. PPE supplies consist of gloves, mask, and gowns. They should be available for care at all times. On 6/25/24 AT 12:05 PM. V8 ADON (Assistant Director of Nursing) stated that every resident on EBP should have a bin that contains the gloves mask, gown. The nurse or CNA should notify the stock person when stock is needed. Every resident in an Enhance Barrier Precautions room should have supplies available when needed for care. The bin should be outside the resident's rooms. The facility EBP sign documents in part, Provider and Staff must wear gloves and gown for the following high contact Resident Care Activities .Device care or use: .urinary catheter, feeding tube . The facility CNA (Certified Nursing Assistant) job description documents, in part, DUTIES/RESPONSIBILITIES/FUNCTION: 14. Make sure that necessary supplies are available . The facility LPN (License Practical Nurse) job description documents, in part, DUTIES/RESPONSIBILITIES/FUNCTION: 11. Ensure that an adequate supply of floor stock .supplies and equipment is on hand to meet the nursing needs of the residents .

Based on observation, interview and record review, the facility failed to ensure a resident's adaptive equipment was functional. This failure affected 1 (R68) resident reviewed for adaptive equipment in the total sample of 59 residents. Findings include: On 06/23/24 at 12:16pm, R68 was sitting on a wheelchair. R68 stated I (R68) have an issue with my (R68) wheelchair. The brakes are both broken. I (R68) got the wheelchair a couple of months ago. This surveyor requested R68 to engage the brakes; the brake on the right was not touching the rear wheel and the brake on the left was loose. The wheelchair moved while the brakes were engaged when R68 propelled the wheelchair. On 06/23/24 at 12:23 PM, this surveyor requested V8 (Assistant Director of Nursing) to check R68's wheelchair and R68 stated the wheelchair brakes are not tight; the one on the right is loose and the one on the left need's adjustment. We (facility) are going to provide a new wheelchair immediately. The purpose of the wheelchair brakes is to steady the wheelchair; for safety, to prevent falls. It is a concern. The restorative is responsible for checking the wheelchair every day; to make sure the wheelchairs are functional and safe to use. On 06/23/2024 at 12:43pm, V10 (CNA/Restorative Aide) stated I (V10) don't know how long she (R68) has been using the wheelchair. On 06/26/2024 at 9:55am, V4 (DON) stated the reason for maintaining the wheelchair, is for the safety of the resident because we (facility staff) don't want the resident to fall or cause any harm to the resident. If broken and not functioning, it may cause harm to the resident; they may fall. Or the resident might not use it and be limited and prevent them from moving around. R68's (05/24/2024-06/24/2024) Physician Order Report documented, in part Diagnoses: cervical disc degeneration and quadriplegia. R68's (05/01/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R68's mental status as cognitively intact. Section GG. GG0120. Mobility Devices: C. Wheelchair. GG0170. Does the resident use a wheelchair? 1- yes. R68's (11/03/2023) care plan documented, in part Problem: at risk for deterioration in bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit. Goal: will not deteriorate in ADL (activities of daily living). The (undated) Restorative Care Nurse Job Description document that, in part The primary purpose of your job position is to perform restorative nursing procedures that maximizes the resident's existing abilities emphasize independence instead of dependence and minimize the negative effects of this ability with an attitude of realistic optimism under the supervision of restorative nurse. Equipment and supply function. Provide necessary equipment for resident to perform required therapy or treatment. The (02/2014) EVALUATION CRITERIA FOR MEDICAL EQUIPMENT PROGRAM documented, in, part Policy Specifications: 1. All medical equipment used in the care of residence will be evaluated prior to use based on functions and physical risk associated with maintenance requirement.

Based on observation, interview and record review, the facility failed to clean and correctly log refrigerator temperatures for one resident's (R135) personal refrigerator. Findings include: On 06/23/2024 at 11:15am observed a black colored refrigerator in R135's room. Observed a temperature log affixed on the front of the refrigerator door. The temperature log was missing the documentation of a temperature reading for the following dates: 6/14/2024, 6/20/2024 and 6/21/2024. Observed a black substance on the thermometer located on the top shelf inside the refrigerator. The refrigerator contained two Styrofoam cups with drinks inside and a bottle of water. On 06/23/2024 at 12:15pm R135 stated the staff clean the refrigerator in my room once a month and the staff check the temperature in the refrigerator once a month. On 06/25/2024 at 10:29am R135 stated staff have not told me I need to clean my personal refrigerator. R135 stated I don't know what that black stuff is on the thermometer in the refrigerator. On 06/25/2024 at 10:43am V18(Housekeeper) stated I am responsible for cleaning the resident's personal refrigerator. V18 stated the housekeepers are responsible for taking the temperature in the resident's personal refrigerator and logging the temperature for the day. V18 stated I don't know what that black substance is on the thermometer in the resident's personal refrigerator. On 06/25/2024 at 12:06pm V19(Maintenance Director) stated the housekeeping staff are to check and log the temperature in the resident's personal refrigerator daily. V19 stated it is my expectation that the housekeeping staff check the temperature in the resident's personal refrigerator daily. V19 stated the housekeeping staff is to clean the resident's personal refrigerator daily. On 06/25/2024 reviewed the undated Housekeeping Aid job description which documents, in part, the primary purpose of this position is to: Provide housekeeping services to assure that a clean, orderly, and homelike environment is maintained in accordance with current federal, state, and local regulations. Clean all equipment and furniture as assigned. All other duties as assigned. On 6/25/2024 reviewed the facility's policy titled Use and Storage of Outside Foods in Resident's Room dated 10/01/2022 which documents in part, Refrigerator in Resident's room [ROOM NUMBER]. Check and monitor internal temperatures. R135's diagnosis includes but are not limited to, Multiple sclerosis, schizoaffective disorder, unspecified, Hemiplegia, unspecified affecting left nondominant side, Hereditary and idiopathic neuropathy, unspecified, Hyperlipidemia, unspecified, and Hereditary and idiopathic neuropathy, unspecified. R135's Brief Interview for Mental Status (BIMS) dated 04/23/2024 documents R135 has a BIMS score of 11 which indicates that R135's cognition is moderately impaired.

Based on interview and record review, the facility failed to rescreen a resident to determine if specialized services under the Preadmission Screening and Resident Review requirements are necessary. This failure affected 1 (R153) resident reviewed for PASRR screening in the total sample of 59 residents. Findings include: R153's ([DATE]) Notice of PASRR (pre-admission screening and resident review) Level I Screen Outcome documented, in part PASRR Level Review Date: [DATE]. PASRR Level I Determination: Convalescence Categorical. Approval period: 60 days. Suspected or confirmed PASRR condition(s): Mental Health Disability. PASRR outcome explanation. Notice of criteria met for convalescence categorical-no PASRR Level 2 required. Your Level one screen shows you have evidence of serious mental illness. Further PASRR evaluation is not required because you meet criteria for a short term convalescence admission. This means you may stay for a limited number of days in a Medicaid certified nursing facility without further PASRR evaluation. If you or your care provider thinks you need to stay longer than the number of approved days listed on the notice of PASRR Level one screen outcome that came with this letter, a nursing facility staff member must submit a new Level one screen to M****** . This must be completed by or before the last approved date after your admission to the nursing facility. This Level I screen is good within 90 calendar days of the notice date listed on the notice of PASRR Level one screen outcome. After that time, any nursing facility you admit to must submit an updated Level 1 screening form to M****** . Outcome. Rationale: 60 day convalescent care approval- a 60 day or less stay in the NF (nursing facility) is authorized. Re-screening must occur by or before the 60 day if the individual is expected to remain in the nursing facility beyond the authorization time frame. On [DATE] at 10:47am, V26 (Psychiatric Rehabilitation Services Director) stated the purpose of pre-admission screening is to determine the need of the resident. In reference to the PASRR recommendation, V26 stated the expectation is to follow the recommendation stipulated in the PASRR. On [DATE] at 10:49am, this surveyor showed V26's R153 Notice of PASRR Level I Screen Outcome. V26 stated it means the person needs to be re assessed within 60 days from the date written in the M****** (PASRR). He (R153) is expected to be rescreened on ,d+[DATE]. I (V26) will check with Admission Director (V20) if there's another PASRR for him (R153). On [DATE] at 11:34am, V26 stated we don't have PASRR for him (R153) after the ,d+[DATE] screening. The only thing we (facility staff) have is the expired ,d+[DATE] screening. On [DATE] at 2:20pm, V26 stated his (R153) rescreening is submitted today. It was not done within the 60 days per ,d+[DATE] PASRR recommendation. R153's ([DATE]-[DATE]) Physician Order Report documented, in part Diagnoses: Bipolar disorder. R153's ([DATE]) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R153's mental status as cognitively intact. Section I. Active Diagnoses. Psychiatric/Mood Disorder. I5900. Bipolar Disorder. Section N - Medications. N0415. High risk drug classes: use and indication. A. Antipsychotic. N0450. Antipsychotic Medication Review. A. Did the resident received antipsychotic medications since admission/entry or reentry or the prior OBRA assessment? 1- yes. R153's ([DATE]) State PASRR (pre-admission screening and resident review) documented, in part Reason for Screening. What is the purpose of this Level I screen. A previous PASRR short -term approval for nursing facility stay has expired (e.g. Convalescence.) Assessment Submitted by V26. The (Undated) Social Service Designee Job Description documented, in part Purpose Of Your Job Position. The primary purpose of your job position is to assist in planning, developing, organizing, implementing, evaluating, and directing our facilities social service programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. Administrative function. Participate in resident assessment.

Based on observations, interviews, and record review the facility failed to ensure that the residents indwelling catheter drainage bag is covered. This failure affected one resident (R165) reviewed for dignity in the sample of 59 residents. Findings Include: R165's admission record includes diagnoses of malignant neoplasm of colon, colorectal cancer, malignant neoplasm of rectosigmoid, and diabetes. R165's (5/11/24) Minimum Data Set documented, in part Section C. Cognitive Patterns. BIMS (Brief Interview for Mental Status) score is 15. R165 is cognitively intact. Section H. Bladder and Bowel: H0100. Appliances check all that apply: A. Indwelling catheter. On 6/23/24 at 10:40 am, R165 indwelling catheter drainage bag was hanging from the bed frame facing the hallway not covered with a privacy bag. On 6/23/24 at 10:50 am, V24 LPN (License Practical Nurse) stated that the urinary drainage bag should be covered with a privacy bag for dignity. On 6/25/24 at 10:00am, V4 DON (Director of Nursing) stated that the urinary drainage bag should be covered in a privacy bag to allow privacy and dignity to the residents. On 6/25/24 at 12:05 pm, V8 ADON (Assistant Director of Nursing) stated that urinary drainage bag should not be on the floor and should be covered in a privacy bag for the dignity of the residents. R165's (6/25/24) Physician Order Report documents in part, Catheter-Indwelling Catheter, Size: 16 French. R165's (4/10/24) Care Plan documents, in part, requires a urinary catheter related to diagnosis of presence of urogenital implants. The facility LPN (License Practical Nurse) job description documents, in part, Purpose: Provide License nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines and regulations. DUTIES/RESPONSIBILITIES/FUNCTION: 2. Ensure that all CNA (Certified Nursing Assistant) personal assigned to your unit/area comply with all written policies and procedures established by the facility. The facility CNA (Certified Nursing Assistant) job description documents, in part, DUTIES/RESPONSIBILITIES/FUNCTION: 30. Follow HIPPA (Health Insurance Portability and Accountability Act) confidentiality requirements. Assure each resident's privacy in all facets. Facility Residents Rights for people in long-term care Facilities, documents in part, Your rights to dignity and respect, your rights to privacy and confidentiality: you have a right to privacy and confidentiality . Your medical and personal care are private. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on observation, interview and record review the facility failed to provide adequate supervision to prevent a fall during incontinence care for one (R1) of three residents (R1, R3 and R4) reviewed for falls. This failure resulted in a fall by R1 who sustained a laceration on the forehead and was sent to the hospital emergency room receiving stitches to repair the laceration. Findings include: R1 is a [AGE] year old male resident with a diagnosis including COPD, Paranoid schizophrenia, Heart failure, Diabetes 2, Anxiety disorder, Depressive disorder severe with psychotic features and Obesity. R1 has a BIMS (Brief Interview for Mental Status) score of 12/15. R1's Minimum Data Set section GG scores 1 (Dependent) for toileting, 2 (Substantial / Maximal assistance) for Shower/bath self and 2 (Substantial / Maximal assistance) To roll left and right. R1's care plan dated 4/16/24 shows R1 is at risk for deterioration in bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene. R/T weakness and poor skills. Requires extensive/total staff assistance. R1 is a high risk for falls R/T weakness, poor bed mobility poor safety awareness. R1's 4/21/24 progress note states resident is alert and oriented. Resident was being changed by CNA and accidentally rolled out of bed. Resident has an open area to the right side of his forehead. Resident noted lying on stomach and hitting head on the floor. Forehead cleaned and pressure applied to open area by staff while waiting for ambulance to arrive to take to hospital. Full Body assessment performed. Resident Eyes are reactive to light, Neurological checks provided, and level of conscious is normal. Resident skin is warm to touch and has laceration to left side of forehead. Resident Mucous membrane pink and moist, and no open area to mouth. Resident lung sounds in normal limits, and no respiratory distress noted. Resident heart rate with normal limits. Resident has full range of motion to upper and lower extremities, and no bruise, redness, or open areas to extremities. Resident Abdomen is soft and round, bowel sounds present times 4 quads, and no distention noted. Resident is assisted into bed with 2 person assistance and pressure to the open wound on the forehead to continue to be applied till 911 arrives. Resident has no complaints of pain or discomfort. ADON and Guardian Notified. Physician is notified and gave order to send to hospital. R1's hospital record dated 4/21/24, shows R1 sustained a right forehead laceration, 5 cm laceration to right side of forehead. This required 13 stitches to repair. Facility incident report dated 4/26/24 shows, on 4/21/24 approximately 2:35pm, R1 had a witnessed fall from the bed. The resident slid out of the bed, landing on his face on the floor in his room. The resident was immediately assessed by the nurse on duty and noted a facial laceration and bloody nose. First aid applied, bleeding controlled, 911 called. R1 transferred to ER for further evaluation and treatment. On 4/26/24 at 10:35 AM R1 was observed in his room. R1 was in his bed. R1 had stitches on the forehead and a right black eye. On 4/26/24 at 10:35AM R1 stated the CNA (V3) came to change me. He rolled me over and I fell from the bed to the floor. I hit my head hard. I had to get stitches at the hospital. The CNA was by himself and could not stop me from falling. They usually change me with two people. On 4/26/24 at 10:38AM R1 stated I am not in the original bed I fell from. The mattress on the other bed used to fall off the edge of the bed frame. I almost fell before because of that. On 4/26/24 at 10:40AM V3 (CNA) stated it was on Sunday I went to R1's room to change him. I started to roll him over. The mattress shifted off the edge of bed frame. R1 tried to help by rolling over himself. With me rolling him and him trying to help he went off the opposite edge of the bed and fell to the floor. I tried to stop him, but my hands were wet, and he slipped from my grip. On 4/26/24 at 11:31AM V2 (Assistant DON) stated R1 is a two person assist with transfers but to change it is a one person. V3 (CNA) should know if he needs help to just ask. On 4/26/24 at 12:30PM V5 (Physician) stated R1 had an injury due to his fall from bed on 4/21/24. R1 is sometimes non complaint with ADL care. He had one CNA providing care and as I am aware R1 tried rolling himself over and didn't stop when directed by the CNA. One person for this ADL care is probably ok but two people would have been better. It is unfortunate that this happened. On 4/26/24 at 1:10PM V6 (Restorative Nurse) stated V3 CNA was doing care and instructed R1 to stay still and R1 kept rolling and fell from bed. There was just one staff present. Facility policy titled Fall Reduction Program states including: Objective: 1. It is the policy of this facility to have a Fall Reduction Program that promotes the safety of residents in the facility. The programs intent is to assist clinical staff in determining the needs of each resident through the use of standard assessments, the identification of each residents' individual risks, and the implementation of appropriate interventions, supervision, and /or assistive devices deemed appropriate. Quality Assurance Program will monitor the program to assure ongoing effectiveness.

Based on observation, interview and record review, the facility failed to adequately supervise one resident (R3). This failure affected 1 resident (R3) causing R3 to sustain a right eyebrow laceration with one suture to R3's face. Findings include: R3's Brief Interview for Mental Status (BIMS) dated 03/07/24 show that R3 has no BIMS score and indicates that R3 has memory problems. The facility's initial Reportable Incident to the local state agency dated 03/21/24 at 7:18 pm documents, in part that CNA (Certified Nursing Assistant) reported to the nurse on duty that R3 was observed in a sitting position on R3's bedside floor mat. Upon nurse head to toe assessment and observation, R3 was noted with a 1/2-by-1/2 laceration and minimal amount of blood to the right side of R3's brow. R3 was sent to the local hospital. The facility's final Reportable Incident to the local state agency dated 03/29/24 at 6:34 pm documents, in part R3 returned to the facility the same evening of R3's fall from the local hospital and was noted with one suture to R3's right eyebrow. On 04/08/24 at 12:27pm, R3 was observed sitting across from the fourth-floor nursing station. R3 was alert but unable to communicate verbally with Surveyor. R3 able to point at objects to express R3's needs. R3 was not interviewable for this investigation. On 04/09/24 at 11:54 am, V13 (Registered Nurse, RN) stated that V13 was R3's nurse on 03/20/24 during the time of R3's fall. V13 stated that R3's Certified Nursing Assistant (CNA) informed V13 that R3 was on the floor in R3's room. V13 stated that V13 observed R3 on the floor mat on the side of R3's bed with a small laceration to R3's eyebrow (V13 could not recall which one of R3's eyebrows were affected). V13 stated that V13 applied pressure to R3's eyebrow and called R3's physician who gave an order to send R3 to the local hospital for evaluation. V13 stated that V13 called R3's family to inform them of R3's condition. V13 stated that R3 was sent to the local hospital for evaluation and received one suture to R3's eyebrow and returned to the facility the same day. V13 stated that V13 saw R3 wandering in the hallway ten to fifteen minutes prior to R3's fall on 03/20/24. V13 explained that R3 is a resident known to have frequent falls and that R3's whereabouts are constantly monitored to avoid R3 from falling. V13 also explained that R3 propels R3's wheelchair back and forth in the hallway to the dining room and R3 is always in view of staff. V13 then stated, I (V13) know that R3 is a high risk for falls but on this day I (V13) didn't know where R3 was. It was the beginning of the shift, and I was trying to do a lot of other things that I needed to do for the day. When V13 was asked regarding the importance of supervising residents who are high risk for falls V13 stated, It is important for the resident safety, but we cannot supervise all the time. On 04/10/24 at 10:50 am, V21 (R3's Physician) stated that R3 is a resident who has some levels of dementia and confusion. V21 stated that R3 is a resident who has had frequent falls at the facility and that V21 is not surprised that R3 has not had more falls at the facility. V21 stated that V21 recalls R3 falling on 03/20/24 and V21 gave orders to send R3 to the local hospital for evaluation. V21 explained that R3 received one stitch due to R3's fall at the facility on 03/20/24. V21 stated in V21's professional opinion, it is safer for R3 to have staff supervise R3 to prevent R3 from an injury. On 04/10/24 at 12:58 pm, V2 (Director of Nursing, DON) stated that R3 is a resident that is alert to self, difficult to understand and has difficulty communicating needs. V2 explained that R3 ambulates with a wheelchair, is a high risk for falls, requires supervision and assistance from staff for transfers and R3's care. V2 stated that on 03/20/24 staff reported responding to R3's call light and observed R3 sitting on the floor in R3's room. V2 explained staff did not know how long R3's call device was alarming. V2 then explained that V13 (RN, R3's nurse at the time of R3's fall), assessed R3 on the floor, R3 was observed with a laceration to R3's right eyebrow. V2 explained that V13 called V21 (R3's Physician) who gave orders to send R3 out for an evaluation. V2 stated that R3 was transferred to the local hospital and returned with one suture to R3's right eyebrow. When V2 was asked in V2's professional opinion if a resident is high risk for falls and requires assistance from staff for transfers and care; should they be supervised? V2 stated, Yes. When V2 was asked if a resident who is high risk for falls, sustains a fall, could the resident sustain an injury, V2 stated, In most cases, yes. V2 also stated that nurses and CNAs should be supervising the residents, answering call lights promptly and rounding every hour to check on the residents at the facility. The facility's document dated 12/08/24 through 04/08/24 and titled All Falls For the Facility shows that in the past 120 days, R3 sustained a fall on 03/20/24, 02/13/24 and 01/24/24. R3's progress note dated 03/20/24 at 3:51 pm, authored by V13 (Registered Nurse, RN) documents in part, CNA responded to call light and noted R3 in a sitting position on her floor mat. V13 was called to the room and observed R3 had a small amount of blood to the right side of R3's face . physician notified with orders to send R3 to the local hospital. R3's progress note dated 03/20/24 at 10:39 pm, authored by V13 (Registered Nurse, RN) documents in part, resident back to the facility via ambulance from local hospital with one suture to the laceration to right eyebrow. Sutures to be removed in seven days. R3's care plan dated 03/14/24 documents in part: Problem: R3 is high risk for falling due to unsteady gait, impaired mobility, uses wheelchair for locomotion. Approach: Educate never to transfer without staff assistance . observe frequently and place in supervised area when out of bed. R3's hospital records dated 03/20/24 documents in part that R3 was sent to the emergency room from skilled nursing facility after mechanical fall where R3 struck her head . Irrigated and sutured by physician assistant (PA) at the local hospital. Assessment/Plan: Head injury, Laceration of face (right eyebrow), right hip pain, and left hip pain. R3's Fall Risk Observations dated 01/24/2024, 02/13/2024 and 03/21/24 indicate that R3 is high risk for falls. The facility's undated document titled Routine Resident Checks and Safety Room Checks documents, in part: Routine checks shall be made to ensure the resident safety and wellbeing are maintained. The facility's job description titled LPN (Licensed Practical Nurse)\Charge Nurse documents in part: Purpose: The primary purpose of this position is to: Supervise the day-to-day CNA services for assigned unit to assure that care is being rendered in accordance with current federal, state, guidelines, and regulations . Duties and Responsibilities/Function: 3. Closely monitor and supervise all facility residents per facility policies and as warranted by good nursing judgement.

Based on observations, interviews, and record reviews the facility failed to follow their wound prevention policy to ensure 2 [R7, R10] residents did not develop pressure wounds and the facility failed to prevent pressure wounds from worsening for 1 [R7] resident. These failures resulted in R7 and R10 developing facility acquired pressure wounds; [R7] stage-4 (sacrum), stage-3 (left lateral heel), stage-2 (left fifth toe), and [R10] stage-3 (right ankle). Findings include, R7's clinical record documents in part; medical diagnosis of hypertensive heart disease without heart failure, weakness, need for assistance with personal care, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and bipolar disorder. R7's physician orders and care plan does not document heal protectors as an intervention. R7's physician orders in part: - [5/5/23] Alginate calcium/Santyl Special Instructions: Cleanse sacrum area with normal saline, apply Alginate with silver/Santyl silver cover with gauze island with border. Once A Day. - [5/5/23] Cleanse wound of Left medial foot/Right medial heel with normal: Apply calcium alginate with silver/povidone gel, cover with gauze island with border. Once A Day. - [4/30/23] Leptospermum Honey/iodoform, Special Instructions: Cleanse Right Hip with normal saline, pack iodoform gauze packing strips, apply gauze island with border. On 6/21/23, at 8:03 AM, surveyor observed R7 resting in bed laying on his left side, clean and dry. No heel protector boots in place. On 6/21/23 at 8:04 AM, V6 [Certified Nurse Assistant] stated, I been working here for seven years. I am very familiar with the resident. R7 used to have heel protector boots, but I am not sure what happened to them. On 6/21/23 at 1:04 PM, surveyor observed V23 [Wound Care Physician] and V13 [Wound Care Nurse-Licensed Practical Nurse] assess R7's wounds. V23 stated, R7's sacrum was initially noted moisture associated skin damage on 3/8/23, measured 3.1x 2.9 x0.4cm, today the sacrum area measures 6.2x 5.8x 0.2cm with 2.0cm undermining, and there is muscle tissue exposed, the moisture associated sacrum area is now a stage 4 pressure wound. In the system I am not able to change the site etiology from moisture associated to stage 4 pressure ulcer. Last week (6/14/23), I noticed the muscle exposed, I should have classified the wound a stage 4 at that time, but the computer charting that I use, would not allow me to. Stage-3 left lateral heel facility acquired pressure wound noted on 3/15/23 measured 1.1x 1.3x 0.2cm, the area today measures 1.2x 1.5x 0.2cm. Today a new facility acquired pressure wound stage 2 on R7's left fifth toe with partial thickness, measuring 2.5x 3.6x not measurable. R7 was admitted (12/14/22) with right hip unstageable pressure wound measured 3.8 x 3.9 x 0.2cm, today the is stage-3 pressure right hip wound measures 7.2 x 6.0 x 1.9cm. R7 developed pressure wounds and the right hip worsening due to him being bed bound, moisture, and pressure. I did recommend R7 to keep the heel protector boots on at all times, while in bed. I do not know why R7 does not have them on his feet, now R7 has a new pressure wound on his toe. V18 stated, I do not see the protective heel boots in the room, maybe the boots are in laundry, I am not sure. R10's clinical record document in part: medical diagnosis of: Paraplegia, Essential (primary) hypertension, and asthma. Physician order dated 5/26/23- Apply Calcium Alginate/Leptospermum honey, special instructions: cleanse right lateral ankle with normal saline; cover gauze island with border, once a day. R10's physician orders and care plan does not document heal protectors as an intervention. R10's minimum data set [MDS] Brief Interview Mental Status score= 15. Indicates R10 is cognitively intact On 6/21/23 at 8:38 AM, surveyor observed R10 resting in bed lying on his right side. Right foot was resting on the bed. R10 stated, I was admitted here on 2/10/23, I did not have any wounds. I cannot move myself because I am paralyzed. The staff do not reposition me often. Staff assist me with repositioning maybe once to twice a shift. Laying on my side, for a long time caused me to develop a pressure wound. The nurses clean and dressed my wound maybe three times per week, only because I keep asking them. Most of the nurses tell me no, it is not their job to complete wound care, it is the wound nurse responsibility. I have not had any heel protector boots since I have been here at this facility. Also, when I get dressed and, in my wheelchair, the nurses do not put anything on my feet to protect them from pressure. On 6/21/23 at 11:42 AM, V18 [Wound Care Nurse-Licensed Practical Nurse] stated, I been working here almost a year as the treatment nurse. I been a Licensed Practical Nurse for ten years. I only work on Wednesdays and Thursdays. On Wednesdays I make wound rounds with V23 [Wound Care Physician]. Thursdays I completed my documentation from wound rounds. The staff nurses complete the daily wound care. New admission and re-admissions are assessed, however there were no measurements taken. After I see the resident have a pressure ulcer, I'll fax their face sheet over to V23. The resident is seen on the upcoming Wednesday. At that time V23 will assess the wound and complete measurements. There are times resident's weekly measurements were missed due to V23 being out of town. The wound care treatments continue to be completed. On 6/21/23 at 12:52 PM, V7 [Licensed Practical Nurse] stated, R10 is left out the facility on pass with a family member. On 6/21/23 at 1:15 PM, V23 [Wound Care Physician] stated, On 5/31/23, R10 was noted with a facility acquired pressure ulcer to the right ankle, stage 3 measured 1.6 x 1.9x 0.3cm. On 6/14/23, R10's right ankle measured 1.8 x 2.1x 0.3 cm. R10's right ankle wound got larger due to R10 laying on his side, paralysis, and pressure. I recommended for R10 to have heel protector boots. I do not know why he did not have them on. R10 needs to have them on at all times especially while in bed. That can potentially make his [R10] wound worse due to pressure. R10 left out on pass with family. I will assess and measure his [R10] wound next Wednesday (6/28/23), R10 knew I was going to be here today for wound care, but he left the building anyways. V18 stated, I will let the nurse know that R7 and R10 need their heel protector boots on. Policy Documents in part: Pressure Wound Treatment dated 1/2017 -Provide guidelines for care of exiting pressure injuries and prevention of additional pressure injuries -Pressure injury treatment program should focus on the following: Managing tissue -Wound shows bone, tendon, muscle, joint or ligament the wound is a stage 4 -Off loading pressure -Monitor nutrition and hydration status

Based on observation, interview and record review, the facility failed to perform the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures caused R3's sacral pressure ulcer wound to decline and increase in size. Findings include: R3's Face Sheet documents, in part, that R3 is a [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS), dated [DATE], documents, in part, that R3 has a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R3 is cognitively intact. On 11/29/21 at 12:26 pm, R3 was observed lying in bed with blankets covering R3's body from the waist to the foot of the bed. When this surveyor asked R3 when the last time R3 was turned and repositioned in the bed, R3 stated, Early this morning, but R3 couldn't recall the exact time. R3 stated to this surveyor that nursing staff does not turn and reposition R3 every two hours as ordered. R3 stated that R3 stays in R3's bed in the room. On 11/29/21 at 12:31 pm, V7 (Certified Nursing Assistant, CNA) entered R3's room, and this surveyor requested an incontinence check of R3 from V7. V7 donned gloves and pulled back R3's blanket, and a smell of urine was noted. V7 then left R3's room and returned with donned gloves, towels and clean linen. V7 cleaned R3's labia and groin, and V7 turned R3 to the left side by using the linens underneath R3. V7 stated, There's not supposed to be two of these sheets against the wound. This surveyor verified with V7 that a flat sheet that was quadrupled folded and a thick incontinence pad was in between R3 and the low air loss mattress (LAL) on R3's bed. V7 next pulled back R3's quadruple folded flat sheet and thick incontinence pad that was underneath R3, and a strong odor of urine was noted along with a stain of urine that was observed extending to the borders of the folded sheet. R3's sacral pressure ulcer wound dressing was observed as soiled with a maroon, brown color and not intact. R3's sacral wound dressing was observed as not in contact with R3's wound. This surveyor asked V7 if R3's sacral wound dressing was intact to the wound, and V7 stated, Yes. This surveyor asked V7 if R3's sacral wound dressing was touching the wound bed, and V7 stated, No. I will tell (V8, Licensed Practical Nurse, LPN). V7 completed cleansing R3's rectum and buttocks, and V7 removed R3's sacral wound dressing due to the tape falling off the side of the dressing. V7 did not cover the wound with any dressing and placed a clean, double folded flat sheet under R3. V7 turned R3 to the left side and positioned R1 with a pillow. V7 did not place any barrier cream on R3. On 11/29/21 at 12:36 pm, this surveyor observed a sign posted on the wall in clear view above R3's head of the bed which documents, in part, All Shifts: Please turn resident every 2 hours for wound healing . Apply moisture barrier after each incontinent episode . Per Wound Manager (V14). On 11/29/21 at 12:42 pm, V7 (CNA) stated that she (V7) was R3's assigned CNA. V7 stated that when she (V7) performed the incontinence check per this surveyor's request, it was the first incontinence care that she (V7) provided to R3 since at least 9:00 am this morning. The time frame from 9:00 am to 12:31 pm is approximately three and a half hours. On 11/29/21 at 12:49 pm, V8 (LPN) was observed opening the treatment cart drawers at nurse's station. V8 then pushed the treatment cart in front of R3's room. V8 stated that V14 (Wound Care Coordinator) was not in the facility today and that she (V8) would be performing R3's wound care treatment to the sacral wound. V8 reviewed the green treatment book on top of the treatment cart with R3's treatment administration record (TAR), and V8 said that she (V8) can see R3's order for a [MEDICATION(S)] rinse, but there is no [MEDICATION(S)] rinse in the cart. This surveyor and V8 read together R3's current treatment order from the TAR and retrieved the treatment supplies from the cart and placed them in a clean, clear bag. V8 stated, I washed my hands in the bathroom before I came out with the cart. R3's November 2021 TAR, documented, in part, R3's orders as: Site: Sacrum - Cleanse area with [MEDICATION(S)] rinse with NSS (normal sterile saline); pat dry. Apply gauze packing strips 1 (one inch), Calcium Alginate cover with dry protective dressing once daily and prn (whenever needed); order dated 10/21/21 and Turn and reposition q (every) 2 hrs (hours) and prn; order dated 5/26/20. R3's November TAR contains missing documentation entries noted on dates of: 11/24/21, 11/25/21 and 11/26/21. On 11/29/21 at 12:54 pm, V8 walked over to nurse's station and removed gloves from a box and then knocked on R3's door with right bare hand. V7 was observed in R3's room and had positioned R3 to the left side with a sheet covering R3's body. V8 placed the bagged treatment supplies on top of R3's dresser and removed the gauze packing strips bottle and normal saline syringe and placed them directly on top of the dresser table. V8 donned gloves without performing any hand hygiene and removed dry gauzes from supply bag and opened the normal saline syringe; then squeezed normal saline on the dry gauzes and cleaned R3's sacral wound. V8 doffed dirty gloves and did not perform hand hygiene. V8 did not perform the ordered [MEDICATION(S)] rinse. On 11/29/21 at 12:57 pm, V8 donned new gloves and used her (V8) left hand to hold the bottle of the gauze packing strips. V8 continually pulled out approximately four feet of gauze packing strip from the bottle, then balled up the gauze packing strip with her (V8) gloved hands and placed it on top on R3's sacral wound bed. V8 did not pack the tunneling area of R3's sacral wound. V8 then placed a 6 inches by 6 inches Calcium Alginate dressing on top of the gauze packing strip. V8 then asked V7 to hold the Calcium Alginate dressing in place, which V7 did with her (V7) gloved hand, while V8 removed the 4 inches by 4 inches dry border, protective dressing. V8 stated that she (V8) needed to date the outside of the dry border, protective dressing, so staff would know when it was changed. V8 then removed V8's gloves and walked out of room. V8 did not perform any hand hygiene. V8 opened all drawers of the treatment cart that was positioned directly outside R3's room. On 11/29/21 at 1:00 pm, V8 yelled out to R4 who was attempting to stand up from the reclining wheelchair in the hallway. V8 walked over and repositioned R4's legs back into the reclining wheelchair. On 11/29/21 at 1:01 pm, V8 walked over to nurse's station sink and washed her (V8) hands with soap and water for only 10 seconds. V8 then entered R3's room where V7 was still holding the Calcium Alginate dressing on top of R3's sacral wound. V8 then donned new gloves, dated the 4 inches by 4 inches dry border, protective dressing with 11/29/21 date and placed it on top of the 6 inches by 6 inches Calcium Alginate dressing. V8 attempted to attach the left side of the border dressing to R3's left buttock cheek, but it didn't stick to the skin. V8 then pressed the remainder of the dry border dressing on top of the Calcium Alginate dressing where the three remaining sides of the dry boarder dressing did not cover the outer edges of the Calcium Alginate dressing. This surveyor asked V8 if R3's wound dressing is intact to R3, and V8 stated, That's the order in the box. I didn't have a bigger gauze (dry border dressing). I used what I had. There was no supply. I had to use the small one (dry border dressing). On 11/29/21 at 1:03 pm, after V7 and V8 completed R3's sacral pressure ulcer wound care dressing change, V7 did not place any barrier cream on R3. V21 (Wound Physician) documented, in part, in R3's Wound Evaluation and Management Summary on 11/18/21 that R3's dressing treatment plan is to add [MEDICATION(S)] gel daily; continue the primary dressing of Calcium Alginate and gauze packing strips; and the secondary dressing gauze island with border dressing. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Special instructions: May keep at bedside for CNA to apply. Every shift; days, evenings nights and Turn and reposition q (every) 2 hours & (and) prn (whenever needed). Every shift; days, evenings, nights. R3's POS, documents, in part, order dated 5/29/20, Pressure reducing mattress. Continuous; days. R3's POS, documents, in part, order dated 10/21/21, Site: Sacrum - Cleanse area with [MEDICATION(S)] rinse with NSS (Normal Sterile Saline), pat dry. Apply gauze packing strips 1 (one inch), Calcium Alginate cover with dry protective dressing once daily and PRN. R3's POS, dated 11/19/21, documents, in part, current active order, [MEDICATION(S)] gel, 1 % (percent); Topical; Once A Day; 9:00 am. V8 did not apply the [MEDICATION(S)] gel during this surveyor observation of R3's observed wound care treatment on 11/29/21. On 11/29/21 at 1:07 pm, when asked how long V8 (LPN) should wash her (V8) hands with soap and water, V8 stated, 20 seconds. When asked about the wound care treatment order and supplies, V8 stated that she (V8) goes by the physician treatment order in the treatment book on top of the treatment cart. V8 stated that there are more treatment supplies in the basement of the facility and that V14 normally sets up the treatment cart with supplies. V8 stated that if the supply is not in the treatment cart, she (V8) will usually ask V15 (Central Supply Staff) for the supplies. When asked if V8 called V15 about treatment supplies not stocked in the treatment cart, V8 admitted that she (V8) did not call V15 because she (V8) was in the middle of it and she (V8) did not check before I (V8) ever got started. When asked about the dry border, protective dressing being smaller in size than the Calcium Alginate dressing, V8 stated that she (V8) didn't have a big border dressing in the treatment cart. V8 stated that one sheet should be used on a LAL mattress. R3's Care Plan, dated 1/7/20, documents, in part, that R3's problem of a Stage 4 pressure ulcer to sacrum, will be treated with the following approaches: Assess the pressure ulcer for location, stage, size (length, width and depth), presence/absence of granulation tissue and epithelization. Keep clean and dry as possible. Minimize skin exposure to moisture. Keep resident off wound site. Provide incontinence care after each incontinent episode. Turn and reposition every 2 hours. R3's Care Plan, dated 5/12/21, documents, in part, that R3's problem of incontinence, will be treated with the following approaches: Apply moisture barrier to skin as needed. Keep perineal area clean and dry. Provide incontinence care after each episode. V7 stated that R3 does not wear an incontinence brief because it would keep the wound moist. On 11/30/21 at 1:08 pm, V14 (Wound Care Coordinator) stated that she (V14) is the only wound care nurse in the facility, and when she (V14) is not working, the floor nurses will perform the wound care treatments. When asked about the wound care treatment process from start to finish, V14 stated that the ordered treatment is located in the green treatment book on every floor and in the electronic medical record of the resident. V14 stated that nurses must follow that specific order because that's what I (V14) get from the (wound) doctor. V14 stated that she does prepare and fill the treatment cart with supplies, and if the floor nurses find a lack of supplies in the cart, they are to contact V15 (Central Supply Staff) or V2 (Director of Nursing, DON). V14 stated that the nurse should wash hands before entering room or use alcohol based hand sanitizer (ABHS). V14 stated that another staff member will help with assisting R3 in turning in bed. V14 stated that the treatment supplies in the clean, clear bag will be place on top of the cleaned, bedside table. V14 stated with gloved hands, the nurse will remove the dirty wound dressing, put in dirty garbage bag, and wash hands or uses ABHS. V14 stated that the nurse will don new gloves and clean the wound. V14 stated that the nurse will remove gloves after cleaning wound and wash hands. V14 stated, nurse don't want to go from a dirty surface to a clean surface without performing hand hygiene. V14 stated that the nurse will next don gloves and apply the clean wound dressing treatment. V14 stated that R3's order for the sacral wound is for the [MEDICATION(S)] gel. V14 stated that V21 (Wound Physician) recently changed to this order. V14 stated that with R3's gauze packing strip, the nurse will use a cotton swab or tongue depressor to place the gauze packing strip in the wound because it's tunneling and must cover all hidden areas. V14 stated that the nurse will then insert the Calcium Alginate dressing in the wound and cover the wound with the dry, protective dressing. V14 stated that the Calcium Alginate dressing should not extend beyond the border of the wound. V14 stated, It (Calcium Alginate) is a treatment and needs to be protected. V14 stated that she (V14) and floor nurses place their initials of their name on the TAR to show that the wound care treatment was done on a specific date and shift. V14 stated that the LAL mattress prevents sacral wounds from worsening by distributing air throughout the mattress so resident is not on hard frame and that it relieves tension on the sacrum. V14 stated that one flat sheet should be used on top of a LAL mattress. V14 stated, multiple layers of linens on a LAL mattress will impede air flow and create moisture. V14 stated that she (V14) typed the sign for R3 that is posted above R3's bed. V14 stated that nursing staff is to turn R3 every two hours, keep R3 clean and dry and to perform incontinence care every two hours. V14 stated that she (V14) doesn't want (R3's) wound soaked in urine which would cause bigger break down and infection. V14 stated that CNA's should apply barrier ointment after each cleansing and drying of the skin after each incontinent episode. When V14 was asked how often she (V14) is assessing R3's wound for size measurements and characteristics of the wound, V14 stated that the assessments are done every week, and The documentation should be there. V14 stated that the facility did change wound care physicians recently so there are gaps in weekly wound assessments. On 11/30/21 at 2:23pm, V14 was asked for weekly skin assessments for R3 from 8/27/21 to current date, V14 provided this surveyor R3's weekly skin assessments for the requested time frame which was missing all of September. V14 stated, September is not there. I can't tell you why I didn't do them. I am being honest with you. I do a lot and I am here by myself. At 2:46 pm Me (V14) or the wound doctor wasn't here. It was Thanksgiving on 11/25/21. It should be every 7 days. V25 (Wound Physician) documented in R3's Wound Evaluation and Management Summary on 9/21/21 that R3's sacral wound measured 2.8 centimeters (cm) in length by 2.2 cm in width by 1.3 cm in depth, and no undermining is documented. V21 (Wound Physician) documented in R3's Wound Evaluation and Management Summary on 10/7/21 that R3's sacral wound measured 5.1 cm in length by 2.6 cm in width by 1.3 cm in depth with 5.5 cm undermining at 12 o'clock. On 12/2/21 at 11:20 am, V21 (Wound Physician) stated that she (V21) has seen R3 for about four wound care visits and that she (V21) inherited R3 from a previous doctor and is continuing R3's wound care weekly assessments. V21 stated that R3 has a stage 4 pressure ulcer to the sacrum. V21 stated that she (V21) sees R3 weekly and performs weekly measurements of the wound. V21 stated, I (V21) did not see (R3) last Thursday because it was Thanksgiving, and I (V21) don't work on Thanksgiving. V21 stated that if she (V21) is not available to come to the facility weekly, then V14 will see the resident and measure the wound. V21 stated, R3 has an infection in (R3's) wound. V21 stated, The fact that (R3) has not healed over time is there is a bioburden in place in the wound which will cut the healing, and our primary goal is to heal the wound. Bacteria will delay in wound healing. (R3) has a heavy bioburden with a stage 4 wound. Our goal is to decrease the bioburden and thus decrease infection. V21 stated that there is a daily treatment order for R3's sacral wound. When asked what V21's expectation of the facility staff is to perform the daily treatment dressing change as V21 ordered, and V21 stated, Yes. V21 stated that using the [MEDICATION(S)] gel will help R3's wound heal from the inside out. When asked what V21's expectations are of the nursing staff to assist with wound healing, V21 stated that nurses are to keep doing what they are doing so to prevent bacteria from taking over the wound. Asked V21 if staff should secure the dry border dressing to minimize the amount of potential toxins entering the wound, and V21 stated, Yes. The dressing should be secured all the time. Asked V21 if any harm or potential harm could be caused to R3's wound from this surveyor's observations, and V21 stated that bacteria can migrate into the wound. V21 stated that R3's wound is packed with the gauze packing strip which has antimicrobial properties. V21 stated, R3's wound is colonized with bacteria, and (R3) doesn't have enough of an immune response. V21 stated, The (gauze packing strip) is packed to all of wound so it will absorb any secretions. V21 stated that the purpose of the gauze packing strip and Calcium Alginate is to absorb secretions to remove secretions from the wound. V21 stated that R3 has secretions from the sacral wound. When V21 was asked if it is important then for nursing staff to maintain the intactness of the border dressing over the wound, V21 stated, It needs to be secure outside the wound to have the (gauze packing strip) and calcium alginate stay put. It (border dressing) protects the (gauze packing strip) and Calcium Alginate. On 12/1/21 at 11:26 am, V2 (Director of Nursing, DON) stated that residents are to be turned and repositioned every two hours, and incontinence care is to be provided by CNA's every two hours and whenever needed. V2 stated, We want to prevent skin from being wet with incontinent urine because this will cause skin breakdown with urine eating at the skin. V2 stated that the facility has a stock barrier cream that is used for protection of a resident's skin against urine or feces. V2 stated, CNA's are to use it (barrier cream) every time they change residents. V2 stated, Hand washing is actually the number one thing to prevent any spread of infection. V2 stated that staff must wash their hands for a total of 20 seconds. R3's census report documents, in part, that R3 did not have any hospitalization s in 2021. Facility policy, dated January 2020 and titled Prevention of Pressure Wounds, documents, in part: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors . Interventions and Preventive Measures: General Preventive Measures: . Residents with Risk Factors - Moisture: 1. Use a moisture barrier . 4. Place resident on a minimum of a q (every) 2 hour check and change program . Residents with Risk Factors - Bed-Fast: 1. Change position at least every two hours and more frequently as needed. 2. Use a special mattress that meets clinical condition . Residents with Risk Factors - Bowel/Bladder Incontinence: 1. Check resident for incontinence at least q 2 hours and clean skin when soiled. Facility policy, dated January 2020 and titled, Dressings Non-Sterile (Aseptic), documents, in part: Purpose: The purpose of this procedure is to provide guidelines for the application of non-sterile dressings. Preparation: . 2. Review the resident's care plan, current orders . 3. Check the treatment record. 4. Assemble the equipment and supplies as needed . Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 1. Non-sterile dressing supplies . 4. Alcohol based hand gel . 6. Tape, scissors as needed. Procedure: 1. Prepare a clean, dry work area at bedside. 2. Bring supplies into resident's room. Individual resident supplies may be placed on the over bed table after it has been disinfected and a protective barrier placed on the table (clean towel, plastic bag, small chux, foam tray and etc.) . 5. Wash hands. 6. Prepare/open any necessary supplies on top of clean barrier . 12. Apply clean gloves. 13. Clean or irrigate area/wound with solution specified in treatment order . 15. Apply prescribed ointment and/or dressing per physician treatment order. 16. Secure dressing in place, if needed . 21. Initial Treatment Administration Record (TAR) . Documentation: The following information should be recorded in the resident's medical record or Treatment Administration Record: 1. The date and shift the dressing was changed. 2. The initials of the individual changing the dressing. 3. The type of dressing used and wound care given. Facility policy, dated March 2020 and titled Hand-Washing/Hand Hygiene Policy, documents, in part: Policy: It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids. Policy Specifications: 1. All personnel shall be educated on recognized hand-washing/hand hygiene procedures and shall follow such procedures . 3. Facility staff must wash their hands for no less than twenty (20) seconds using antimicrobial or non-antimicrobial soap and water. a. Wet hands with clean running water (warm or cold) and apply soap. b. Lather hands by rubbing them together with the soap. c. Scrub all surfaces of your hands, including the palms, backs, fingers, between the fingers, and under your nails. Keep scrubbing for 20 seconds (e. g. hum/sing the Happy Birthday song twice). d. Rinse hands under clean, running water. e. Dry hands using a clean towel. f. Turn off facet with a clean paper towel. 4. When hands are NOT visibly soiled, employees may use an alcohol-based hand rub (foam, gel, liquid) containing at least 60% alcohol in all of the following situations: a. before direct contact with residents . c. before donning gloves . f. before handling clean or soiled dressing, gauze pads, etc. j. after handling used dressings . 6. The use of gloves does NOT replace compliance with hand-washing/hand hygiene procedures. Facility document, undated and titled Extended Care: Turning-Repositioning and Offloading Educational Training, documents, in part: Goals: Preventions of Pressure Ulcers. Relieving Pressure from a Bony Prominence. Promotion of Skin Integrity. Relieve the Pressure: Reposition and turn residents frequently. Turn and reposition at a minimum of q 2 hours while in bed. Facility policy, undated and titled Low Air Loss Mattress Policy, documents, in part: Policy: It is the policy of this facility to use Low Air Loss Mattress for pressure reduction. It is recommended for residents with stage III and IV pressure ulcers. Purpose: To provide additional pressure reduction and aid in the healing of stage III and IV pressure ulcers. Procedure: . 2. It is recommended to reduce pressure therefore use mattress with a loosely fitted sheet or 1 pad or 1 draw sheet. It is not necessary to use a sheet with this product. The undated, facility provided manufacturer guidelines for R3's LAL mattress documents, in part: Combines two clinically effective therapies: Alternating Pressure with Low Air Loss in a portable blower based system. Provides proper pressure redistribution for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Facility undated job description, titled LPN/Charge Nurse, documents, in part: The primary purpose of this position is to: Supervise the day to day CNA services for assigned unit to ensure that care is being rendered in accordance with current federal, state and local standards, guidelines and regulations. Provide licensed nursing care to residents on assigned unit in accordance with current federal, state and local standards, guidelines and regulations . Duties/Responsibilities/Function: . 7. Provide licensed care to assigned residents as ordered by physician and in accordance with facility, federal, state and local standards, guidelines and regulations . 10. Ensure that appropriate documentation/charting is completed as required and in accordance with established policies and procedures. 11. Ensure that an adequate supply of floor stock medications, supplies and equipment is on hand to meet the nursing needs of the residents. Report needed items to the ADON and/or DON . 20. Ensure that all aspects of resident care plans are implemented and maintained . 23. Ensure compliance with infection control standards. Facility undated job description, titled CNA, documents, in part: The primary purpose of this position is to: Assist nursing personnel in providing nonprofessional nursing care and simple technical nursing services . Duties/Responsibilities/Function: . 4. Keeps incontinent residents clean at all times, changing linens as often as necessary . 7. Making on-going rounds on assigned wing(s)/unit(s) no less than every two hours . 11. Ensure that all residents assigned are turned and repositioned as care planned and promote positioning for comfort.

Based upon interview and record review, the facility failed to provide supervision for one resident (R1) reviewed for supervision in the sample of 7. The facility failure resulted in R1 eloping from the facility, falling 2 times and sustaining multiple fractures and a brain bleed. Findings include: On 10/19/2021 at 1:19pm, surveyor inquired about the incident on 09/14/2021. R1 stated, I (R1) was outside, walking. Then I (R1) fell and broke my (R1) arm. Surveyor asked R1, how she (R1) got out of facility door. R1 stated she (R1) does not know, I (R1) was outside walking. On 10/20/2021 at 12:07pm, V10 (PRSD - Psychiatric Rehabilitation Service Director) stated, R1 has history of mental illness. Schizo affective depressive type. R1 hears voices. R1 requires a lot of encouragement to participate in activities. R1 is heavily dependent on staff to maintain ADL (Activity of Daily Living). On 10/20/2021 at 2:49pm, V11 (Dietary Aide) stated, I (V11) left around 7:30pm, (V14) and I (V11) were punching the code, we (V11 and V14 (Cook)) pushed the door. The first door was closing slowly, and we (V11 and V14) pushed the 2nd door. We (V11 and V14) walked down the stair in front of the building when V14 realized someone (R1) was behind us (V11 and V14). R1 walked past us, she (R1) was walking fast. We (V11 and V14) walked back to the building and asked the janitor who she (referring to R1) was. The janitor did not see either because it happened so quickly. The two of us (V11 and V14) went back to her (R1) and walked behind her (R1). I (V11) asked her (R1) if she (R1) wanted to go back to the building to get a cigarette, she (R1) was walking fast, she (R1) was wearing big gym shoes, slopping then fell , and boom, (R1) was right back up. (R1) walked towards the school by the train station - [NAME]. (R1) fell again and hit her (R1) headfirst on the gate of the school, face down. She (R1) tried to get back up. I (V11) told her (R1) to stay down. She (R1) tried to get back up. V14 called 911 the first time she (R1) fell . We (V11 and V14) also called the security desk prior to the first fall. Couple of CNAs and a nurse came. V2 (DON) came too. We (V11 and V14) called 911 the second time she (R1) fell and trying to get up again. About less than 5 minutes 911 came. V11 further stated, I (V11) have training about elopement, but I (V11) did not know it was a resident at first. I (V11) face time my friend V24 (smoke monitor) and she (V24) told me (V11) it was R1 before she (R1) even fell because I (V11) don't want to just walk behind anybody. Because I (V11) am not sure if she (R1) is a resident. I (V11) was close with her (R1) to make sure she (R1) was safe. On 10/20/2021 at 2:55pm, V11 (Dietary Aide) stated, The security that day was (V20). I (V11) think (V20) was in the bathroom. I (V11) did see the Janitor cleaning. On 10/20/2021 at 3:30pm, V2 (Director of Nursing) stated, In an ideal world, there should be someone monitoring the door due to safety issue. On 10/20/2021 at 3:39pm, V20 (Security) stated, My Job Description: I (V20) answer the phone, I (V20) buzz people in and out, answer the door, I (V20) pass cigarettes and make sure everything remains peaceful and calm. My (V20) responsibility is to make sure I (V20) know who is coming and who is going. On 10/20/2021 at 3:42pm, V20 (Security) stated, I (V20) was on duty when (R1) left the building. I (V20) think it happened around 7:30pm I (V20) was in the washroom when it happened. I (V20) went to the ladies' room. I (V20) asked the housekeeper (V12) to watch my post so I (V20) could go to the bathroom/washroom. I (V20) know that she (R1) is a resident here. He (V12) said okay, and I (V20) just rushed to the washroom. I (V20) told him (V12), Can you watch the front so I (V20) could go to the washroom. And he (V12) said okay when I (V20) got back he (V12) was telling me (V20) that something was wrong. He (V12) was telling about V2 the DON. V2 outside. I (V20) received a phone call from the smoke monitor, V24, that I (V20) needed to call a code yellow because R1 had got out and I (V20) immediately did that to let the staff know and the staff came downstairs, and I (V20) told them what was going on and what direction she (R1) was going. 10/20/2021 at 4:12pm, V12 (Housekeeping) with V17 (Mental Health Professional) translating for V12 stated, On 09/14/2021 at around 7:30pm, (V20) did not ask me to watch the door. On that day, I (V12) saw V20 walked away from the security desk, came back and told me (V12) I (V20) just went to the bathroom. What happened? On 10/20/2021 at 4:40pm, V12 stated, I (V12) don't feel oblige to monitor the door because sometimes (V20) would just walk at the end of the lobby and would come back right away. On 10/21/2021 at 9:23am, surveyor inquired if R1 would thrive in the community. V21 (Primary Care Physician) stated, I (V21) find it difficult for (R1) to be on her (R1) own. For one thing, (R1) will not be taking her (R1) medication. Second thing, I (V21) don't know how she (R1) is gonna eat, and the weather is cold. (R1) would probably have starvation, missed her (R1) medication, be in pain and the weather is cold. All these things are worrisome and have effect on her (R1) health. 10/21/2021 11:34am, V13 (Registered Nurse/ADON) stated, I (V13) am familiar with R1's care. I (V13) was up there as the nurse, passing med, v/s taking care of all the residents on the unit, prior to what happened with R1. I (V13) remember R1 being at nurse's station, she (R1) was in a wheelchair, smiling in a wheelchair, 10-15 minutes go down the elevator. 15-20 minutes, I (V13) start hearing a code yellow, twice, called down the first floor to ask who the code was yellow on. I (V13) finish with resident. Problem, her (R1) wheelchair is right there I (V13) run outside. I (V13) could not imagine, roaming the area, came back, some of us, ambulance was there too, and R1 they were putting R1 in the ambulance. She (R1) had a red spot on her forehead, made comfortable, 2 other nurses on the scene. Bleeding to the forehead. There should be security at the door down stairs, monitoring the residents from going out the door. What I (V13) was told security lady, went to the bathroom, on the camera. 2 staff members came out the door, R1 parked the wheelchair in the lobby, before the door completely close, she (R1) caught and went out the door. Walked to the left, and the 2 staff members were going towards their right, running back inside the building, to see if R1 was one of the residents. Security was in the bathroom, one of them followed, V11 followed. Security, she (V20) was supposed to monitor the door but she (V20) stepped out to go to the restroom. Couple of other things. I (V13) believe she (V20) should be endorsing her (V20) post to someone but to who, I (V13) don't know. Safety issue. On 10/21/2021 at 11:45am, surveyor inquired if R1 would thrive in the community. V13 stated, (R1) is unstable in walking. I (V13) don't believe (R1) would be able to take (R1) medication. I (V13) don't think (R1) would survive in cold weather. There are risks to (R1) physical and medical status if (R1) is outside, in the community. 10/21/2021 at 11:57am, V22 (Nurse Practitioner) stated, I (V22) know she (R1) eloped and got a wound or a fracture last week I (V22) am only seeing her (R1) for mental health issue. I (V22) saw her last week. The staff told me (V22) that R1 eloped and that they found R1 on the street and R1 hit her (R1) head and broke her (R1) hip. Prior to elopement mental status. Her (R1) baseline: she (R1) is alert and oriented to herself (R1), she (R1) does not talk much. Surveyor asked V22 if she (V22) would expect R1 to thrive in the community. No, she (R1) is taking medications, how will she (R1) do that in her (R1) state, she (R1) cannot have independent life. She (R1) is not stable to live independently. Risks: She (R1) is psychotic, paranoid [CONDITION(S)], we're giving her (R1) medication. If she's (R1) not taking her (R1) medication, she (R1) will be a harm to herself (R1) and to people around her (R1). Medical condition, we already know what happened to her (R1). She (R1) got a fracture. It is a safety issue. On 10/21/2021 at 12:14pm, V14 (Cook) stated, On 09/14/2021 around 7:30pm, I (V14) was standing by the door, waiting for security to buzz us (V14 and V11) out. The security was not there. R1's Face Sheet was reviewed; R1's diagnoses include: [CONDITION(S)] disorder, depressive type; Displaced fracture of base of neck of right femur; fall on same level; encounter for other orthopedic aftercare-status post right HEMI AND ORIF (Hemiarthroplasty and Open Reduction Internal Fixation) Presence of right artificial hip joint-Right hemiarthroplasty; unsteadiness on feet; contusion and laceration of right cerebrum without loss of consciousness; Colles' fracture of right radius Review of Prescription Order shows R1 was receiving significant medications. Hospital history and physical reports in part for R1 dated 9/14/2021 shows, XR Hip 2-3 Views w/AP Pelvis Right Impression: Mid cervical fracture. XR Femur 2 Views Right Impression: Right femoral neck fracture. CT Brain/Head w/o Contrast Impression: The finds are concerning for a small acute hemorrhagic contusion in the right frontal lobe anterolaterally. R1 (08/31/2021) Community Access Observation documented, in part Is the resident able to participate in this Community Access Observation? No. If no, indicate reason: (R1) may not participate in independent community access due to history of elopement attempts, poor symptom management, impaired decision making, and low motivation to participate in programming to improve autonomy. Determination Score: 4. Level: Resident may not access the community independently related to safety factor. R1's (09/15/2021) Reportable Event documented, in part Description of Occurrence. On 09/14/2021 R1 eloped from the facility . Called Hospital to follow up on R1 and was informed that (R1) had been admitted with DX (diagnoses): multiple fractures and a small brain bleed. R1 (Print date 09/22/2021) Inpatient Discharge Instructions documented, in part Your Diagnosis: Fall, Fracture of femoral neck, right, distal radial fracture, contusion of right frontal lobe. R1's (09/29/2021) Elopement Risk Review documented, in part (R1) eloped from facility on 09/14/2021 resulting in hospitalization due to injury experienced during the elopement. R1's (10/04/2021) Resident Assessment Instrument documented, in part Section C. Brief Interview for Mental Status (BIMS) score: 14. Section G. A. Bed Mobility: 3/3 Extensive assistance / Two+ persons physical assist. R1's (10/17/2021) Care plan documented, in part Problem: (R1) readmitted with surgical wound to left frontal lobe Resolved 9/29/21 and Right hip/post-surgical dehiscence as of 10/13/21 and cast to right wrist (procedure noted as RLE (Right Lower Extremity) Hip Arthroplasty, RUE (Right Upper Extremity) distal radius fracture treated with cast, and sutures to Let frontal lobe). The (undated) Security Guard/Door Monitor (pertaining to Security Guard job Description) documented, in part Purpose: The primary purpose of this position is to: Provide increased supervision and security. Greet all . residents upon entering or leaving. Ensure the resident . environment is as free from accidents and hazards as is possible. Immediately correct/address potential safety risk as prudent and warranted. The (undated) Housekeeping Aide Job description documented, in part Purpose: The primary purpose of this position is to: provide housekeeping services to assure that a clean, orderly and home-like environment is maintained in accordance with current federal, state and local regulations. Duties/Responsibilities/Function: Ensure the resident/employee environment is as free from accident and hazards as is possible. Immediately correct/address potential safety risks as prudent and warranted. Ensure that all elements of the facility's Abuse and Neglect policies are maintained and enforced as is possible. All other duties assigned. The (undated) LPN (Licensed Practice Nurse)/Charge Nurse - pertaining to LPN/Charge Nurse Job Description documented, in part Purpose. The primary purpose of this position is to: Provide licensed nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines, and regulations. Duties/Responsibilities/Function. 3. Closely monitor and supervise all facility residents per facility policies and as warranted by good nursing judgement.

Based on interview and records review, the facility failed to ensure that the resident environment remains safe, free of hazards and hazardous practices by leaving a bedside table in the hallway. This failure resulted in R2 tripping over the bedside table, falling and sustaining a right [CONDITION(S)] that required hospitalization and right hip surgery. Findings include: R2's Face Sheet documents resident is a [AGE] year old with diagnoses including but not limited to: Nondisplaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, [CONDITION(S)], unspecified, Foot drop, right foot, Presence of right artificial hip joint, History of falling, Difficulty in walking, not elsewhere classified, Unsteadiness on feet, Muscle weakness (generalized), Weakness, Other lack of coordination. Surveyor attempted to reach V11(LPN), the nurse on duty at the time the fall incident occurred on 06/29/2021 and on 06/30/202, unsuccessfully. On 07/01/2021 surveyor was able to reach V11 to obtain interview, but V11 refused to speak to surveyor by disconnecting the phone conversation once surveyor introduced self. On 06/30/2021 at 11:21am V8 (Certified Nursing Assistant- CNA) stated, Therapy gets R2 up every day and they also get him dressed. Since R2 sustained the fracture he is under the care of therapy and right now the therapists get the resident out of bed and help him get dressed. Therapy have not yet allowed the CNAs to get R2 out of bed. When R2's condition improves therapy will let us know that we can get R2 out of bed, but so far we have not received clearance. Prior to the fall on May 29, R2 was independent, he was able to transfer himself and walk independently. After the fall he is not able to ambulate and transfer independently due to the [CONDITION(S)]. On 06/30/21 at 11:29am V10 (Restorative Director) stated, R2 sustained a fall on 05/29/21 close to 1 am. R2 usually sits in the dining room and watches television. On May 29, R2 was walking back to his room after he was done watching TV and fell . The nurse on duty documented that she heard a sound in the hallway and observed R2 laying on the ground. R2 complained of pain after the fall to the right side of his hip. When I reviewed the camera footage which captured the entire incident, I saw that R2 tripped over a bedside side table which was left in the hallway. The bedside table was not being used at the time of the incident and was not put back where it belongs. Sometimes staff use a bedside table for meals in order to space the residents out, and they also use the side tables for activities. The side table was not in use and they did not place the side table back. There was no reason as to why the bedside table was left behind in the hallway. The reason R2 had the fall is because he tripped over a piece of furniture that should not have been there in the first place. On 06/30/2021 at 12:42pm V14 (Certified Occupational Therapy Assistant- COTA) stated, Prior to the fall, which occurred on 05/29/2021, R2 was ambulatory. He was able to transfer, walk independently. After the fall R2 is ambulatory with contact guard assist, minimal assist from sit to stand position. R2 is stand by assist from wheelchair level. Upper body is minimal assist. R2 lower body requires maximum assistance. R2 requires total assist with putting on shoes and maximum assistance with putting on pants. R2's bed mobility requires minimal to moderate assistance, depending on his pain level at the time. R2 is getting out of bed with the help of therapy at this point. When R2's condition improves and we feel that he is stronger, we will let the staff know that it's safe to get R2 up, but not at this time. R2's condition still has to improve. Surveyor attempted to interview R2 on 06/30/21 at 9:36am and 07/01/21 at 10:01am, however; R2 stated that he was sleepy and took pain medication. On 07/01/2021 at 2:20pm V1 (Administrator) stated, There is not supposed to be any furniture stored in the hallway. The bedside table should not be in the hallway. The table should not have been there. Sometimes they use those tables during mealtimes to provide social distancing for the residents, but when the table is not in use, it would have been removed especially from the hallway. Progress note (05/29/2021 12:49am) and fall incident report (05/29/2021 7:50am) documented by V11 (LPN) reads, R2 stumbled fell hard to his right side in the hallway, not able to stand or perform full Range Of Motion, sent to (hospital's name) ER. Video footage of fall incident was requested by surveyor for review. Surveyor received response from V1 on 07/01/2021 stating that video footage of fall incident is not available. Accident/Incident Management Meeting (IDT) Form pertaining to date of incident 05/29/2021 determined the root cause of R2's fall to be: Resident tripped on a table, lost balance and fell . The document states a fall prevention intervention related to the root cause of the fall is to ensure floors and hallway is free of obstacles for safe ambulation. Per Facility Assessment Tool (dated 08/18/2017): Provide person-centered direct care identify hazards and risks for residents. Fall Care Plan (dated 03/16/2021) lists one of the fall prevention intervention is to provide resident an environment free of clutter. Fall Risk Assessment (dated 03/15/2021 1:15pm) prior to fall incident on 05/29/2021 states that R2 activity level was up and about as desired (UP Ad Lib) and independent for elimination and has balance problems while walking. Post incident Fall Risk Assessment (dated 06/01/2021) states that R2 has balance problems while standing, walking and has change in gait pattern when walking through doorway; requires assistance with elimination/up to commode. Fall Risk Assessment (dated 06/09/2021) states that R2 is confined to chair, totally unable to ambulate without assistance and requires wheelchair for locomotion. Physical Therapy Discharge summary (dated 04/16/2021 prior to fall) documents R2 functional activity performance as: Static Standing: good; Transfers: 1/7; requires no assistive devices. Physical Therapy (dated 06/02/2021 post fall) documents R2 as: Toileting: total assistance; standing during ADLs: poor. Minimum Data Set (MDS) Section G (dated 04/16/2021) scored R2 as (1) needing supervision with transfers, walking, toilet use, dressing, bed mobility. MDS Section G (dated 06/08/2021 post fall) scored R2 as (3) needing extensive assistance with bed mobility, (4) needing total dependence with personal hygiene, toilet use, dressing, transfer, (8) activity did not occur with walking. Comprehensive Fall Review (dated 06/02/2021) states R2 was observed walking from the dining area to his bedroom, tripped over a table, lost balance, and fell on his right side. Facility Incident Final Report Form Occurrence Resolution (dated 05/29/2021) states R2 tripped over a bedside table in hallway. This incident was also observed on camera review. Hospital Medical Records Progress note (dated 05/31/2021 10:29 CDT) documents R2 arrived to the emergency room department after mechanical fall complaining of right hip pain. Right hip x-ray showed acute subcapital femoral fracture. Care plans will be developed for any resident who is identified at risk (Mild / Moderate / High / Severe Risk) according to the Braden risk assessment score and for any resident who currently has an ulcer. The care plan should address: Diagnosis, behaviors, factors, and conditions that put resident at risk or impede healing status such as co-morbid conditions, medications, or complications. Goals that are appropriate and measurable. Interventions individualized to the resident's condition / situation to prevent the development of an ulcer, or if present, for the care and treatment of the ulcer. Disciplines that will implement each intervention.

Based on interview and record review, the facility failed to protect and prevent (R1) a cognitively impaired, nonverbal resident from being sexually assualted by (R2) a resident with known sexual inapproriate behaviors, as a result R1experienced an avoidable sexual assualt perpertrated by R2. Findings include: R1 is a seventy year old, female resident. R1's face sheet indicates that R1 is diagnosed with [REDACTED]. R1's care plan documents that she is at risk for abuse due to impaired communication and cognitive deficits. A brief interview for mental status dated 07/15/2020, notes that R1 is non-verbal and cannot make her needs known. R2 is a sixty-six year old, male resident. R2's face sheet notes that he has a [DIAGNOSES REDACTED]. A brief interview for mental status, dated 04/15/2020, documents that R2 is alert and able to make his needs known. R2 no longer resides in the facility. R2 was admitted on [DATE]. R2 was involuntarily discharged on [DATE]. Review of R2's progress notes documents various behaviors: 1. On 04/09/2020, R2 swearing at staff; drug seeking behavior during the shift. Needs constant redirection. Verbally abusive towards staff. R2 continues to display verbal aggression and threatening behaviors, exit seeking behaviors, treatment noncompliance, poor judgment, and impaired decision making. Staff intervention has been unsuccessful throughout the day, and due to this a petition for involuntary hospital admission was completed and submitted to the floor nurse. 2. On 04/10/2020, R2 has some insight into his [MEDICAL CONDITION] [DIAGNOSES REDACTED]. R2 has been observed by staff displaying paranoid delusions regarding his health. His hospital records indicate delusions in the hospital including his wrists are bombs and may explode. He displays poor impulse control and problem solving skills. He will scream and threaten staff if they do not assist him exactly when and how he wants. He is difficult to de-escalate and requires time for staff to talk through his issues and calm down. 3. On 04/13/2020, R2 noted with increased agitation on the first floor. He has been displaying intermittent verbal outbursts since his admission and requires frequent staff intervention to calm down. 4. On 04/14/2020, social services met with R2 following his socially inappropriate behavior. R2 denied any socially inappropriate behavior, like masturbating in public and selling/buying stuff to peers, despite multiple eye witnesses. He displayed delusional thinking, including the entire first floor is working with Satan. He displayed agitation and left the social services office. He stated, May God have mercy on your soul. 5. On 04/15/2020, social services met with R2 regarding his inappropriate behavior. R2 has been inappropriate with peers and staff. He has been disrespecting boundaries (by going into peer's rooms and taking their merchandise). He has also been sexually inappropriate with female peers by asking for sex. 6. On 04/16/2020, R2 harassed other residents all night going room to room stealing their belongings, not compliant with redirections, pilled clothing and items on his bed and took some to the dining room. On 04/16/2020, at 8:00AM, R2 displayed inappropriate sexual behavior with another peer. V1 (Administrator), V14 (Social Services Director), and V2 (Director of Nursing), were notified of his behavior. R2 is non-compliant with redirection and treatment at this time. He refused medication and was placed on one to one monitoring. At 8:35 AM, R2 displaying verbal aggression, inappropriate sexual behaviors, and impaired decision making. Staff interventions were ineffective, and therefore, a petition for involuntary admission for psychiatric hospitalization was completed. 7. On 04/16/2020, at 12:09 PM, R2 presented with increased agitation and aggression towards peers and staff members. Sexually inappropriate behavior, impaired decision making, poor impulse control, and impaired judgment. Staff intervention and redirection have been ineffective. Orders were obtained to have R2 transferred to a local behavioral hospital for evaluation. At 1:37 PM, interdisciplinary team determined that R2 will be issued a notice of immediate emergency discharge. R2 was served with the notice. Initial facility report dated 04/16/2020, notes that R2 was observed touching R1 inappropriately. Final facility report dated 04/21/2020, notes that on 04/16/2020, V14 (Psychosocial Rehabilitation Services Director) reviewed camera footage. R1 was sitting in the fifth floor hallway by the dining room in a chair. R2 came onto the floor where R1 was sitting. R2 proceeded to pull out his penis and masturbate by R1. R2 then got closer to R1 and touched the top of her head. R2 then pulled down the front of R1's hospital gown to peer down at her breast. Around this time, V4 (LPN) intervened and escorted R1 off of the unit. Surveyor conducted interviews during this investigation on 08/21/2020 and 08/25/2020. On 08/21/2020, at 11:18 AM, V3 (Security) stated, I was working the night shift, I saw R2 rubbing R1's hair and looking down her gown. I called V4 and told him to go down to the unit where this incident was occurring. V4 went down to the unit and escorted R2 away from R1. I am not allowed to leave my post unless I go to the restroom or have my break. On 08/21/2020, at 11:43 AM, V4 stated, this incident occurred in the middle of the night on the 11 PM-7 AM shift. Everyone is usually asleep. I didn't see anything. I got a call from V3 (Security) that another resident was touching another female resident. I was working on the 2nd floor. I immediately took the stairs and went to the 5th floor. I saw R2 walking away. I approached R2 and he immediately got defensive and stated he didn't do anything. I told the nurse, from the third floor, how R2 was acting. V3 may have seen R2 touching his private part, but I didn't see anything. I am the nurse manager. When I got up to the 5th floor, there was no nurse on the floor. The aide was giving care. On 08/21/2020, at 12:21 PM, V5 (MDS Coordinator) stated, R1 is not alert and oriented, she needs direction. R1 cannot verbally talk. On 08/25/2020, at 9:57 AM, V10 (Restorative Director) stated, before the incident occurred, I received a call from security that R2 was in the dining room. I do not recall which floor it was on. When I arrived to the dining room, R2 was by the window touching and pleasuring himself. I do not recall if there were any residents around or if there were staff present. It is protocol for staff to be in the dining room when there are residents in the dining room. On 08/25/2020, at 10:00AM, V12 (Social Worker) stated, R2 had inappropriate behaviors and I had to sit with him on a one to one basis. R2 was cussing, saying obscenities, and was not easily directed. R2 required supervision one hundred percent of the time. R2 was very inappropriate and would show his private parts to me and other residents. R2 would tell me that his penis was sixteen to eighteen inches and I should really take a look at it and that I would really enjoy it. On 08/25/2020, at 12:14 PM, V14 stated, when I reviewed the footage, R1 was sitting by herself, in a chair, in the hallway. R1 was in the dining room. R2 was not even supposed to be on the floor. There was no staff in the dining room or the hallway. There should have been someone walking or making rounds. Review of the facility staff sheets for 04/15/2020 and 04/16/2020, document that there is only one nurse for two floors in the facility the night of the sexual assault. Review of R2's care plan does not note any of his behaviors or list any interventions. Facility Policy titled Abuse Prevention Policy, dated 02/2020, notes abuse means any physical, mental, or sexual assault inflicted upon a resident other than by accidental means. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault.