Every finding on record at St Anthony's NSG & Rehab CTR

Based on interview and record review, the facility failed to administer intravenous medications as ordered by the physician, for one of one resident (R1), reviewed for medications, in the sample of three.R1's Hospital After Visit Summary documents that R1 was hospitalized from [DATE] to 6/22/26 with a diagnosis of cellulitis of toe of right foot. This same form includes the following physician orders Daptomycin (antibiotic) 50 MG (Milligrams)/ML (Milliliter). Inject 540 MG into the vein daily for 21 days. R1's facility Medication Administration Record, dated June 2026 documents that the administration times of R1's Daptomycin was changed on 6/27/26, by facility staff, from daily at 8:00 A.M., to daily at 4:00 P.M. R1's Nursing Progress Notes, dated 7/1/26 document, At approximately 1600, this nurse went to administer scheduled IV (intravenous) medication to (R1), however, (R1) stated he had already received the dose earlier in the morning. This nurse verified with V2/Director of Nurses/DON, who confirmed administering the IV medication that day and the previous day. Upon review, it was identified that the resident had received a duplicate IV dose the previous day. V3/Nurse Practitioner/NP notified immediately and advised to call 911 for further evaluation. Emergency Medical Services was activated, and (R1) was transferred to the hospital. Family was present at bedside, informed of the situation, and expressed concern. (R1) was sent out for further evaluation. The facility form, Facility Final Report, dated July 8, 2026, and signed by V1/Administrator documents, (R1) Medication Error. The facility completed its investigation regarding the medication error involving (R1). The initial report was submitted on July 1, 2026, after the facility identified that (R1) had received an additional dose of IV Daptomycin, which was ordered to be administered once daily for cellulitis of the right toe. During the investigation, it was confirmed that (R1) received one additional dose of IV (intra Venous) Daptomycin on June 30, 2026. No evidence was identified of repeated additional dosing beyond this one extra administration. (R1's) IV antibiotic administration time had been adjusted previously due to (R1) being out of the facility for surgery, and this change in timing contributed to the medication administration discrepancy. The medication error was identified on July 1, 2026, at approximately 4:00 PM when the nurse attempted to administer the scheduled IV medication and the resident stated he had already received the dose earlier that day. The nurse immediately reviewed the record and confirmed with (V2/Director of Nurses) that the IV medication had been administered that day and the previous day. Upon review, it was identified that (R1) had received a duplicate IV dose the previous day. The provider on call (V3/Nurse Practitioner) was notified immediately, and EMS (Emergency Medical Services) was activated per provider direction. (R1) was transferred to the emergency department within one hour of discovery for further evaluation. Family was present at bedside and was informed of the situation. On 7/27/26 at 2:05 P.M., V1/Administrator verified (R1) received an additional dose of an IV antibiotic on 6/30/26, after the timing schedule was changed due to R1's outpatient surgical appointment on that day. On 7/28/26 at 9:01 A.M., V2/Director of Nurses confirmed she administered an extra dose of intravenous antibiotic to R1 on 6/30/26, in error. V2 states R1 had been out to an appointment and upon return his antibiotic was rescheduled and she was unaware. V2 confirms she did not check current physician order prior to the administration of the dose. V2 states error was discovered the next day when she (V2) went to again give R1 a dose of his antibiotic and he stated he had already had one that morning. The facility policy, Medication Administration, dated (revised) 3/24/25 directs staff, The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administration of all medications, to meet the needs of each resident. Before administering medication, the nurse will confirm the identity of the resident, confirm the medication and order by checking the label of the medication against the order on the resident's Medication Administration record, ensuring it matches the following: Name of the medication, Dose, Route, Times to be given, ensuring the time for the medication is correct.

Based on record review and interview the facility failed to prevent a resident to resident altercation between two of 6 residents (R1, R2) reviewed for abuse allegations. On 7/17/26 at 11:30am R2 stated, I remember that guy that hit me. He pulled me by my (gestured towards oxygen tubing) towards him, I thought he was going to punch me but he just kind of slapped me in the forehead and I got the hell away from him. I am not scared. (V1/Administrator) called the cops, he took care of it. This resident-to-resident altercation is documented in R1 and R2's medical records, as well as facility records, including Incident/Accident logs for June 2026. The altercation was reported to the state agency on 6/22/26, and documents on 6/22/26 at 2:15pm, R1 and R2 were in the facility's elevator when R1 pulled R2's oxygen cannula off R2's face and hit R2 on the forehead with an open hand on 6/22/26. R1's medical record documents R1's diagnoses include Intracranial Injury with loss of consciousness; Delusional Disorders; Psychotic Disorder with Delusions due to Physiological Condition and Bipolar Disorder. R1's Care Plan documents R1 exhibits verbally aggressive behavior. On 7/17/26 at 2:10pm R2 stated, Last month, I was in the elevator with R1, and he grabbed my oxygen tube off my face and hit me in the head. On 7/17/26 at approximately 1:45pm V1 verified a resident-to-resident altercation occurred in the facility's elevator, on 6/22/26 at 2:15pm, at which time R1 grabbed R2's oxygen tubing off R2's face, and hit R2 on the forehead with an open hand. The facility's undated Abuse Prevention policy states the facility will prevent resident abuse from occurring. The facility's report to the state agency, dated 6/22/26, documents a resident to resident altercation occurred on 6/22/26 at 2:15pm when R1 pulled R2's oxygen tubing off R2's face and hit R2 in the forehead with an open hand.

Based on observation, interview, and record review the facility failed to ensure call lights were within reach and working for residents. This applies to 4 of 8 residents (R1, R2, R4, & R8) reviewed for call lights in the sample of 8. The findings include:On 6/6/26 at 9:35 AM, R1's call light was on the floor behind his recliner. His bed was alongside his recliner. R1 also had a wireless call light that was tied to the bed post on the other side/furthest side from his recliner. R1 could not reach either call light. R2 was in her wheelchair in her room. She had two call lights. Both were draped over her night stand out of reach. She stated, she didn't have a way to call for help because they told her the call lights weren't working. She stated, she did not have a wireless call light. She never received one. R4 was in bed with the head of the bed up. His call light was draped over a chair that was up against the wall at the head of his bed. R4 could not reach the call light with the head of bed raised. His wireless call light was also tied to the same chair hanging down towards the floor. His bed was raised up and not lowered. R4 stated, he doesn't have a way to call for help besides to yell for help. R8's call light was on the floor next to his bed. His bed was also raised up. When asked how he calls for help from the staff he yelled, HELP. His wireless call light was tied to his bedside table. He had a mat on the floor and then his bedside table was next to his bed. He could not reach either call light. On 6/6/26 at 12:06 PM, V4 & V5 both Certified Nursing Assistants (CNAs) stated, residents use the call lights to call for help. They should always be within reach. On 6/6/26 at 1:51 PM, V1 Administrator stated, he was having some issues with call lights not working or being within reach. All residents have a traditional call light in their room as well as a wireless call light they can take with them wherever they are in the building. They should always have a call light with them. This surveyor showed V1 Administrator the placement of R1, R2, R4, & R8's call light and how they were not within reach. He stated, staff needed re-education. The facility's call light response policy dated 9/12/25 shows, Policy Statement: The facility is committed to ensuring prompt and appropriate response to all resident call lights to promote safety, dignity, and quality of care. All residents will have access to a functioning call light system, and staff will respond in a timely manner in accordance with facility standards and regulatory requirements. Purpose: To ensure timely response to resident needs and requests. To promote resident safety and prevent adverse events such as falls. To maintain compliance with federal and state regulations. To enhance resident satisfaction and quality of life. 1. Accessibility of Call Lights: All residents will have a functioning call light. Call lights must be checked at the beginning of each shift and after any resident repositioning or transfer. Non-functioning call lights must be reported immediately and repaired promptly. 4. Rounding and Proactive Care: Staff will conduct routine rounds (at minimum every 2 hours) to anticipate resident needs. During rounding, staff will ensure: Call light is within reach, Resident is comfortable and safe.

Based on interview and record review the facility failed to ensure a wound culture was picked up in a timely manner. This applies to 1 of 3 residents (R1) reviewed for lab services in the sample of 8. The findings include:R1's un-witnessed fall report dated 5/8/26 shows, he had a fall and obtained a skin tear to his leg. On 6/6/26 at 9:16 AM, V10 R1's Power of Attorney (POA) stated, R1 had a fall and scraped his leg. The wound ended up getting infected and she was concerned that the resident had a MRSA (Methicillin-resistant Staphylococcus aureus) infection. She requested a swab to be done to check for MRSA. V7 Wound Care Nurse did the swab in front of her and put it in the top drawer of her treatment cart. She forgot it was there. V10 stated, she asked for several days what the results were and no one knew. Finally, they got results that it was inconclusive because she left the sample in her cart for 5 days and then sent it off. R1's progress notes dated 5/18/26 shows, New orders obtained to swab wound to r/o (rule out) MRSA. Orders written, swab to be obtained for collection in the am. R1's progress notes dated 5/19/26 shows, .Wound swab completed at this time placed for collection. POA at bedside pictures of wound taken by her. R1's progress notes do not show any further information about the wound culture until 5/26/26.R1's progress notes dated 5/26/26 by V8 Nurse Practitioner (NP) shows, LATE ENTRY Lab notified facility that the wound culture sample collected 5/19/26 had sample integrity issues and that the specimen will need to be recollected. Examined the patient at bedside wound is healing as desired no s/s (signs/symptoms) of infection at time of assessment. No drainage, redness, or warmth noted. R1 denies pain at time of assessment. The patient was prescribed Doxycycline (antibiotic) which has broad coverage no ATB (antibiotic) change or duration extension required. No new orders. No culture recollection required at this time. R1's progress notes dated 5/27/26 shows, Wound culture still pending, POA advised of wound progression and wound culture remaining pending. Previous progress notes, show the NP did not re-order further cultures and the first culture had integrity issues. R1's progress notes dated 5/28/26 by V7 Wound Care Nurse shows, Received call from lab wound culture was not able to be processed d/t (due to) sample expiration. Pt leg wound has healed and no further testing needs to be completed at this time, order cancelled. R1's wound was never cultured to rule out MRSA. On 6/6/26 at 12:59 PM, V7 Wound Care Nurse stated, R1 had a fall in his room and slid underneath a nightstand or table ending up with an abrasion on his right lower extremity area. The area ended up looking like cellulitis, so they treated him with antibiotics. They wanted to rule out MRSA. On 5/18/26 she got the orders to check for MRSA and did the actual swab on 5/19/26. The lab comes Monday, Wednesdays and Fridays. The swab was to be picked up on 5/20/26. They have a binder at the nurses station that lab signs when they pick up the labs. She didn't check anything else after she took the sample and put it where it needed to be for lab pick up. A few days later they received a call about the integrity of the sample and needing a new one. She let the lab know at that time, the wound was healed and they wouldn't be re-collecting the sample. She denied forgetting about the sample and said she did put it in the top drawer of her cart but only until she got back to her office to get the paperwork ready. The laboratory standing order daily log shows, R1's wound culture was picked up on 5/22/26 (3 days after collection). The log is initialed by a lab associate. On 6/6/26 at 2:06 PM, V7 Wound Care Nurse stated, she was not aware that the culture/sample was not picked up on 5/20/26. On 6/6/26 at 10:00 AM, R1 was up in his wheelchair self-propelling around the facility. His right lower leg had a few scabs on it and was red on the shin area. The facility's laboratory services policy dated 9/8/25 shows, Purpose: The purpose of this policy is to ensure that laboratory services are ordered, obtained, reported, reviewed, and followed up in a timely and appropriate manner to support resident care and safety. Procedure: . 14. If lab results are not received within the expected timeframe, the licensed nurse shall follow up with the laboratory provider and document the follow-up.

Based on observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner. This applies to 1 of 3 residents (R2) reviewed for safety in the sample of 8.The findings include:R2's face sheet lists her diagnoses to include: dementia, muscle weakness, need for assistance with personal care, depression, osteoarthritis and weakness. R2's injury of unknown cause report dated 6/5/26 shows, Nursing description: CNA (V9 Certified Nursing Assistant/CNA) notified writer (V6 Licensed Practical Nurse/LPN) of the report that resident has a skin tear at R (right) forearm. On assessment, resident has a skin tear of the size of 4.5 cm (centimeters) at his [her] R forearm. Wound is cleansed with normal saline, clean and dry dressing with steri strips applied. Predisposing Situation Factors: during transfer. Report shows, the injury was unknown however, it was known it happened during a transfer as stated in the report itself. On 6/6/26 at 11:59 AM, R2 was sitting in her wheelchair in her room. She had a gauze bandage on her right forearm. She stated, last night her arm got slashed when the certified nursing assistant (CNA) was putting her in her chair. The CNA (V9 CNA) had the belt around her higher than normal and she didn't like it. Her arms were up there too and the belt slashed her arm. She screamed in pain. It was a nasty looking thing. The nurse (V6 - LPN) had to put those fly things (steri-strips) on it and covered it with the gauze.On 6/6/26 at 1:28 PM, V6 LPN stated, R2 got a skin tear while the CNA (V9) was transferring her. V6 wasn't sure if the gait belt got her or what, but it was during the transfer. On 6/6/26 at 4:21 PM, V9 CNA stated, she was transferring R2, when R2 became agitated and fidgety during the process. Her arm grazed the gait belt and she got a skin tear. She thought she should be a two-person transfer since she can become anxious at times during transfers. She also stated, she felt R2 was alert and oriented but really anxious. R2's skilled evaluation progress note dated 6/5/26 shows, Resident is alert and oriented x 3. Oriented to person. Oriented to time. Oriented to place. Mood is pleasant no unwanted behaviors witnessed. R2's care plan dated 5/18/26 shows, I have a diagnosis of muscle weakness (generalized), other abnormalities of gait and mobility, other lack of coordination, unspecified osteoarthritis, unspecified site and weakness. The facility's resident transfer policy dated 7/28/25 shows, Purpose: The purpose of this policy is to provide safe and consistent guidance for assisting residents with transfers within the facility, including but not limited to bed-to-chair, chair-to-bed, wheelchair, toilet, shower chair, and sit-to-stand transfers. This policy is intended to promote resident safety, dignity, independence, and reduce the risk of injury to residents and staff. Conclusion: This policy is intended to ensure that resident transfers are performed safely, consistently, and respectfully while promoting resident independence and reducing the risk of injury to residents and staff.

Based on observation, interview, and record review the facility failed to ensure there was reasonable access to phone communication for residents (R1 & R3) reviewed for residents' rights in the sample of 7.The findings include:On 3/18/26 at 11:47 AM, V16 Paramedic stated the facility got rid of their landlines and switched to cell phones. V16 stated they had their dispatch call the cell phone and they could not get anyone to answer.On 3/22/26 from 9:35 AM - 9:56 AM there wasn't a receptionist at the desk at the entrance of the facility. The phone was ringing and there wasn't anyone there to answer it. V4 Housekeeper came to the reception area and stated there wasn't a receptionist today; and yesterday they did not have one until 12:00 PM.On 3/22/26 at 10:22 AM, on the second floor the land line was not operational. The cell phone for the floor was sitting inside the nurse's station. V5 Certified Nursing Assistant - CNA was sitting on the other side of the nurse's desk in the hallway area.On 3/22/26 at 10:39 AM, V2 Assistant Director of Nursing - ADON stated every floor has one cell phone that is used by the staff and the residents. The floors don't have landlines. The nurse is supposed to always carry the phone with her. V2 stated from 8:00 AM - 8:00 PM there is a receptionist at the front desk that transfers the calls to the cell phones. After hours the landline should be switched so calls that come in go to the second-floor cell phone. The nurse is responsible for always answering the cell phone during their shift. There should not be a reason for the phone not being answered. V2 did not know why there wasn't a receptionist this morning.On 3/22/26 at 11:21 AM, V1 Administrator stated, there is always someone at the reception desk from 8:00 AM to 8:00 PM. The receptionist answers the phone during those hours and sends the calls to the cell phones. Each floor has a cell phone. V1 stated he did not know why there wasn't someone at the desk this morning.On 3/22/26 at 11:32 AM V6 (R1's wife/power of attorney) stated there is a certain number that you must call at night to get anyone at the nursing home. V6 stated they have tried to get people before and were not able to. Her granddaughter called and no one answered the phone. There were times they couldn't reach anyone.On 3/22/26 at 11:59 AM, V1 Administrator stated the cell phone on each floor is used by staff and residents. The residents use cell phones to communicate with their families. The nurse on duty should carry the phone. During the hours from 8:00 AM - 8:00 PM calls are transferred from the switchboard to the cell phones. After 8:00 PM there isn't anyone to answer the phone. There is a recording that gives the caller a number to press to leave a message for the business office, administrator, social services etc. The hospitals have direct cell phone numbers. V1 confirmed the police, paramedics, fires stations, etc. do not have the cell phone numbers and would not be able to call them directly after hours.On 3/22/26 at 12:50 PM V8 (R3's mother/POA) was feeding R3 her lunch. V9 (R3's sister) was sitting in a chair in R3's room. V8 (R3's Power of attorney - POA) stated she has had problems when she has called the facility with no one answering the phone. V8 stated the staff do not answer the cell phone. V9 stated she had problems with the phone not being answered when she called.On 3/22/26 at 1:07 PM, V10 (Registered Nurse) stated the phone system here is a problem. Families have complained that they will call, and no one answers. There is a cell phone, one cell phone that the staff and the resident's use. There are text messages to the doctor and communication back and forth on the phone. The residents can see that when they use the phone and can read information about other residents. V10 stated she has complained about that and families calling with no one answering the phone.The facility's Resident Rights policy (7/28/25) showed the policy was to ensure that all residents in our care are treated with dignity, respect, and fairness while safeguarding their rights, safety, and access to services.

Based on interview and record review, the facility failed to ensure that a resident at moderate risk for skin impairment received interventions to prevent and properly manage an unstageable pressure ulcer, resulting in deterioration of the wound and osteomyelitis for one (R2) of three residents reviewed for pressure ulcers. This failure resulted in R2's wound progressing to a painful facility acquired an unstageable pressure ulcer with tunneling and osteomyelitis, requiring intravenous antibiotics and debridement. Findings include:The facility's Pressure Ulcer Policy revised 4/18/25 documents the facility is committed to the prevention, early identification, and evidenced based treatment of pressure ulcers. All residents will receive comprehensive skin assessments, risk evaluations, and appropriate skin interventions to promote skin integrity and prevent deterioration. Reassessment will occur with any change in condition or following identification of skin breakdown. New wounds, signs of infection, or wound deterioration must be reported promptly to the Nurse Supervisor and Medical provider. The wound Nurse must be notified to reassess and update treatment orders. Ongoing training will be provided to nursing staff on pressure ulcer prevention and wound care protocols. The facility's Notification of Change in Condition policy revised 9/17/25 documents notification to resident's physician and representative by the interdisciplinary team when there is a significant change in the resident's physical, mental, or psychosocial condition. Notification will also be made if there are any changes that may impact the residents plan of care or prognosis. The interdisciplinary team will review the change in condition and determine whether modifications to the care plan are necessary.R2's Braden Risk Assessments dated 8/1/25 and 1/2/26 documented that R2 was at moderate risk for skin impairment.R2's care plan did not include pressure-relieving interventions, repositioning schedules, or documentation of pressure ulcer care.R2's MDS (Minimum Data Set) dated 1/19/26 documents R2 has one unstageable pressure ulcer due to slough or dead tissue. This same MDS documents R2 is severely cognitively impaired.On 3/8/26 at 11:45 AM, R2 was lying in bed with eyes closed. R2 has a feeding pump next to his bed which is not connected. R2 has an abdominal binder in place. G tube visualized and in place.R2's Wound Note dated 2/10/2026 documents R2 was evaluated by V20 (Wound Physician), V12 mechanically debrided wound to R2's coccyx, bone scraping obtained to confirm diagnosis of osteomyelitis after topical analgesic applied to wound bed. R2 has Copious amount of bright red blood observed from debridement site. V20 documents in R2's Wound Evaluation and Management Summary R1's wound is a stage 4. Staff applied direct pressure with gauze and covered the wound bed with calcium alginate, blood stop granules applied to wound bed and secured with abdominal pad. V2 advised leaving R2 lying supine with direct pressure to wound bed to stop bleeding. R2 was positioned with green foam wedges, and head of bed elevated due to tube feeder. R2 tolerated procedure well and Measurements obtained. New order to discontinue collagen dressing to wound bed and utilize calcium alginate only, orders updated. Wound culture sample labeled, order written and sample placed for lab pick up. POA to be made aware of above findings.R2's Wound Notes dated 2/10/26 documents R2's wound measurements Pressure ulcer staging for R2's coccyx is Stage 3 Pressure ulcer / injury with full thickness skin loss. R2' Wound was acquired in-house, and it is unknown how long the wound has been present. The coccyx wound Length (centimeters/cm): 5.57 Width (cm): 4.82 Depth (cm): 0 Area (cm2): 19.53 with Tunnel length (cm): 2.2 Tunnel location 1: 12 o'clock.R2's Nurse Progress Note dated 2/17/2026, documents Call placed to infectious disease in regard to R2's bone specimen results as V12 (Wound Doctor) does not want to dose antibiotics due to R2 being in kidney failure. V12 (Nurse Practitioner) made aware, and order was received to follow up with infectious disease. R2's Labs faxed to V21 (Infectious Disease Physician) office awaiting further instruction. Bone debridement performed this shift by V20, wound cleansed with normal saline solution, packed with 4x4 gauze to assist with stopping bleeding. Area applied with firm pressure and will continue to monitor for active bleeding. Clean dressing to be applied to wound bed.R2's Nurse Progress Note dated 2/19/2026, documents R2 in bed this shift, coccyx wound bed cleansed with normal saline solution, bone particle appears to be showing through wound bed, no active signs and symptoms of infection noted, wound bed displays with copious amounts of serosanguineous drainage, no foul odor, peri wound is clean, dry an intact.R2's Physician Orders document on 02/26/26 may draw blood from feet if necessary and start Vancomycin Intravenous Solution 500 milligrams per milliliter(mg/ml) infuse intravenously one time a day every Monday, Wednesday, and Friday for wound infection for six weeks given at dialysis.On 3/9/26 at 9:30 AM, V17 (Licensed Practical Nurse/Wound Nurse) stated R2's Coccyx Ulcer is a stage three pressure ulcer developed at the facility. V17 confirms that R2's wound was cultured and R2 has osteomyelitis in his bone of his coccyx and was started on IV Vancomycin approximately two weeks ago. V17 confirms the Wound Doctor follows R2 for wound care and orders. V17 further stated R2 is dependent on staff for all cares. V17 stated that R2 will often grimace or pull away during dressing changes and debridement's.On 3/9/26 at 10:50 AM, V17 stated she was unable to locate the initial assessment for when R2's pressure ulcer developed. V17 stated she documented the pressure developed in July of 2025 because that's when she took over the position.

Based on interview and record review, the facility failed to ensure the nursing department was directed by a qualified Director of Nursing responsible for oversight of nursing services and coordination of care, resulting in a lack of direction and communication within the nursing department and therapy regarding resident care needs for one (R1) of three residents reviewed for gastrostomy tube (G-tube) management. This failure has the potential to affect all 81 residents residing in the facility. Findings include:The facility's Resident Roster dated 3/6/26 documents 81 residents reside at the facility. On 3/7/26 at 11:45 AM, V1 (Administrator) stated the facility has not had a Director of Nursing for several months. During the same interview, V1 stated there had been communication issues between departments and the facility plans to improve this process. On 3/8/26 at 10:22 AM, V1 stated nursing staff did not have access to therapy documentation and there was no defined communication process for therapy recommendations.On 3/6/26 at 10:30 AM, V2 (Assistant Director of Nursing/Licensed Practical Nurse) stated the former Director of Nursing had left approximately eight months ago and the facility had not replaced the position. V2 stated that she has been doing her best to address nursing needs. R1's Speech therapy documentation dated 9/30/25 through 11/24/25 documented R1 had a feeding tube in place and recommended puree consistencies with therapeutic feedings with the Speech Language Pathologist (SLP) only.R1's Nurse Progress Note dated 8/30/25 documents R1 pulled out her G-tube, and a progress note dated 8/31/25 documented enteral feeding orders were discontinued per V12 (Nurse Practitioner), and G-tube site care was initiated.On 3/6/26 at 2:45 PM, V11 (Speech Language Pathologist) stated that at the time R1 was discharged from therapy on 11/24/25, V11 understood that R1 continued to have a feeding tube in place and was not informed R1 had pulled out her G-tube and a new feeding tube was not inserted.

Based on interview and record review, the facility failed to ensure the nursing department was directed by a qualified Director of Nursing responsible for oversight of nursing services and coordination of care, resulting in a lack of direction and communication within the nursing department and therapy regarding resident care needs for one (R1) of three residents reviewed for gastrostomy tube (G-tube) management. This failure has the potential to affect all 81 residents residing in the facility. Findings include:The facility's Resident Roster dated 3/6/26 documents 81 residents reside at the facility. On 3/7/26 at 11:45 AM, V1 (Administrator) stated the facility has not had a Director of Nursing for several months. During the same interview, V1 stated there had been communication issues between departments and the facility plans to improve this process. On 3/8/26 at 10:22 AM, V1 stated nursing staff did not have access to therapy documentation and there was no defined communication process for therapy recommendations.On 3/6/26 at 10:30 AM, V2 (Assistant Director of Nursing/Licensed Practical Nurse) stated the former Director of Nursing had left approximately eight months ago and the facility had not replaced the position. V2 stated that she has been doing her best to address nursing needs. 1.R1's Speech therapy documentation dated 9/30/25 through 11/24/25 documented R1 had a feeding tube in place and recommended puree consistencies with therapeutic feedings with the Speech Language Pathologist (SLP) only.R1's Nurse Progress Note dated 8/30/25 documents R1 pulled out her G-tube, and a progress note dated 8/31/25 documented enteral feeding orders were discontinued per V12 (Nurse Practitioner), and G-tube site care was initiated.On 3/6/26 at 2:45 PM, V11 (Speech Language Pathologist) stated that at the time R1 was discharged from therapy on 11/24/25, V11 understood that R1 continued to have a feeding tube in place and was not informed R1 had pulled out her G-tube and a new feeding tube was not inserted.2. R2's Wound Notes dated 2/10/26 documents R2's wound measurements Pressure ulcer staging for R2's coccyx is Stage 3 Pressure ulcer / injury with full thickness skin loss. R2' Wound was acquired in-house, and it is unknown how long the wound has been present. The coccyx wound Length (centimeters/cm): 5.57 Width (cm): 4.82 Depth (cm): 0 Area (cm2): 19.53 with Tunnel length (cm): 2.2 Tunnel location 1: 12 o'clock.R2's Nurse Progress Note dated 2/17/2026, documents Call placed to infectious disease in regard to R2's bone specimen results as V12 (Wound Doctor) does not want to dose antibiotics due to R2 being in kidney failure. V12 (Nurse Practitioner) made aware, and order was received to follow up with infectious disease. R2's Labs faxed to V21 (Infectious Disease Physician) office awaiting further instruction. Bone debridement performed this shift by V20, wound cleansed with normal saline solution, packed with 4x4 gauze to assist with stopping bleeding. Area applied with firm pressure and will continue to monitor for active bleeding. Clean dressing to be applied to wound bed.On 3/9/26 at 9:30 AM, V17 (Licensed Practical Nurse/Wound Nurse) stated R2's Coccyx Ulcer is a stage three pressure ulcer developed at the facility. V17 confirms that R2's wound was cultured and R2 has osteomyelitis in his bone of his coccyx and was started on IV Vancomycin approximately two weeks ago. V17 confirms the Wound Doctor follows R2 for wound care and orders. V17 further stated R2 is dependent on staff for all cares. On 3/9/26 at 10:50 AM, V17 stated she was unable to locate the initial assessment for when R2's pressure ulcer developed. V17 stated she documented the pressure developed in July of 2025 because that's when she took over the position.

Based on observation, interview and record review, the facility failed to maintain resident room temperatures at a comfortable, safe level for three of seven residents (R1, R5 and R7) reviewed for comfortable room temperatures, in a sample of seven.The facility policy, Emergency Procedures for Heat Loss, dated September 2017 directs staff, The inability to heat the facility can be a critical issue in many parts of the country. The loss of the heating system should be assessed quickly to determine if the situation can be remediated while temperatures remain steady in the facility. If not, partial or full building evacuation may be necessary.On 01/26/2026 at 8:20 A.M., R1 was seated in a wheelchair in his room, on the facility second floor, wearing multiple layers of clothing and a knitted hat. The room temperature in R1's room measured 62.4 degrees via an infrared thermometer laser temperature gun. At that time R1 stated he was cold and stated it had been cold in his room for the past week.On 01/26/2026 at 8:26 A.M., R5 was seated in an easy chair in his room with multiple layers of clothing on, and a coat and a hat. At that time R5 stated he was cold. The room temperature in R5's room measured 61.1 degrees via an infrared thermometer laser temperature gun.On 01/26/2026 at 8:32 A.M., R7 was seated on his bed with multiple layers of clothing on. At that time R7 stated it's cool in here. The room temperature in R7's room measured 59.9 degrees via an infrared thermometer laser temperature gun.The facility Resident Room Temperature Logs dated 01/18/2026 to 01/25/2026 document random occupied resident room temperatures ranged from 54 to 68 degrees for that period.On 01/25/2026 at 3:10 P.M., V1/Administrator states the facility is heated by two steam boilers, with only one functioning currently. States the working boiler does have the capacity to heat the entire building itself. States the facility has been having trouble with the air temperatures inside the building for the past week, due to the sub-zero wind chills. States facility staff have been actively taping plastic and blankets to resident room windows, offering residents extra blankets and warm fluids and monitoring the resident room temperatures. States V3/Maintenance Director has been checking resident areas on all three floors routinely and recording the results. States the facility has active agreements with five other health care facilities, including the local hospital, to utilize in the case an evacuation of residents is warranted.On 01/26/2026 at 9:31 A.M., V3/Maintenance Director stated it's been cold in the building for about the past week. He (V3) has placed thick plastic and blankets on most windows, primarily on the second floor. It's an old building with one operating boiler that is working at full speed. A second boiler is currently shut off as it needs major part repair. The one functioning boiler has the capacity to heat the entire building, as it should. The building is 100 plus years old, with high ceilings, large old windows and has multiple elevators where cold air gets in without restriction. This past Thursday and Friday he took room temperatures in all resident rooms in the facility twice daily. The resident room temperatures have ranged from 54 to 68 degrees.

Based on interview and record review the facility failed to administer medication as ordered by the physician for one resident (R3), reviewed for respiratory treatments, in a sample of three residents. The facility's Medication Administration Policy dated 10/14/24 documents, The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident.R3's medical record documents R3 was admitted to the facility 9/15/25 with the following diagnoses: Acute respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease (with acute exacerbation), chronic systolic (congestive) heart failure, atrial fibrillation, and hypertension. R3's hospital discharge order documents the following: Albuterol (2.5milligrams/ 3 milliliters) 0.083% nebulizer solution, take 2.5 milligrams by nebulization every six hours.A review of R3's Order Summary Report and Medication Administration Records dated September 2025 document, Albuterol Sulfate Nebulization Solution (2.5 milligrams/ 3 milliliters) 0.083%, 2.5 milligrams inhale orally via nebulizer every six hours as needed for SOB (shortness of breath), does not show staff documentation of medication being administered as ordered.R3 stated that R3 admitted to the facility 9/15/25 from the hospital and he did not receive any nebulizer treatments while residing at facility (1 day). R3 stated that he has been prescribed continuous oxygen therapy and nebulizer treatments for many years. R3 stated that he asked to be discharged on 9/16/25 because he was not getting the medication he needed. V15 (Facility Nurse Practitioner) verified R3's nebulizer treatment orders were not transcribed or administered as ordered.

Based on interview and record review the facility failed to identify a pressure injury prior to advanced staging and failed to assess a new pressure injury for 1of 3 residents (R1) reviewed for pressure injuries in the sample of 3.The findings include:R1's admission record shows she was admitted on [DATE] with multiple diagnoses including unspecified severe protein-calorie malnutrition, anemia, Alzheimer's Disease and anxiety. She was discharged on 7/15/25.R1's admission resident assessment and care screening dated 4/25/25 documents R1 to have severe cognitive impairment. She was dependent on staff for bed mobility including rolling side to side. She was always incontinent of bowel and bladder. The same assessment documents R1 was at risk for pressure injuries and had no open wounds on admission.On 7/23/25 at 12:15 PM, V5 Certified Nursing Assistant (CNA) said R1 was dependent on staff for all of her care. She required assistance to get up in her chair for meals, had to be fed by staff and was incontinent of bowel and bladder. She was checked and changed every 2 hours and repositioned. R1s nursing progress notes of 6/4/25 documents 2 small superficial open areas were found on the right and left buttocks. The notes have no indication of measurements, staging or assessment of the wounds.R1s nursing progress notes for 6/24/25 show V4 Registered Nurse (RN) identified a new stage 2 pressure injury on R1s right shoulder. The wound measured 7.8 cm length by 2.2 cm wide by 0.2 cm depth.On 7/23/25 at 1:00 PM, V2 Director of Nursing (DON) said when R1 was admitted she was unable to really speak, dependent on staff for all of her needs, and was unable to move herself in bed. She had upper and lower body contractures. She was at a high risk for pressure injury due to her being underweight, and her nutrition was not good. The aides should be checking her skin every time they provide care and report any reddened or open areas. She said wounds should be identified and found prior to becoming stage 2. Early identification helps so the wound can possibly be healed and prevent any potential for infection.On 7/24/25 at 12:20 PM, V3 Nurse Practitioner (NP) said on 6/4/25, V9 Licensed Practical Nurse (LPN) should have documented the open areas as stage 1 and noted a little more information regarding the wounds including measurements.The facility 4/18/25 pressure ulcer policy document the facility is committed to the prevention, early identification, and evidence-based treatment of pressure ulcers. Identification and Documentation: Documentation will include wound type and stage (if pressure ulcer), location, size (length by width by depth), tissue type, drainage, odor, surrounding skin condition, pain level.

Based on interview and record review the facility failed to initiate a skin assessment upon admission, failed to initiate admission wound orders and failed to initiate an appropriate wound care plan for one resident (R1) with a sacral pressure wound of three residents reviewed for pressure wounds. This failure resulted in R1 acquiring a Stage IV necrotic sacral pressure ulcer. Findings include: Facility Policy/Pressure Ulcers/Skin Integrity/Wound Management (undated) documents: A system is in place for the prevention, identification, treatment, and documentation of pressure and non-pressure wounds. Procedure Upon Admission: A head to toe skin assessment will be conducted by a licensed nurse. It is recommended that this assessment is completed within the shift that the resident was admitted ; however, it must be completed within 24 hours of admission. It is important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that the factors that may have influenced its development, the potential for development of additional ulcers, or the deterioration of the pressure ulcer(s) be recognized, assessed, and addressed. Residents with risk for or who have a loss of skin integrity will receive the appropriate treatment/services, and residents who are determined to be at risk for or who have loss of skin integrity will receive the appropriate treatment/services which may include: Specific physician ordered medications/treatment Documentation Re: Assessment History of pressure ulcers For a resident who was admitted with a pressure ulcer or who developed one within two days, the admission documentation should include at least the following: Ulcer site and characteristics at the time of admission, including measurements; Possibility of underlying tissue damage because of immobility or illness prior to admission; Skin condition on and within a day of admission if suspected deep tissue injury. Care Planning: For new admission/readmissions, an immediate plan of care will be developed to address the immediate interventions to preserve and/or treat skin integrity issues. This should be communicated to staff. The care plan should address prevention of any skin breakdown, including shearing or friction, repositioning, offloading; pressure relief equipment; and the care and treatment to be provided to the resident for a pressure ulcer or non-pressure wound behaviors and characteristics. If a resident refuses or resists staff interventions, the care plan should reflect efforts to seek alternatives as well as education to resident and/or family regarding the risks. This education should be documented. All care plan interventions should be revised if there is recurring pressure ulcers, a lack of progress toward healing, or if the resident acquires a new ulcer. Physician Orders dated 10/18/24 indicates R1 was transferred from an out-of-state VA (Veterans Administration) hospital to a Skilled Nursing Facility (previous facility) on that date. Skilled Nursing Facility Progress Notes dated 10/19/24 at 9:41pm indicate R1 had Small sheared area under scrotum and coccyx with shearing and multiple small open areas. Initial (Physician) Wound Evaluation & Management Summary dated 10/21/24 indicates R1 with a History of Stage IV sacral pressure wound/full thickness Now with scattered areas with minimal depth. Summary indicates wound size 6cm (centimeters) x 6cm x 0.1cm; cluster wound with open ulceration area; light serous exudate; 80% granulation tissue; 20% intact normal color skin. Summary Treatment Plan/Primary Dressing: Zinc ointment to affected area twice daily and as needed. for 30 days. Skilled Nursing Facility Physician Orders indicate R1 had the following orders upon discharge and transfer (10/24/24) to current facility: Cleanse sacral area with soap and water and apply Zinc twice daily and as needed (order date 10/21/24). Facility Admission (10/24/24) Physician Orders indicate wound care orders for R1 were not initiated until 11/1/24. TAR (Treatment Administration Record) dated 11/1/24 indicates sacral wound treatment was initiated on that date after R1 was seen by Wound Physician on 11/1/24. R1 received no wound treatment from 10/24/224 to 11/1/24. No admission skin assessment was found or presented after R1 was admitted to the facility on [DATE] until 11/1/24. On 4/1/25 at 2:45pm V2, DON (Director of Nursing) confirmed a skin assessment was not completed upon admission for R1 and acknowledged the first skin assessment completed for R1 was provided by V6, Wound Physician on 11/1/24. Telemedicine Wound Care Follow Up Evaluation dated 11/1/24 indicates R1 sacral pressure wound as full thickness Stage IV: Wound Size: 9.0cm x 8.5cm x not measurable Depth not measurable due to presence of nonviable tissue and necrosis. Periwound Radius: Surrounding DTI (Deep Tissue Injury) Moderate serous exudate Thick adherent black necrotic tissue (eschar): 100% Wound Progress: Exacerbated due to unknown since admission to facility on 10/24/24. Wound Evaluation Treatment Plan dated 11/1/24 included: Initiate Leptospermum Honey once daily for 30 days, cover with foam silicone border for 30 days. No sharp debridement due to Telemedicine visit. Wound Evaluation and Management Summaries dated 1/16/25, 12/19/24 and 11/20/24 indicate R1 received surgical debridement of his sacral wound by V6, Wound Physician on those dates. Telemedicine Wound Care Follow Up Evaluation dated 1/23/25 indicates R1 sacral pressure wound as full thickness Stage IV with healing potential as Poor with following description: Wound Size: 12.4cm x 10.1cm x 0.2cm Periwound Radius: Erythema, Induration Moderate serous exudate Thick adherent black necrotic tissue (eschar): 100% Wound Progress: Exacerbated due to infection. Wound Evaluation Treatment Plan dated 1/23/25 included: Off-load wound; reposition per facility protocol; antibiotic choice: Cipro 750mg (milligram) once daily and Metronidazole 500mg three times per day x 7 days. Progress Note dated 1/23/25 at 10:16am R1 colostomy with no BM (Bowel Movement) noted this shift. NP (Nurse Practitioner) made aware and notified, R1 sent to ED (Emergency Department). Progress Note dated 1/23/25 at 10:54am indicates Notified POA (Power of Attorney) of (R1) transfer to ED and change in condition. Hospitalist Progress Note dated 1/28/25 indicates: Patient (R1) is [AGE] year-old male who has significant past medical history of including but not limited to diabetes type 2, coronary artery disease, hypertension, history of colostomy, status post C2-T4 spinal fusion with laminectomy C2-C3, vertigo, paraplegia, neurogenic bladder with indwelling urinary catheter, history of brain bleed, patient was sent to the emergency roiagnom on [DATE] from nursing care facility with chief complaint of low urine output. As per information from the chart, patient (R1) was recently diagnosed with UTI (Urinary Tract Infection). On further evaluation it was also noted that patient (R1) has a large sacral pressure ulcer, foul-smelling (pictures in the chart). Patient was admitted . Patient (R1) underwent excisional debridement of sacral wound in preparation for flap closure on January 27, 2025. Hospital Palliative Care Note dated 1/29/2025 LOS (Length of Stay) 5 days: Massive wounds. stage IV pressure ulcer located on his sacrum, stage III pressure ulcer located on his scrotum and a stage III pressure ulcer located on his right ischium. ID (Infectious Disease) discussed with R1's family that the best case scenario of R1 going to a tertiary care center where there is a plastic surgery/general surgery and grafting and in the best cases this heals versus wound care recurrent infection, and this does not heal. Discussed comfort care hospice care limited care. R1's Care Plan indicates Problem Area date initiated and revised 10/28/24 indicates Alteration in skin integrity - location coccyx. Identified on admission. Care Plan indicates Initial size and stage - see wound notes. All Interventions were initiated on 10/28/24 and are as follows: Refer to Nurse Practitioner as appropriate Dietary consult as indicated Turn and reposition routinely. Document any refusal. R1's care plan was never reviewed, revised or updated despite wound deteriorating, debridement by wound physician and did not include any pressure relief equipment, changes in treatments or subsequent wound infection. On 4/1/25 at 3:10pm V7, NP (Nurse Practitioner) stated I did not actually visualize (R1's) wound when he was here. I was doing physiatry - not wounds at that time. I knew he came in with a wound. He was previously at another local facility. (R1) was being followed by wound physicians at (the previous facility) so it was continued when he came here. I would never have recommended debridement for that wound. It was too extensive. I had no idea it was that big. I'm surprised they debrided it in the hospital. V7 stated R1 was very non-compliant with care and resistive to weight shifting, offloading when he was at this facility. V7 stated R1 was also verbally aggressive, cussing staff out. V7 stated (R1) would never have complied with precautions or interventions after debridement. It would have ended up infected. V7 stated that R1's care plan should have included his non-compliance with wound care interventions. On 4/2/25 at 1:18pm V4, Wound Physician stated R1 did not have eschar on his sacral wound when she saw him on 10/21/24 (prior to facility admission on 10/24/24). V4 acknowledged she recommended Zinc for R1's wound at that time and stated, Zinc is not an appropriate treatment for a wound with eschar. V4 stated that she ordered Zinc because the wound had low drainage and would protect fragile skin. V4 stated I doubt if not having Zinc for a week would lead to a wound covered in 100% Eschar - so there must have been more factors at play. The order for Zinc twice daily should have been carried over though or re-evaluated upon admission.

Based on record review and interview the facility failed to document staff were provided education regarding the benefits and potential risks associated with the Covid-19 vaccination. This failure has the potential to affect all 82 residents in the facility. Findings include: A Policy titled Employee Vaccination last revised 10/14/24 documents the purpose of this policy is, To reduce the risk of infectious disease transmission among employees, residents, and visitors by providing access to recommended immunizations. Procedure 4. Education and Awareness documents, Educational materials regarding the benefits, risks and availability of vaccines will be provided to all employees. Employees will be informed about recommended vaccination schedules and any updates from the Centers for Disease Control and Prevention (CDC) or Illinois Department of Public Health (IDPH). Review of employee Covid-19 Consent forms for staff who received a Covid-19 vaccination this year documents three staff received the Covid-19 vaccination (V4, V12, V13). There is no documentation these three or any staff received education regarding the benefits and potential risks associated with the Covid-19 vaccination. On 02/26/25 at 11:34 AM V9/Assistant Director of Nursing and Infection Preventionist confirmed she cannot provide documentation that staff were provided with education regarding the potential risks and benefits of receiving the Covid-19 vaccination.

Based on observation, interview and record review the facility failed to prevent one of five residents (R46) from sustaining a smoking/vape-related burn and failed to complete quarterly Smoking Assessment Evaluations for four of 18 Residents (R33, R46, R51 and R79) reviewed for smoking in the sample of 33. Findings include: Facility Resident and Employee Smoking Policy dated 10/14/24 documents: It is the policy of the facility to provide a safe environment for Residents, staff and visitors by providing guidelines for the use of smoking materials; and the Smoking Evaluation tool will be done upon admission, quarterly and with change of condition; and the information will be available to staff members and will be updated with any changes in the Resident's capabilities and needs. Procedure for Residents: Smoking is only permitted under the supervision of a staff member in the facilities designated smoking areas based upon a smoking evaluation. the Smoking Evaluation tool will be done upon admission, quarterly and with change of condition; and the information will be available to staff members and will be updated with any changes in the Resident's capabilities and needs. The Facility Resident Smoking List, dated 2/24/25, documents R33, R46, R51 and R79 as smokers. Progress Note dated 2/10/25 at 11:31am indicates V11. NP (Nurse Practitioner) reported to V2, DON (Director of Nursing) that R46 showed V11 an area on his right forearm and stated he burned it while he was out smoking. Note indicates V2 assessed R46 and observed a 3cm (centimeter) X 1.6cm red and yellow area to R46's right forearm. At that time R46 told V2 he might have got the wound from his vape pen. Note indicates R46's wound Does appear size and shape of a vape pen. Note indicates V2 spoke with R46 regarding his non-compliance with only smoking at supervised times. Note indicates R46 stated he will go outside whenever he wants to. Note indicates an alarm was applied to R46's wheelchair to alert staff whenever R46 attempts to leave the unit/enter the elevator. Skin Check Note dated 2/10/25 at 12pm indicates R46 has a new skin issue right anterior arm - Type: Partial Thickness Burn. On 2/26/25 at 2:25pm R46 pulled his right sleeve up and an oval thickened scabbed wound was noted middle anterior arm. Peri wound had no signs/symptoms of infection. At that time R46 acknowledged vaping at times when he was unsupervised. On 2/27/25 at 10:20am V11, NP stated that the affected area on R46's right arm did initially look like it may have had blistering but blisters were not present when she first saw the wound. V11 stated R46 told her the burn was from a vape pen. R46's current Care Plan indicates R46 has an actual skin impairment of right forearm related to a burn from vape/cigarettes. Care Plan indicates R46 is not compliant with Smoking Policy as he is supposed to be supervised but leaves his unit unattended. Care Plan indicates R46 is non-compliant with Smoking Policy as evidenced by going outside to smoke at undesignated times. Care Plan indicates R46 requires Supervision during smoking. 33975 R51's Medical Record documented R51's most recent Smoking Assessment (dated 6/18/24). R33's 06/04/24 Smoking assessment documents Resident is cognitively intact, able to light his own cigarettes and put his cigarettes out safely. Resident is able to self propel himself outside. He is safe to smoke without supervision. There is not a quarterly assessment completed for R33. A sheet of residents who smoke dated 02/24/25 documents R79 smokes independently. Review of R79's assessments does not have a smoking assessment. On 02/26/25 at 10:05 AM V1/Administrator stated there is no quarterly smoking assessment for R33 and no smoking assessment completed for R79. On 2/27/25 at 10:05 am, V1 (Administrator) stated, We do not have any quarterly Smoking Assessments for R33, R46, R51 or R79. It looks like we are only doing the Assessments annually.

Based on observation, interview, and record review, the facility failed to ensure staff follow infection control practices during wound care, in that, V4/Licensed Practical Nurse failed to change gloves during pressure ulcer wound care for R25. This failure has the potential to effect one resident [R25] of two residents reviewed for Pressure ulcer wound care, in a total sample of 33. Findings include: The [NAME], A., [NAME], P., [NAME], W., & [NAME], N. (2024). Clinical Nursing Skills & Techniques (11th ed., pp. 1115-1116). Elsevier Health Sciences, document: 11. Apply clean gloves and remove soiled dressings; remove gauze one layer at a time; 12. Examine dressings for quality of drainage (color, consistency), presence or absence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). Discard dressings in waterproof biohazard bag. Remove and discard gloves; 13. Perform hand hygiene and apply clean gloves; 17. Apply dressings per order. Place time, date, and initials on new dressing; and 19. Discard biohazard bag and soiled supplies per agency policy. Remove and dispose of gloves. Perform hand hygiene. R25's Electronic Medical Record/EMR Physician Order, dated 2/24/25, document, Cleanse right buttock with NS [normal saline], apply barrier cream and border gauze daily and prn [as needed] until healed. On 2/25/2025, at 10:15 a.m., V4 performed hand hygiene, applied gloves, and without changing gloves, V4 removed R25's wound dressing from R25's right buttock wound; grabbed a clean 4 x 4 gauze; cleansed R25's wound; grabbed a dry 4 x4 gauze and dried R25's wound; grabbed container of barrier cream and placed small amount of V4's glove; applied barrier cream to wound area; and grabbed new foam dressing and applied to R25's right buttock wound. On 2/25/25 at 10:30 a.m., V4 confirmed not changing gloves after removing R25's soiled right buttock wound dressing. On 2/27/25, at 8:25 a.m., V2/Director of Nursing confirmed the expectation that V4 should have changed gloves/performed hand hygiene after removing R25's soiled right buttock wound dressing.

Based on observation, interview and record review the facility failed to prevent a significant medication error for one resident (R21) who receives an antipsychotic medication of five residents reviewed for unnecessary medications in the sample of 33. Findings include: Facility Policy/Medication Administration dated 10/14/24 documents: The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident. On 2/25/25 and 2/26/25 at random times throughout both days R21 was observed in his room, frequently calling out for help. On 2/27/25 at 3:15pm V2, DON (Director of Nursing) stated R21's behavior is mostly a constant yelling out. Hospice Physician Order dated 1/22/25 indicates to Start Seroquel (antipsychotic) 50mg (milligrams) by mouth three times per day. Nurse Note dated 1/27/25 at 11:22am indicates Hospice nurse in facility for routine visit and received new orders for R21 to increase the following medications from twice daily to three times daily: Lorazepam (antianxiety) 1mg, Seroquel 50mg, Tramadol (pain) 50mg, and Trazodone (antidepressant) 100mg. Orders updated. R21's January 2025 Physician Order Report Summary indicates Quetiapine/Seroquel (antipsychotic) 100mg twice daily was ordered on 6/25/24 and indicates on 1/27/25 that order was changed to Seroquel 100mg three times daily on 1/27/25. R21's Medication Administration Record (MAR) dated January 2025 indicates R21 received Seroquel 100mg three times per day from 1/27/25 until 2/27/25 when the error was discovered. The MAR indicates R21 received twice the dosage ordered (300mg per day instead of 150mg per day) from 1/27/25 through 2/27/25. Medication Error Report - Date and Time of Error 1/27/25 at 1200 for R21 indicates: Medication ordered: Seroquel (antipsychotic) 50mg (milligrams) three times per day Medication given: Nurse (V8) entered Seroquel 100mg three times per day into R21 Physician orders Report indicates No Adverse Effects noted At this time On 2/26/25 at 3:25pm V2, DON stated It looks like this is a medication error. The nurse who transcribed the order in error has already been terminated for other reasons.

Based on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication and failed to provide supporting behaviors for the use of an antipsychotic medication for one resident (R21) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 33. Findings include: Facility Policy/Psychotropic Medications dated 10/14/24 documents: The facility must ensure that residents who: Have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Antipsychotics will be used only for Behavioral Symptoms that are: A danger to the resident or to others OR cause the resident inconsolable or persistent distress, a significant decline in function, and/or substantial difficulty receiving needed care, AND Not due to a medical condition or problem AND Persistent or likely to reoccur without continued treatment AND Not sufficiently relieved by non-pharmacological interventions AND Not due to environmental stressors that can be addressed to improve the psychotic symptoms or maintain safety AND Not due to psychological stressors that can be expected to improve or resolve as the situation is addressed AND Conditions/diagnoses listed in the (Mental Illness Directory) or subsequent editions: Schizophrenia Schizoaffective disorder Delusional disorder Mood disorders Schizophreniform disorder Psychosis NOS Atypical psychosis Brief psychotic disorder Dementing illnesses with associated behavioral symptoms Medical illnesses or delirium with manic or psychotic symptoms R21's January 2025 Physician Order Report Summary indicates Quetiapine/Seroquel (antipsychotic) 100mg (milligrams) twice daily was ordered on 6/25/24 and indicates on 1/27/25 that order was changed to Seroquel 100mg three times daily on 1/27/25. R21's February 2025 Physician Order Report Summary indicates R21 continued on Seroquel 100mg three times per day until 2/27/25 for Mild Vascular Dementia with Behavioral Disturbance. R21's Current Care Plan indicates R21 has the potential to be verbally aggressive, yelling out exaggerated claims example: ripping his hair out when putting on his shirt. Care Plan indicates R21 has Ineffective coping skills and Mental/Emotional illness; Poor impulse control; Rolls self out of bed when not getting enough attention. (Last revised 9/14/22). Care Plan also indicates R21 has a behavior problem of yelling out constantly for help and wants someone to be in his room at all times; attention seeking; loud and disruptive. (Last Revised 09/14/2022) On 2/25/25 and 2/26/25 at random times throughout both days R21 was observed in his room, frequently calling out for help. On 2/27/25 at 3:15pm V2, DON (Director of Nursing) stated R21's behavior is mostly a constant yelling out. V2 stated they are going to try and reduce R21's Seroquel/Quetiapine and acknowledged it hasn't really reduced R21's yelling out behavior and also acknowledged the dosage is higher than usual.

Based on record review and interview the facility failed to ensure a resident was free from sexual abuse by a staff member for 1 of 3 residents (R33) reviewed for abuse in a sample of 33. Findings include: A policy titled Abuse and Neglect Prevention last revised 10/14/24 defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. It includes abuse, sexual abuse, physical abuse, and mental abuse including facilitated or enabled through the use of technology. The policy continues, 3. Willful, as defined at 483.4 and as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm and 6. Mistreatment means inappropriate treatment r exploitation of a resident. This abuse policy documents, No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. A facility reported incident report dated (undated) documents R33 has a Brief Interview for Mental Status/ BIMS of 15 indicating he is cognitively intact. This report documents that on 02/21/25 at approximately 12:30 PM R33 showed a staff member a picture of a woman's naked vagina and some messages. R33 stated V8/Registered Nurse (RN) sent him the photo and messages. The messages were sent under the name Hot (V8's first name) and were from V8's phone number. The message read, Tell me the first thing that comes to mind when you see this. Mine was holocaust victim. An interview with R33 dated 02/21/25 and signed by V2/Director of Nursing documents R33 showed V2, V1/Administrator and V3/Human Resources a nude photo which R33 stated V8 had sent to him via text message. The message was from Hot/ (V8's first name) and was from V8's personal cell phone number. R33 stated that he and V8 do sometimes exchange messages, but he didn't expect or appreciate this message. R33 stated that he wasn't really too upset, but that it was inappropriate and shouldn't have happened. An interview dated 02/24/25 and signed by V2 titled (V8) abuse investigation documents V1 and V3 interviewed V8 and asked if V8 had sent an explicit photo to R33. V8 initially denied this and then admitted she had sent the photo to R33. V8 stated she knew it was inappropriate to send the photo, but she doesn't have many friends outside of work, so just thought she'd send it to R33. On 02/25/25 at 11:07 AM R33 stated V8 had sent him inappropriate text messages and pictures trying to entice him. R33 stated the messages upset him and were inappropriate so he reported this occurrence to staff and to V1. An undated final report, provided to surveyors on 02/26/25 documents, The facility has concluded its investigation and does believe (V8) is guilty of sending an explicit photo to (R33). V8 was terminated on 02/24/25.

Based on observation, interview, and record review, the facility failed to have the survey binder readily available, and in a conspicuous place, for residents review the results of State Agency surveys. This failure has the potential to affect all 82 residents residing in the facility. FINDINGS INCLUDE: Centers for Medicare and Medicaid Services [CMS] form 671 [Long-term Care Facility Application for Medicare and Medicaid, dated 2/27/2025, signed by V1/Administrator, document 82 residents reside in the facility. On 2/25/2025 and 2/26/2025, during the facility's annual survey [by the State Agency], the survey binder, containing State Agency survey results, could not be located. On 2/26/2025, at 10:00 a.m., Resident Counsel residents, R12, R13, R28, R45-Resident Council President, and R66 all statee they were not aware the survey binder existed, nor were they aware they were entitled to review the results/findings of State Agency surveys. On 2/27/2025, at 8:45 a.m., V1, Administrator confirmed the binder containing survey results was not readily available to residents.

Based on interview and record review the facility failed to accurately assess a resident at risk for elopement and failed to implement interventions for a resident at risk for elopement resulting in R1 eloping form the facility unsupervised on 4/19/24 at approximately 7:00 PM. R1 did not return to the facility until approximately 1:00 PM on 4/20/24. This applies to one of three residents (R1) reviewed for elopement in the sample of eight. The Immediate Jeopardy began on 4/10/24 when R1 did not return from a leave from the facility with a friend until the city public bus system brought R1 back to the facility between 8:00 PM and 8:30 PM. When the city public bus dropped R1 off at the facility, they reported they had noticed R1 sleeping on a park bench in the local downtown area and recognized him. When R1 was returned to the facility he had large reddened areas around his eyes, his eyes were bloodshot, and he was exhibiting erratic behaviors and slurred speech. V1 Administrator was notified of the Immediate Jeopardy on 5/3/24 at 9:50 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 5/3/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include activated protein c resistance, epilepsy, disorganized schizophrenia, hypothyroidism, gastro-esophageal reflux disease, Bell's Palsy, nicotine dependence, and bipolar disorder. R1's facility assessment dated [DATE] showed he was cognitively intact, required only set up assistance for cares, and was exhibiting no behaviors. R1's care plan initiated 1/31/24 showed, I do not show potential for discharge to the community due to current health status. Goal: Care needs will continue to be met at the facility. Interventions: Allow me to verbalize my feelings about long term care. Reassess care needs and potential for discharge as needed. Support patient, family and/or representative as needed. R1's care plan initiated 3/1/24 showed, There is no plans of discharge at this time. I require assistance with ADLs (activities of daily living), mobility, and safety issues. I require, 24 hour care, will be long term . Revisit discharge plan and potential annually and PRN (as needed) . Encourage resident to be realistic in expectations, point out positives. R1's complete care plan was reviewed and showed no evidence of R1 making repeated statements regarding leaving the facility or having a risk of leaving the facility unattended. R1's 3/19/24 Psychiatry Physician Note showed, . Recent suicidal statement . He was recently sent out to ER (emergency room ) on 3/16/24 after making suicidal statements; he was reported crying I hate this place, there is nothing to do, I'm gonna run away, I'm gonna kill myself! . He endorses feeling down due to being stuck at his current placement . The facility's final investigation report to (State Agency) written by V1 Administrator and dated 4/20/24 showed, . Resident left facility unauthorized . The male resident had just been outside with other residents and the monitoring staff member at the 7 PM smoke break Within 15-20 minutes later, he was seen by a dietary staff member who was walking home and observed [R1] walking quickly (almost running) down a street a few blocks away . The employee tried to keep eyes on him while he called the facility but the resident got out of sight and he could not locate him Resident has already been connected with resources to help him transition into a community setting (i.e. low income housing, halfway house, etc.) and sometimes he states he would rather live homeless than be confined in the nursing home setting. States he 'does not belong here' and wants the freedom to use marijuana to calm his anxiety. Facility will continue to seek alternate more appropriate placement for this gentleman upon his return. Conclusion: The resident was located with the assistance of his sister whom was contacted by one of [R1's] friends. The friend stated that he had shown up at his house late last night, hungry and tired, so he fed him and let him stay there . AMA (against medical advice) paperwork and consequences were discussed with him . [R1] proceeded to sign AMA paperwork stating he understand the associated risks . R1's AMA paperwork showed he signed out at 4/20/24 at 1:40 PM. On 5/1/24 at 11:10 AM, V17 (Housekeeper) said she was the staff member that had taken R1 for cigarette break that evening at approximately 6:45 PM - 7:00 PM and she had taken him back up to his floor. V17 said she does not know how R1 managed to get back down and leave. V17 said they have had problems with R1 following the rules and he been across the street once. V17 said R1 had a lady that would come take him out sometimes and this lady took R1 downtown and left him there. V17 said R1 was found laying on a pillar downtown. V17 said one of the bus drivers recognized R1 and knew where he came from so they brought him back home. V17 said, He was acting like he was on some other drugs. His eyes were all blood shot and he was slurring his words. He couldn't hardly walk. He stumbles at times, but this was 10 times worse . this was a week or two before this time that he disappeared . The bus driver was telling me he was acting like he was on drugs. He was getting handsy with me and I told him he needed to sit down. I called up to [his floor] to get the nurse but she did not answer. I had another resident watch him who had been sitting down there. I ran up to [R1's] floor and got the nurse. There were a few residents down in the lobby at the time [R4, R5, and R6]. CNAs (Certified Nursing Assistants) came down and got him. The nurse wouldn't even come check him out. The nurse that day was [V15 LPN (Licensed Practical Nurse)] R4's facility assessment dated [DATE] showed he has no cognitive impairment. R5's facility assessment dated [DATE] showed he has no cognitive impairment. R6's facility assessment dated [DATE] showed he has no cognitive impairment. On 5/1/24 at 1:09 PM, V15 LPN (Licensed Practical Nurse) said she had heard from a kitchen staff member that R1 was seen down the street from the nursing home on 4/19/24. V15 said she remembered one time before that R1 left but that he had signed out that time. V15 said she didn't smell liquor or drugs on him when he was brought back and she would say he was a little more tired than usual. V15 said someone told her the city bus had brought him back. I wasn't right there in that area that's why I may not know what [V17 Housekeeper] had said. V15 said she heard the bus driver had seen [R1] sleeping downtown .V15 said R1 would call his sister and beg her to come pick him up and she would do it because he would get very angry with her if she didn't. On 5/1/24 at 12:59 PM, R4 said he was in the lobby on the day R1 came in from the shuttle bus. R4 said the staff had been looking for R1 so he had come down to the lobby to see if R1 was there. R4 said R1 came stumbling in and V17 was trying to get the aides to come and get him. R4 said 2 CNAs did come down and took him back to his floor. R4 said R1 was not acting right, he was swaying, mumbling, and he had blood shot eyes that he could barely keep open. R4 said R1 mentioned to him a couple of times that he wanted to leave the facility. On 5/1/24 at 12:32 PM, R5 said he thinks the previous incident with R1 occurred about 3 weeks ago. R5 said he and R6 were heading out to smoke when R6 got his attention and pointed out R1 in the lobby. R5 said R1 was stumbling all over the place and looked like he was groping or fighting with V17 (the housekeeper in the lobby). R5 said they went down to see what was going on. R5 said, I started questioning him and he said he did not know how he got there. He didn't really smell like alcohol to me but he was clearly, clearly intoxicated on something . when [R1] first came in I was down at the desk and he came in from outside smelling so much like marijuana. Really strong. They would search his pockets when he would get back. Recently before he left, he said they found marijuana on him . On 5/1/24 at 12:15 PM, R6 said, [R1] had come in the door with [V17]. He looked like he was on something. Super weird dancing and walked up to [V17] and starting sexually assaulting her, grabbing her breasts. He looked like he was trying to attack her his eyes were beat red blood shot, [V17] tried to call up to his floor but no one answered so she ran upstairs . On 5/1/24 at 1:50 PM, V23 (Admission Director) said when the previous incident had occurred R1 actually had signed out and left with his friend. V23 said, I don't know what transpired with him being with [R1's friend] but my understanding was that he was with them, he fell asleep and they didn't want to bother with him sleeping so they left him. They saw him laying on a bench and [the city bus driver] for him on a bus and brought him back. I didn't see him that day. I don't know what time they brought him back . On 4/30/24 at 3:10 PM, V1 Administrator said if a resident were to return from a visit with family or friends and appear intoxicated or under the influence of illicit drugs they would document the incident, educate the resident and power of attorney regarding the incident, notify the physician, and the resident's medications would be held. V1 said the facility does not drug test. V1 said the incident and the follow through would be documented in the residents progress notes in the electronic record. On 5/3/24 at 2:23 PM, V1 Administrator confirmed the previous incident with R1 being left downtown occurred on 4/10/23. R1's complete electronic record was reviewed and showed no evidence of the 4/10/24 incident, no notification to the physician regarding the incident, no medications were held, and no education was documented. The facility sign out sheets for April were reviewed and showed the last time R1's female friend signed him out of the facility was on 4/10/24. On 5/1/24 at 3:48 PM, V24 (Dietary Cook) said he was at home at approximately 7:15 PM when he saw R1 running down the street. V24 said, He (R1) was moving pretty fast and looked like he was trying not to be seen . It was pretty cold out there because that was before the weather started warming up. I called the facility and told them I saw him. He was alone. It seemed like it was pretty far for him to be away from the facility. V24 provided his address which is located one half mile from the facility. On 4/30/24 at 12:14 PM, V5 CNA said in regards to the 4/19/24 incident, . He feels like he doesn't belong here. He just wants to do his own thing. Wandered all day long He had been calling his parents more lately and would ask them to come get him. One time they had just brought him back and he was calling them again . I was coming back from break when I heard he was seen by a staff member down by the [local grocery store] . I was here when he came back. He seemed like he was king of high. He didn't look like himself. His eyes looked weird . It was about 1:50 PM and [V1] came up to (R1's floor) to see if someone could help pack his things because he was leaving . On 4/30/24 at 12:42 PM, V7 (CNA and Scheduler) said she heard from V5 that R1 was missing. We jumped in our cars and started looking. V7 said R1 was not in the elopement book and he doesn't have a wanderguard. V7 said R1 was always good about signing out. V7 said R1 said multiple times that he did not want to be at the facility and that he wanted to be independent. V7 said R1 made these statements throughout his stay at the facility. V7 said R1 came back to the facility on Saturday and she was up all night worried about R1. V7 said R1 stated all the time that he wanted to smoke marijuana. On 4/30/24 at 12:28 PM, V6 ADON (Assistant Director of Nursing) said, . I got a text around 7:30 PM that [R1] had left the building. I got in the car and spent the next 3 hours looking around the town where homeless are and where I know drug deals go down. [R1] just sleeps wherever he is, he has narcolepsy I think . He was at risk for elopement. He would take his wanderguard off consistently I've been told. On 5/1/24 at 1:25 PM, V18 CNA said she was working on 4/19/24 when R1 left the building. V18 said, . After dinner [R1] goes all over so you can't really watch him . One day he was looking at me and I said what's wrong? He said he had some marijuana, that he went and did it with his friends . V18 said the day R1 left she had heard from another floor that someone had seen him walking. V18 said everyone started walking around looking for him and she and some others went outside and walked around . On 4/30/24 at 1036 AM, V3 Activity Director said, . [R1] always wanted to go somewhere, always wanted someone to pick him up. He would use the activity phone, his cell phone, and he used the front desk phone to call and see if someone could come get him and bring him back . On 5/1/24 at 10:50 AM, V9 CNA said, . We never had issues with him just wandering off and leaving like that. He did say a lot that he didn't belong here. Towards the middle of April I was working a lot of late shifts . He would comment a lot that he wanted to leave but he never did it . V9 said the elevator is locked for most residents but R1 was able to use the elevator at will. On 5/1/24 at 3:00 PM, V4 (Social Service Director) said, . [R1] was always trying to get into arguments because he wanted to smoke marijuana. Him and his dad would get into yelling arguments because his dad didn't want certain people coming in to see him. He would always ask (about marijuana) and we would go over why we can't have it here There was a time that a friend came and passed him some marijuana and we got it from him . He just wanted to be able to go and do what he wanted to do which he has a right to do . I'm not even sure why he was here, I think we were providing medication management. He was lower functioning. We were working on discharge to a different setting . I try to keep documentation of referrals. It would normally be in their progress notes when I am working on referrals . V4 said he did not hear about the 4/10/24 incident with R1 but that would not be the only time, depending on where he went with his friends, that he would come back looking like he was high. There was no evidence found in R1's record of V4 sending referrals or working towards discharge. V4 said the facility does not drug test residents that she knows of. V4 confirmed R1 had no emergency room visits for being under the influence. On 5/1/24 at 10:33 AM, V16 CNA said, [R1] definitely was a wanderer. He liked to be outside, liked to go outside and smoke and stuff. He just kept wanting to go outside. We try and keep the elevators locked for the residents that like to wander. He constantly was trying to leave. He would constantly ask to go outside to smoke. We have designated smoking times for residents to go out . We would try and tell him it wasn't time for his cigarette. He had to have supervision with smoking . I considered him an elopement risk. I don't know if we actually ad him on an elopement list like some of the residents who are high risk of escaping. I don't think he was on the list but he was definitely at risk. He would go and sit by the birds downstairs and try and go out in the back for an extra smoke break . He didn't like staying in one place. He was someone that we tried to keep out of the elevator. The elevators are locked for a reason. We have a key that we keep on a hook next to the elevator. During the day there are more people to watch the residents, at night there are less staff, less management so it can be harder for us so we try and keep it locked. Sometimes they get out without us knowing. Especially if they are wanting to get out. [R1] was a little sneaky about it especially at night. Last smoke break is between 7 PM and 7:30 PM, around 8 or 9 PM he would be ready for another cigarette and he would try and go down the back elevators so we didn't know. He was definitely sneaky . There were a couple of times that we would realize we hadn't seen him in a while and have to look for him. He would either be out front or out back in the smoke area. He liked to go out front a lot too . On 4/30/24 at 9:36 AM, V1 Administrator said, [R1] had mental health issues and enjoyed marijuana. He was not happy. We were trying to find placement . He would routinely sign himself out and he had questionable friends. He had a friend that would pick him up and bring him back impaired. That night (4/19/24) he didn't sign out, he just left. We put a search party together and notified the police we canvased bridges, bars, etc . and couldn't find him . His sister had received contact from a mutual friend the next day and they said he had arrived at his house hungry and either cold or tired . He and his friend decided they would come in (4/20/24). He left the facility then AMA after he returned . He did not understand why we were upset. We asked ourselves over and over why he was here? He was well managed healthwise, had questionable disability mentally . He was asked to leave his sisters apartment building before because he would go knocking door to door asking for cigarettes throughout the night . When he would sign out at the front test he wouldn't usually be out overnight . he would come back late at night sometimes. The facility's policy undated policy showed, . Behavior Committee . Purpose: The purpose of [the facility's] behavior committee is to assist in developing a comprehensive plan of care for those residents that exhibit behaviors that are disruptive or unsafe to themselves or others . 1. The committee is comprised of individuals from Social Services, Care Plans, nursing, and others as deemed appropriate . 3. The committee will review the plan of care and behavior monitoring and tracking documentation for residents identified as having untoward behaviors in order to identify possible causes for the behavior and to identify interventions to aid in handling the behaviors . 6. Referrals will be brought to the committee through use of morning report, facility staff referral, resident/family member referrals . The facility's undated policy showed, [The facility's] Drug Free Environment . Purpose: [The facility] believes strongly in making the living environment of all residents free of drugs and the accompanying abuses. Further the residents shall understand that the facility does not allow the use of any illegal drugs or cannibas/marijuana . If a resident chooses to participate in the use of illegal drugs inside or outside of the facility, the facility has the right to have a drug panel screening completed on the resident for confirmation. IF the resident partakes in the use of cannibas/marijuana off of facility grounds then he/she shall be evaluated by the nurse and physician shall be notified if any prescribed medications need to be held or any further steps taken to assure the residents well-being . The facility's undated policy showed, Resident Elopement; Purpose: To provide a safe environment for all it's residents and to maintain their independence while safeguarding their physical well-being, both within the facility and outside of it . Procedure: 1. There will be a list of residents at risk for elopement posted at the front desk. A photo of each resident will be included. 2. All new residents will be added to this list. Once it is determined the resident is not an elopement risk the picture will be removed . 4. If a resident is found to be at risk for elopement, the resident's care plan will include interventions for the prevention of elopement. 5. If the resident is thought to have eloped, the charge nurse or designee will notify staff to do a room to room search including bathrooms, shower rooms, storage areas, kitchen, all resident rooms, and stair wells. A code Silver is initiated simultaneously . The Immediate Jeopardy that began on 4/10/24 was removed on 5/3/24 when the facility took the following actions to remove the immediacy. In order to abate this Immediate Jeopardy and to ensure that all associated issues are resolved, the facility has completed and/or will have completed the following by end of day on 05/04/24 and ongoing: 1) R1 left the facility Against Medical Advice on 04/20/24, immediately following his return to the facility. 2) An elopement binder is kept at the front desk identifying those residents who may pose a risk for attempted elopement or wandering out of the facility. 3) All Staff are being re-educated on : * Elopement/Elopement risks amongst residents (including wandering) *Managing behaviors and effective interventions * Resident Drug Free Environment This training is being conducted with employees in the building as they report to work until all employees have received the training (including any agency staff on duty). Completion date May 4, 2024 and ongoing. This training has also been uploaded to the nursing staff agency the facility occasionally uses so that all staff coming to the facility will be required to complete the education before their first/next scheduled shift at the facility. 4) All current residents are being re-evaluated for elopement risk and care plans updated accordingly with any new interventions. Completion date May 4, 2024. New residents are evaluated upon admission and then re-evaluated as changes are indicated. Interventions and risks are reviewed and revised accordingly minimally at care plan reviews, more often as indicated. 5) In order to assure ongoing compliance, the Administrator and/or designee shall conduct an audit of 10 residents per week for the next 10 weeks to assure that all elopement assessments are up-to-date and current care plan interventions in place. Any issues shall be addressed immediately and corrected with findings reviewed at the quarterly QAPI meeting. Behavior Committee meetings to be held one time per month to review residents requiring behavioral monitoring, use of antipsychotics and GDRs being conducted, elopement risks/factors, etc.

This failure resulted in two deficient practice statements. A. Based on interview and record review, the facility failed to have adequate qualified staff to conduct basic life support/cardiopulmonary resuscitation (BLS/CPR) per their job descriptions, failed to provide BLS/CPR for 1 resident (R6) of 9 residents reviewed for CPR in the sample of 22. B. Based on document review and interview, it was determined the facility failed to ensure emergency equipment was available for resident care. This failure has the potential to affect all residents with a current census of 87 residents. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on [DATE]. The Immediate Jeopardy was identified on [DATE] and the administrator was notified on [DATE]. While the immediacy was removed as of [DATE], the facility remained out of compliance at a Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of their removal plan and quality assurance monitoring. Findings include: The facility assessment dated ,d+[DATE] documents, The facility must have sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Physician Services policy dated [DATE] documents H. Any significant change in resident's condition will be reported to the attending physician immediately. At the time of accident or injury, personnel trained in first aid procedures shall provide immediate treatment. On [DATE], the physician's admitting orders noted R6 was a full resuscitation, and the record lacked a Practitioner Order for Life-Sustaining Treatment (POLST/an advanced directive for resuscitation orders) form. On [DATE] at 10:15 AM, V5 (Licensed Practical Nurse/LPN/day shift nurse) stated R6 couldn't talk and didn't understand English. I repositioned R6 to R6's left side toward the window and R6's (family member) played music and was moving around like she/he was dancing and singing and R6 smiled like R6 enjoyed the activity. When I came in the next morning V12 (LPN) stated R6 had expired during the night. R6's (family member) was here ([DATE]) and stated I don't understand. What happened? R6 was so bright yesterday.R6 was a full code (resuscitation), and CPR was not initiated. On [DATE] at 3:15 PM, V13 (LPN/second shift nurse) stated R6 was ok. I did trach (tracheostomy) care and R6 was on an antibiotic. R6 didn't really respond but R6 couldn't speak or understand English. R6 was stable on my shift. On [DATE] at 4:14 PM, V12 (LPN/third shift nurse) stated I don't recall the trach (R6) or what I was doing in the room, but I questioned R6's condition and what was R6's baseline. I went back (to nurse's station) to review R6's admission papers to determine if R6 needed to be transferred out (to hospital). I couldn't really tell if R6 was a code or not. I called 911 but when I went back into the room, R6 had expired. I canceled the transport. V12 stated V12 did not have a current BLS/CPR certification. On [DATE] at 3:25 PM, V21 (Medical Director and Attending Physician) stated If R6 had a full code order, CPR should have been initiated. On [DATE] the Third Shift ([DATE] 10:00 PM to 6:00 AM shift) daily assignment sheet noted V12, V19 and V20 were the three (3) LPNs assigned to staff the three (3) floors with residents in the facility. The facility was unable to provide current BLS/CPR certifications for 3 of 3 (V12, V19, V20) LPN's working in the facility when R6 expired on [DATE] as of [DATE]. B. The Crash Cart Checklist (Third Shift Nurse Check Every Wednesday) noted Top of Cart 1. Suction Machine 2. 02 (oxygen) [NAME] (Full in Proper Container) 3. CPR (cardiopulmonary resuscitation) Backboard 4. Supply List; Drawer 1 1. Stethoscope 2. Blood Pressure Cuff 3. Trash Bags 4. Note Pad/Ink Pens 5. Box of Non-Sterile Gloves 6. Face Shield; Drawer 2. 1. 1000 CC (cubic centimeters) of Normal Saline 2. IV (Intravenous) Start Kit 3. Sterile Water 4. J Loop IV accessory) 5. 3 cc Syringes for IV Flush 6. 22 Gauge IV Catheter 7. 24 Gauge IV Catheter 8. Alcohol Prep Pads 9. Continue Flo IV Tubing 10. Suction Tubing 11. Yankar Suction; Drawer 3 1. Oxygen Masks 2. Oxygen Cannulas 3. Oxygen Extension Tubing 4. Oxygen Connector 5. Oxygen Wrench 6. Oxygen Regulator; Drawer 5. Ambu Bag with 02 Connection Apparatus 2. IV Pump On [DATE] at 11:10 AM, the 3rd floor emergency/crash cart was observed in the nurse's station. The first drawer contained two (2) ,d+[DATE] by 1 ,d+[DATE]-inch sterile suction tubing's which were observed to have brown and red stains on the packages and were expired [DATE]. The second drawer also contained the same suction tubing and was expired on [DATE]. The cart lacked a suction machine, a backboard, stethoscope, blood pressure cuff, face shields, normal saline, 22- or 24-gauge catheters, oxygen wrench, oxygen regulator and IV pump. The crash cart checklist/supply list located on top of the emergency cart was noted as last being checked on ,d+[DATE]. On [DATE] at 10:40, V11 (LPN, 3rd floor) stated What is an airway box? Do you mean like a crash cart? V11 demonstrated the crash cart. V11 stated I haven't received trach care education since the previous patient. Maybe 6 months to a year. At 12:10 PM, V11 stated R3 hasn't had oxygen since being on this floor. (If oxygen was needed) I'd call the head of housekeeping and they would bring it (oxygen concentrator) up and I'd take it in there (residents' room). The suction machine (for the crash cart) is in R3's room. On [DATE] at 12:00 PM, V9 (LPN Admissions Coordinator) stated If there is an admission, especially one with special needs, I send a message to everyone on our dashboard (electronic medical record). I will get the key from the DON or floor nurse and check storage. The ADON or DON are supposed to check to ensure supplies are available and now I'm the Assisting Director of Nursing.C The American Red Cross CPR/AED (Automated External Defibrillator) for Professional Rescuers and Health Care Providers handbook documents If unconscious but breathing, place in a recovery position; If unconscious and no breathing but there is a pulse, give ventilations; If unconscious and no breathing or pulse, begin CPR. An Immediate Jeopardy situation was identified on [DATE]. On [DATE] at 1:59 PM, V1 (Administrator) was notified of the Immediate Jeopardy. On [DATE], the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy. 1. On [DATE], V1 (Administrator) signed a contract with a provider who will provide American Heart Association's Basic Life Support Course effective [DATE]. 2. On /,d+[DATE], V38 (Human Resources) and V9 (Nurse Scheduler) began to develop a staff tracking sheet which also includes agency staff with BLS/CPR certification dates to ensure facility was staffed with a minimum of two (2) BLS/CPR certified personnel 3. On [DATE] and [DATE], the 2nd, 3rd and 4th floors were observed to have CPR certified nurses on shift. 4. The staff assignment sheets dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] noted two (2) staff members with current BLS/CPR certifications were assigned to each shift. 5. On [DATE], V2 (Acting Director of Nursing) began in-servicing all nursing staff on the Death of a Resident, POLST (Physician Order for Life Sustaining Treatment) and Documentation for Nurses policies. This in-service was completed on [DATE]. 6. On [DATE], a Death Chart Review audit tool was developed and V2 and V9 began to conduct audits on all deaths.

A. Based on observation, interview and record review, the facility failed to ensure tracheostomy supplies were available for tracheostomy care and emergency treatment, failed to obtain physician orders for tracheostomy care, failed to have a tracheostomy policy and procedure, failed to ensure staff were qualified and/or competent to perform tracheostomy care and order appropriate tracheostomy supplies for 3 of 3 residents (R3, R6, R7) admitted with tracheostomies int the sample of 22. These failures resulted in an Immediate Jeopardy: The Immediate Jeopardy started on [DATE]. The administrator was notified of the Immediate Jeopardy on [DATE]. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of their plan of correction and Quality Assessment oversite. Findings include: R3 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident (stroke), had an inability to speak, was cognitively impaired, had acute respiratory failure that required an insertion of a tracheostomy (an opening in the neck into the windpipe to help air and oxygen reach the lungs). On [DATE] a Physician's Order noted to Provide tracheostomy cleaning daily and PRN/as needed every night shift for Trach (Tracheostomy) care. Suction tracheostomy as needed for increased sputum production and Sodium Chloride Inhalation Nebulization Solution 3% 4 ml (milliliter) inhale orally via nebulizer two times a day for SOB/shortness of breath and wheezing Start Date:[DATE] D/C/discontinue Date: [DATE]. The Medication Administration Record noted R3's lung sounds were clear before and after nebulizer treatments [DATE] through [DATE]. On [DATE] at 3:45 AM, the Progress Note noted the trach was nasopharyngeal (suction catheter inserted into the nose down to the back of the throat to remove upper airway secretions) suctioned for a small amount of thin green secretions. On [DATE] at 5:27 AM, the Progress Note noted V3 (Licensed Practical Nurse/LPN) Attempted to suction resident at beginning of shift due to increased secretions, inner cannula not in place. On [DATE] at 8:35 PM, the Progress Note noted V23 (LPN/Agency) Suctioned trach as needed with return of thin clear secretions. On [DATE] at 2:37 PM, the Progress Note documented V21 (Attending Physician/Medical Director) made aware of residents situation due to trach not having inner canula. Verbal phone order to send resident to ER (emergency room ). On [DATE] the ED/Emergency Department Provider's Note stated R3 presented to the ED by ambulance for a tracheostomy tube problem; the ED physician consulted with RT/Respiratory Therapist regarding tracheostomy tube replacement which was ultimately replaced successfully; then, R3 was discharged back to facility. On [DATE] at 7:30 PM, the Progress Note noted R3 returned to facility per AMT/Advanced Medical Transport, no new orders received. Resident remains alert and w/o/without s/s/signs and symptoms of distress. Tracheostomy tube size 4 DCT (disposable cuffed tracheostomy) in place with inner cannula noted. On [DATE] at 8:26 PM, the Progress Note noted the Advanced Practical Nurse was contacted for tracheostomy orders, new orders were received, and an extra trach tube (provided by the hospital) was affixed to the wall above head of bed for emergency interventions. On [DATE] the Order Summary Report noted orders to Change tracheostomy tube (size 4 DCT) every month and prn/as needed; Change tracheostomy inner cannula daily and prn; Tracheal suctioning every shift and prn; Tracheostomy care every shift et (and) prn. On [DATE] at 2:42 PM, V3 (LPN) stated R3 did have an inner cannula upon admission and identified the inner cannula was missing on [DATE]. V3 stated the lack of inner cannula was known by the former Director of Nursing/DON (V4) on [DATE]. V3 stated V4 was observed to suction R3 without the inner cannula in place and that's when we (V3 and V23/LPN) knew R3 had to go to the hospital and get this remedied (new trach tube insertion). Oxygen levels never dropped and R3 was never in distress. On [DATE] at 3:31 PM, V3 stated No, you can definitely not suction a resident without an inner cannula in place or you could damage their airway. On [DATE] at 3:00 PM, V1 (Administrator) stated I know V4 DON took the inner cannula (from R3's room). We didn't have any (tracheostomy tubes) that size. I sent V4 to (a medical supply store) but they didn't have that size. We called the hospital, but they said they didn't have any either. I don't know that the admissions office would call to ensure we had the right size of trach prior to admission and I'm sure it's not in any policy. V1 stated that V4 had been suctioning R3 without the inner canula in place. V1 stated there was a module for tracheostomy care and maintenance on the facilities e-learning software although the module had not been assigned or completed by any employee as of [DATE]. On [DATE] at 1:00 PM, V21 (Medical Director/R3's Attending Physician) stated I asked them (facility) to get a Respiratory Therapist to come down and assess or evaluate R3. I told them they needed to have the RT review the trach protocol with them (facility staff). I specifically told them to consult RT during rounds with V4. I was surprised they had a trach patient here. Staff never stated they felt uncomfortable, but I don't think they get any training on it (trach care). I actually sent them a faxed protocol from (local hospital) for trach care. Yes, they should have emergency equipment available and tach tubes, inner cannulas and ambu bags should be at the patient's bedside. At this point I haven't heard that anything has been put into place to keep this from happening again. We need a Respiratory Therapist, and one should be on call. I didn't even know the facility would accept a trach patient. Really surprised me. As of [DATE] at 1:30 PM, the facility lacked a policy and procedure for tracheostomy care based on nationally recognized guidelines. On [DATE] at 1:59 PM, V1 (Administrator) was notified of the Immediate Jeopardy. On [DATE] at 10:00 AM, V1 (Administrator) stated V21 (Medical Director) had not reviewed policies, the survey plan of care or staff training material. V1 stated the Quality meeting will be next week and the material will be presented to V21 at that time. V1 stated the Tracheostomy Care policy updated [DATE] and the Tracheostomy Care Education presented to the staff on [DATE] and [DATE] lacked a reference it was based on a Nationally Recognized Guidelines. V1 verbally agreed the policy and the staff education presented lacked procedural instruction for tracheostomy suctioning and required emergency equipment. On [DATE] the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. A Service Agreement with a medical staffing agency signed on [DATE] by V38 (Facilities Chief Executive Officer) and the staffing service's National Business Development Manager. The contract noted staffing service will provide CPR certifications (if applicable). This Service Agreement is intended for use of Respiratory Therapy staff. 2. On [DATE], the 2nd (R13, tracheostomy resident) and 3rd floor (R3, tracheostomy resident) nurses' station was observed to have a stock of required tracheostomy equipment and R3 and R13's rooms were observed to have suction, oxygen, and tracheostomy supplies. On [DATE], ambu bags were observed in R3 and R13's rooms. 3. On [DATE] and [DATE], a contracted Respiratory Therapist began in-servicing all nursing staff on tracheostomy care, supplies and treatment. The in-services will continue to be offered until all staff have been trained. 4. On [DATE], the Tracheostomy policy was updated although lacked instruction on suctioning, emergency equipment required and which nationally recognized guidelines the policy was based on. 5. On [DATE], Tracheostomy care audit tools were developed and began implementation of the audit tool on [DATE]. This audit will be ongoing. 6. Quality Assurance/QAA process going forward will be overseen by V1 (Administrator) and V21 (Medical Director).

Based on record review and interview, the facility failed to ensure physician orders were clarified upon admission to provide cares for 2 of 7 (R3, R6) residents reviewed for orders. This failure resulted in R3 and R6 receiving care without verified admission orders from their attending physician in the sample of 18. Findings include: 1. R3 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident (stroke), cognitive impairment, and had acute respiratory failure which required a tracheostomy (an opening in the neck into the windpipe to help air and oxygen reach the lungs). On 12/11/23, R3's Order Summary Report noted to provide tracheostomy cleaning every evening and on an as needed basis. The record lacked orders about the tracheostomy size, how often to change the tracheostomy tube and if the inner cannula was reusable or disposable and how often to change the tracheostomy inner cannula. On 1/10/24 at 1:30 PM, V21 (Medical Director and R3's attending physician) stated the facility should have called V21 to clarify tracheostomy care orders. 2. R6 a non-English speaking cognitively impaired resident, was admitted to the facility on [DATE] with diagnoses of stroke and acute respiratory failure with a tracheostomy tube. The record lacked documentation and admission orders were faxed to the admitting physician for signature or obtained verbally. The record noted the Hospital's Physician Progress Notes last dated 9/18/23, the most recent medication list was dated 9/13/23 and the record lacked a hospital discharge summary. On 1/11/24 at 11:25 AM, V24's (V21's office staff member for Medical Records specific to Nursing homes) stated I will look for R6's referral and orders. On 1/11/24 at 4:00 PM, V24 stated no admission records or faxes for orders were received by the office for R6. On 1/18/24 at 10:00 AM, V9 (Admission Nurse) stated We don't send orders to the physician, and we don't call to clarify orders. The doctors have signed off on them at the previous hospital. We use the discharge orders. On 1/17/24 at 12:30 PM, V21 stated Normally, admission orders are sent via fax to my office for review and signature. I would expect the facility to notify me of an admission. The Physician Services policy dated 10/20/21 noted C. Upon resident admission, the physician is responsible for informing this facility in writing of the following: a. Medications b. Treatments. e. Special procedures for continuing health and safety of patient i. Code Status.

Based on observation, interview and record review, the facility failed to implement wound interventions, failed to notify resident representative of a new wound, failed to follow physician orders, failed to develop a plan of care to address all wounds, failed to assess a posterior knee wound dressing resulting in an avoidable traumatic wound to right contracted posterior knee for one resident (R1) reviewed for wounds in the sample of four. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/27/23, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of their wound management program. and Quality Assessment oversite. Findings include: Facility Policy/Pressure Ulcers/Skin Integrity/Wound Management (undated) documents: Definitions: Pressure Ulcer: A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear are not primarily causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: Define and Implement interventions that are consistent with the resident needs, resident goals, and recognized standards of practice; Monitor and evaluate the impact of the intervention's; and/or revise the interventions as appropriate. Wound Assessment: All interventions should be evaluated for efficacy and modified/changed as needed. Documentation: Assessment information should identify specific factors that might increase the risk of pressure ulcer development or healing of a pressure ulcer such as: decreased mobility, cognitive impairment, significant weight loss in a resident who has mobility/positioning concerns, impaired nutrition or history of impaired nutrition, non-compliance or history of non-compliance, altered sensory perception, incontinence, significant abnormal lab values, history of pressure ulcers and any decline in clinical status or co-morbid diagnoses affecting mobility/positioning or tissue tolerance. Care Planning: For the resident who is at risk for developing a pressure ulcer or who has a pressure ulcer, an individualized care plan will be developed per the Resident Assessment Manual/care plan timelines. The care plan should address prevention of any skin breakdown, including shearing or friction, repositioning or off-loading, pressure relief equipment and the care and treatment to be provided to the resident for a pressure ulcer or non-pressure wound behaviors and preferences. All care plan interventions should be revised if there is recurring pressure ulcers, a lack of progress toward healing, or if the resident acquires a new ulcer. Routine/Ongoing Documentation: Daily and/or routine ongoing documentation should be conducted by the licensed nurse related to the resident's skin condition and the resident's response to the care and treatment of the skin. Measurements of all pressure ulcers and non-pressure wounds will be done at least weekly and with any noticeable changes. Facility Policy/Wound Care Policy, Comprehensive Wound Program (undated) documents: If a residents Braden score equals out to high risk, they will continue to have appropriate interventions in place deemed necessary by wound care nurse/DON (Director of Nursing). Any high-risk resident or a resident with a wound will receive the appropriate pressure relieving devices deemed appropriate by wound care nurse/DON. The designated wound nurse will weekly measure all wounds, completing weekly wound care report. The care committee will review and discuss. The facility wound care program takes into account the patient as a whole including nutrition, Braden scale, dietary supplements needed to heal the wound, weight loss and weekly wound changes. Facility Policy/Wound Care Documentation and Management dated 8/25/19 documents: It is the policy of this facility to provide wound care as needed and to record care given. Wound assessment documentation will be completed at least weekly and as changes in the wound are apparent. Weekly wound documentation will include a description of the area, including color, size, depth, location, extent of any drainage; condition of the wound area, as well as surrounding area; assess for pain. Weekly documentation of skin care will include measures used to prevent development of pressure ulcers (special mattress, protective dressings or lotions, pressure-relief devices, etc.) Also included will be any signs and symptoms of infection, cultures obtained. Documentation of all skin injuries will include a description of condition, size, and treatment required, how the accident happened, reports completed, and notification of family and physician. Treatment of all wounds will be administered per physician/Wound NP (Nurse Practitioner) order. Current Physician Order Summary Report indicates R1 was admitted to the facility on [DATE] with diagnoses that include End Stage Renal Disease/Dialysis Dependent, Seizure Disorder, Hemiplegia/Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Unspecified Protein Calorie Malnutrition, Dementia, Gastrostomy. Order Summary indicates R1 has orders as follows: --Liquid nutritional feeding every 24 hours as needed may give 2 cans of (liquid nutrition) if dialysis meal is not available before leaving for dialysis and/or returning from Dialysis; flush with 170cc water before and after bolus, date ordered 11/13/23. --Enteral Feed three times per day bolus 1 can (liquid nutrition) with water flush 170cc before and after bolus, date ordered 11/30/23. --Instill 500ml (milliliters) water into R1 stomach through feeding tube three times per day, give R1 at least one 8-ounce container of thickened water orally every 8 hours, date ordered 11/8/23. --Cleanse R1 middle finger to left hand with normal saline, pat dry, apply triple antibiotic ointment and cover with bandage every 8 hours everyday shift and as needed. --Doxycycline Hyclate (antibiotic) 100mg (milligrams) two times a day for wound to left middle finger, date ordered 11/27/23. --Left distal thigh treatment: Cleanse with normal saline, apply antibiotic ointment to wound bed, cover with (petrolatum infused gauze) 4 x 4 dressing, abdominal dressing, wrap daily and as needed related to Necrotizing Fasciitis, date ordered 11/27/23. Braden Scale for Predicting Pressure Ulcer Risk dated 8/2/23 indicates R1 is at High Risk for pressure ulcer development. Practitioner Wound Care Note dated 12/11/23 indicates R1 has multiple wounds including a left hip to knee wound with history of Necrotizing Fasciitis and debridement, left hip surgical wound, left posterior knee traumatic wound, and wound to left middle finger knuckle. Note indicates left posterior knee wound Traumatic, onset 11/20/23 suspect related to dressing and patient contractures. Wound description includes 10% yellow slough, moderate exudate, wound bed pink. Note indicates left middle finger knuckle traumatic wound length 0.9cm (centimeters), width 0.8cm, depth 0.1-0.2cm with slight decline in depth; wound bed pink, moderate exudate; 70% slough with observed shiny striation/suspect possible tendon. Wound Plan Note indicates: Discussed with PT (Physical Therapy) - need for strengthening and endurance exercises. Discussed with Dietician - treatment plan including need for protein supplements with meals. Discussed with OT (Occupational Therapy) need for evaluation for ADL's (Activities of Daily Living). Discussed with patient frequent repositioning for pressure relief/nutritional support/hygiene and incontinent cares. Discussed with RN (Registered Nurse)/ADON (Assistant Director of Nursing) treatment plan, frequent wound care treatment orders and risk for significant wound decline. Patient and staff re-instructed to wear pants/sweats at all times to promote wound healing. Instructed staff to attempt to place small pillow to posterior calf/post thigh for his contracture. On 12/12/23 at 1:30pm R1 was in bed with a mitt restraint on right hand and left hand partially tucked underneath left side of R1's body. R1's left hand was in a closed position with all knuckles of left hand pressing against the mattress surface. R1's left hand was removed from under his body by V4, Wound Nurse and a small bandage was removed from around left middle finger knuckle. At that time V4 stated that I personally believe the wound to (R1's) knuckle is from pressure/friction from the way R1's arm/hand get positioned under his body against the sheets. V4 stated R1's left side of his body is the stroke-affected side. V4 stated she discussed with V5, Wound NP (Nurse Practitioner) about putting a restraint mitt on R1's left hand as well to try to keep the pressure off his knuckles. V4 then removed the bandage from R1's left knuckle which exposed an irregular ulcer of R1's entire knuckle and stated (R1) is receiving antibiotics for wound infection. V4 cleansed the left knuckle wound, re-bandaged and placed R1's arm/hand back onto the bed with no off-loading of affected areas. R1's left leg was noted to be in a contracted position without any pillows or appliances in place to lessen the severity of the contracted leg. V4 removed the wrapped gauze from R1's left upper thigh that extended down past R1's knee which exposed a large scar that extended from mid-left anterior thigh past R1's left kneecap. The area closest to R1's knee was open requiring cleansing and treatment. V4 then assessed behind R1's left knee which also had an open area. At that time V4 stated the wound behind R1's knee was caused from having the gauze wrap dressings too tight - so a combination of constricted pressure and R1's contracted knee joint. The wound behind R1's knee was reddened with a white cord -like striation extending across the open wound. V4 stated The wound didn't look like that the other day. I've never seen it this bad. I think that's an exposed tendon. The other day it was just red with some drainage. V4 stated that when the wound under the knee started out it was from trauma. I believe it was from bandage being too tight. There should have been some padding to prevent a wound from forming. Now as of yesterday we are adding an ABD (abdominal pad) under the gauze wrap. V4 also stated Today is the most extended I've seen (R1's) leg. It's usually more contracted and difficult to assess. No pillow or other positioning device was placed under R1's knee after wound care was completed. V13, R1's POA (Power of Attorney) was also present during R1's wound care. V13 stated that she has talked to staff about keeping a carrot or rolled washcloth in R1's left hand to help with the contraction and would also help keep his knuckles from pressing into or rubbing on the sheets. V13 then asked V4 when R1 had developed the wound under his knee because she was not notified. V13 stated This is the first I'm finding out about this wound. On 12/13/23 at 10am R1 was sitting in a recliner chair in the hallway. R1's left hand was positioned partially under the left side of his body with all fingers/knuckles of left hand in contact with the chair cushion. On 12/14/23 at 9:10am V5, Wound Nurse Practitioner (NP) stated half of the time he encounters R1 at the facility his dressings are off. V5 stated he had to initiate the elastic stocking over R1's left leg to keep the dressings in place for the anterior wounds on R1's left leg. V5 stated the combination of the gauze wrap on R1's leg and leg contractures caused the wound behind R1's left knee. V5 stated If the tendon is exposed behind (R1's) knee it would require a surgeon to assess because that type of wound would be beyond my ability to heal. (R1) is probably not a surgical candidate due to his present physical state and dialysis. V5 stated I can put in all the best orders but if they're not followed, they won't work. V5 stated that the nutrition and protein supplements are Essential for healing R1's wounds These are key factors in wound healing. V5 stated R1 can't feed himself so he is reliant on staff to follow orders and be sure he is getting the nutrition and hydration he needs. Wound NP wound assessment notes dated 12/11/23 indicates left posterior knee wound measures 1.6cm (centimeter) x 1.4cm x 0.1cm. NP wound assessment notes dated 12/18/23 indicates left posterior knee wound measures 3.1cm x 1.2cm x 0.2cm. Note indicates wound with moderate serosanguinous drainage, 30% yellow with striation - suspect tendon and 70%pink. Note indicates Referral to surgeon related to possible tendon. Progress Note dated 12/18/23 at 3:24pm indicates New order for surgeon in regard to possible tendon (exposure) of left posterior knee. R1's current care plan - date initiated 5/17/23/revised 10/17/23 - indicates R1 has a pressure ulcer or potential for pressure ulcer development related to disease process, history of ulcers. Care plan indicates R1 has necrotizing Fasciitis to left hip, thigh, knee. Care plan does not identify left finger knuckle wound or left (popliteal) posterior knee wound. Interventions include: R1 Requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing, date initiated 5/17/23. Inform caregivers/family of any new area of skin breakdown, date initiated 5/17/23. Weekly treatment documentation to include measurements of each area of skin breakdown - width, length, depth, type of tissue and exudate, date initiated 5/17/23. Dietician to review nutritional needs for wound healing, date initiated 11/23/23. No interventions to off-load, reposition or any preventative interventions are included in R1's current care plan to prevent further damage or deterioration of wounds. Dietary Recommendation dated 11/13/23 indicates R1 had a non-significant undesirable weight change of (negative) 2.5% 1 month, 3 months and 6 months. An order added: On Dialysis days (M/W/F) if dialysis meal is not available before or upon returning from dialysis, give 2 cans (therapeutic liquid nutrition) in place of meal with water flush 170cc (cubic centimeters) before and after bolus. Dietary Recommendation dated 11/30/23 indicates increase R1's nutrient needs related to Hemodialysis. Added liquid nutrition (therapeutic liquid nutrition) bolus three times per day with water flush 170cc (cubic centimeters) before and after bolus. Medication Administration Record (MAR) dated 11/23 to 11/30/23 indicates the following: Progress Notes dated 11/3, 11/6, 11/8, 11/10, 11/13, 11/22, 11/27 and 11/29, 2023 indicates liquid nutrition was not given prior to dialysis due to R1 Ate 100% of breakfast meal. No (liquid nutrition) needed. CNA (Certified Nurse Assistant) documentation Amount Eaten (per meal) indicates R1 did not eat 100% on these dates. Amount eaten was zero on 11/3, 11/8, 11/13, 11/22; 51-75% on 11/27 and 26-50% on 11/29. MAR dated 12/1/23 to 12/31/23 indicates the following: Progress Notes dated 12/6, 12/8, 12/11 and 12/13 indicate liquid nutrition was not given due to R1 Ate 100% of breakfast. No (liquid Supplement) needed. CNA documentation Amount Eaten indicates R1 ate zero on 12/6, 51-75% on 12/8, 12/13 and 25-50% on 12/11, 2023. None of the current physician orders or dietary recommendations are based on a percent of meal eaten by R1. TAR (Treatment Administration Record) dated 12/1/23 to 12/31/23 indicates Record feeding intake at the end of every shift for R1. No intake is documented for day shift on 12/1, 12/3 through 12/10, 100ml is documented on 12/11, 12/12, 12/13, 12/15, 12/16 and 12/18; 500ml is documented on 12/2 and 875ml is documented on 12/18/23. TAR indicates no intake is documented for evening shift on 12/2, 12/3, 12/8, 12/9, 12/10. No intake documentation for night shift except 12/5 and 12/14, 2023. TAR dated 12/1/23 to 12/31/23 indicates Record water intake at end of each shift for gastric tube. No water intake is documented for 12/1, 12/3, 12/4 and 12/6 through 12/10. On 12/13/23 at 2:40pm V7, LPN (Licensed Practical Nurse) stated We haven't had cans of (liquid nutrition) for a long time. We use these and showed a large bottle (1000ml/milliliters) of liquid nutrition. V7 stated she gives R1 320ml three time/day. At that time, V8, LPN stated Well, isn't that interesting? I give 240ml. V7 then stated If you ask other nurses, they will probably also give a different amount. V7 also stated (R1) ate 100% of his meal this morning. He didn't need extra. Both V7 and V8 did not know how much was in one can of liquid supplement or how much the physician's order indicated to give. Both V7 and V8 acknowledged the amount (volume) of liquid nutrition to be given should have been clarified with the dietician. Nutrition/Dietary Note dated 12/18/23 at 1:44pm indicates RD (Registered Dietician) note for malnutrition diagnosis, dialysis and tube feeding. Note indicates R1 oral intake per intake log is between zero and 75% which most likely does not meet enteral nutrition as evidenced by general appearance and dialysis information. On 12/19/23 at 9:41am V14, RD (Registered Dietician) stated that one can of (liquid supplement) is 237ml or 8 ounces. V14 stated she was not aware the facility did not have cans of liquid supplements or that nurses were giving various amounts. V14 stated her expectation is R1 should be getting meals and supplements as ordered. V14 stated R1 is no longer getting the liquid supplements based on percent of meal eaten That order changed on 11/30/23. V14 stated she spoke to the dialysis dietician on 11/30/23 and was told R1 was coming into dialysis dehydrated so recommendation was made to give additional water by bolus and orally. V14 stated that R1's Albumin level did drop and is now 3.2g/dl (grams per deciliter). V14 stated We are offering an excessive amount of calories to maintain his general nutritional status. The focus with residents with dialysis and wounds is protein - an essential part of healing. On 12/15/23 at 11:30am V4, Wound Nurse stated prior to 12/13/23 there was no wound documentation in R1's chart. V4 stated R1 does not have an air mattress but he should have because he is prone to pressure. On 12/19/23 at 11:40am V4 stated she previously was the ADON) Assistant Director of Nursing) at the facility and in the summer she became the wound nurse. V4 stated she does not have any specific wound training and only started (this month) doing wound care plans. The Immediate Jeopardy was identified on 11/20/23. V1, Administrator was notified of the Immediate Jeopardy on 12/20/23 at 1:23pm. The following Abatement Plan was submitted on 12/20/23: In order to abate this Immediate Jeopardy and to ensure that all associated issues are resolved, the facility has completed and/or will have completed the following by end of day on 12/21/23: 1) All residents who have been assessed as high risk for pressure ulcers shall have their clinical records reviewed assuring that updated skin/pressure ulcer assessments are in place; all dietary recommendations for these residents are either put in place or otherwise declined by the physician and then put in place and care planned accordingly; and that all wound measurements and assessments are entered into the electronic health record as part of the resident's clinical record. 2) All residents who have been identified as high risk for pressure ulcers have their wound care plans updated and current with any preventative measures appropriately care planned, 3) All nursing staff are being re-in serviced/educated on the facility's policies and procedures regarding skin care, repositioning, assessing skin, use of shower sheets, reporting any areas of concern to nurse responsible for communicating those issues to the wound nurse/wound NP/physician and POAs/responsible family members. This education has been conducted with those staff who have been on site since time of IJ citation and training will be ongoing each day until all nursing staff have received this education. 4) Audit tools have been developed for the purpose of auditing: Wound care/skin/pressure ulcer assessments being completed timely and recorded in the resident's medical record. Dietary recommendations and/or nutritional orders for the purpose of wound healing being implemented or otherwise declined by physician and care planned accordingly; Wound care plans for residents with pressure ulcers or at high risk being kept current and accurate. These tools shall be implemented with audits being conducted for 8 residents per week for 3 weeks, then 4 residents per week for 4 weeks and 2 residents per week for 2 additional weeks. All results to be reviewed weekly and addressed at morning leadership meeting so issues can be addressed immediately. Total results to be reviewed at QAPI (Quality Assurance Performance Improvement) meeting with determination if additional PIP (Performance Improvement Plan) needs to be initiated or audits need to be continued. COMPLETION DATE: December 21, 2023 Facility has also hired a new Wound Care Nurse/RN (registered Nurse) to oversee facility's wound care program. She will join the team on January 2, 2024. The removal plan could not be accepted until 12/27/23 due to the amount of wound care documentation needing to be added to resident medical records and the absence of the only wound care nurse in the facility that had access to resident wound assessments and documentation. On 12/27/23 the surveyor confirmed through observation, interview and record review the facility fully implemented all components of its abatement plan and immediacy was removed.

Based on interview and record review, the facility failed to follow its policy of assessing a resident's skin condition using a standardized assessment, failed to implement interventions to prevent the development of pressure wounds, for a resident that was at risk for developing pressure wounds and failed to monitor a resident's skin for the development pf pressure wounds. These failures resulted in R1 developing an avoidable, infected, unstageable wound that resulted in surgical amputation of R1's, first metatarsal and the development of osteomyelitis. FINDINGS INCLUDE: The (reviewed 08/20/2021) facility policy, Pressure Ulcers/Skin Integrity/Wound Management, directs staff, A system is in place for the prevention, identification, treatment and documentation of pressure and non-pressure wounds. Upon admission: A Braden skin assessment be completed upon admission. Those residents who represent a high risk will have further preventative interventions put in place. Weekly: A weekly skin check will be conducted and documented for at-risk residents. This is a hands-on, direct visual assessment. Assessment information should identify specific factors that might increase the risk of pressure ulcer development such as: Decreased mobility, Cognitive impairment, Significant weight loss in a resident who also has mobility/positioning concerns, impaired nutrition of history of impaired nutrition, altered sensory perception, incontinence. Care Planning: For the resident at risk for developing a pressure ulcer or who has a pressure ulcer, an individualized care plan will be developed per care plan timelines. The care plan should address prevention of any skin breakdown including, sheering or friction, repositioning, pressure relief equipment and the care and treatment to be provided to the resident. Daily and/or routine ongoing documentation should be conducted by the licensed nurse related to the resident's response to the care and treatment of the skin. R1's facility Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Cerebrovascular Disease with Aphasia, Dysphasia and Hemiplegia, Type 2 Diabetes Mellitus, Quadriplegia, Retention of Urine, Severe Protein-Calorie Malnutrition, Contractures of Muscle. R1's baseline Care Plan, dated 9/12/23 documents, (R1) NPO (Nothing Per mouth), Tube Feeding, Non-verbal, Total Dependence on staff for ADLs (Activities of Daily Living), Tracheostomy, Incontinent of Bowel, Foley Catheter. No interventions to prevent/minimize the development of pressure wounds are included. R1's electronic medical record contains R1's Braden Scale, dated 9/12/2023, that is incomplete. R1's September and October 2023 Treatment Administration Records for 2023 contain no documentation that R1's skin was assessed weekly and documented, as required. R1's individualized care plan, developed 10/2/2023 contains no reference to R1's risk for development of pressure wounds nor interventions to prevent/minimize the development of pressure wounds are included. R1's Nursing Progress Notes, signed by V3/Wound Nurse and dated 10/23/23 at 3:21 P.M. document, (R1's) sister reported to nurse that (R1) had an open wound on his right foot. Upon examination of the foot, it was (an) ulcer on his bunion the size was 6.5 x 2.5 and on the lateral side of his great toe measured 4.0 cm x 2.0 cm. Both wounds were 80% yellow and 20% pink in color. A call was placed to NP (Nurse Practitioner) to get orders for the treatment: Ordered: Cleanse with normal saline, apply (enzymatic debrider) to the wound bed, apply Z-guard to the peri-wound, cover with 4x4's, wrap with gauze daily. (NP) also ordered an air mattress. The dressing was applied as ordered. (NP) ordered Doxycycline (antibiotic)100 mg (milligrams) BID (twice daily) x 14 days for the infection of the wound. R1's Nursing Progress Notes, dated 10/24/2023 at 9:48 A.M. document, (R1)'s sister came in and requested (R1) to be sent to the hospital to have the Dr. (Doctor) look at the wound on (R1's) foot and bottom to make sure we are cleaning his wounds and doing the proper treatment. (R1) sent by ambulance. R1's emergency room Report, dated 10/24/2023 documents, Chief Complaint Patient presents with Wound Check. 60 y.o. (year old) male presenting to the ED (Emergency Department) by ambulance for a wound check. Sister reports that she noticed a wound to the medial aspect of patient's right foot yesterday. She explains that patient has been living in a nursing home for the past month. In addition to patient's wound, sister claims that patient has lost a significant amount of weight and has had a nonstop cough for the past week. Sister states that (R1) has 'not been acting like himself' recently. Brother voices that (R1) has a history of diabetes. Sister reports that (R1) is non-verbal at his baseline. They deny that (R1) has had any recent episodes of fevers. Feet: Right foot: Skin integrity: Ulcer (Ulceration to the medial aspect of the first MTP joint measuring approximately 3 cm in length and depth to the subcutaneous layer) present. Disposition: Admit. Clinical Impression and Disposition: Ulcer of right foot, unspecified ulcer stage. R1's Hospital Note documents, Date of Service: 10/25/2023. Procedure(S) Arthroplasty Right First Metatarsal. Preop Diagnosis: Decubitus ulcer right foot first metatarsal, osteomyelitis first metatarsal. Postop Diagnosis: Same. Procedure Performed: Resection right first metatarsal head. (R1) was brought to the operating room placed in a supine position. Anesthesia via the trach (Tracheostomy). The right lower extremity was scrubbed prepped and draped in the usual aseptic technique. A standard timeout was performed. An incision was made on the dorsal medial first metatarsal. Dissection was carried down to the first metatarsal head. The first metatarsal head was dissected free and then a sagittal saw was used to perform a transverse cut through the neck region of the first metatarsal. The head of the first metatarsal was then surgically removed from the operative field. A rongeur on the back table was used to harvest a sample of bone for aerobic and anaerobic culture. The metatarsal head itself was also sent for gross. The operative site was then flushed with saline, and 3-0 nylon was used for skin closure. The right foot was washed with saline. Xeroform 4 x 4's Kerlix and an Ace wrap was applied to the right lower extremity. Patient tolerated this procedure well. There were no known complications. (R1) will be discharged back to hospitalist care for further treatment. On 10/30/23 at 8:50 A.M., V4/LPN (Licensed Practical Nurse) stated, I was the nurse that admitted (R1). I didn't do a Braden Scale (assessment) on the day (R1) was admitted . (R1) would be considered high risk for pressure wounds due to his immobility, incontinence, decreased sensation and poor nutrition. On 10/30/23 at 12:24 P.M., V3/Wound Nurse stated, A Braden Scale (skin assessment) is supposed to be done upon admission to assess whether a resident is at risk for skin breakdown. I can't find a completed Braden Scale for (R1) when he was admitted . He was at high risk for breakdown because of his immobility and incontinence. When a resident is at risk for skin breakdown, they are supposed to have a care plan to address their skin and weekly skin checks by a nurse. The weekly skin checks get documented on the TAR (Treatment Administration Record). I don't see any weekly skin checks for (R1). At that time, V3/Wound Nurse confirmed that R1's care plan did not address R1's skin risk and no interventions were in place to reduce/modify the risks.

Based on observation, interview and record review the facility failed to perform wound care as ordered by the physician for two residents (R49 and R70) of four residents reviewed for pressure ulcers in a total sample of 18. This failure resulted in causing R49's wound to bleed and lose viable tissue during a wound care treatment. Findings Include: 1. R49's Medical Records document R49 was admitted with a tunneling sacral wound and a right outer ankle wound on 10/28/22. R49's Physician Order Sheet dated December 2022 documents: Right outer ankle (Petroleum Jelly Impregnated Gauze) 1(inch)x 8 (inches): apply to the right outer ankle topically one time a day every Monday, Wednesday, and Friday, cover with (rolled gauze). On 12/14/22 at 9:00 A.M. V5 (Wound Doctor) removed the dressing on R1's right outer ankle. The wound bed of the ankle began seeping blood and there was noticeable scabs/skin debris on the dressing. V5 stated Someone put the wrong dressing on this ankle, see this bleeding? All the stuff on the dressing is all good tissue that we wanted to keep. V5 stated It was a Telfa Dressing that I took off, and that shouldn't have been on there. That type of dressing is used when we want the dressing to stick to tissue. I specifically told these nurses to not use Telfa on (R49) because then we must heal the damage we just did with the dressing. It is a vicious circle. R49's TAR (Treatment Administration Record) dated December 2022 documents (Sodium Chloride Dressing) may use plain packing or Dakin's 25% Moistened (rolled gauze) when (Sodium Chloride Dressing) not available. Change as needed when soiled or displaced. One time a day for pressure wound for 30 days (Sodium Chloride Dressing) packed into wound daily and cover with silicone gauze bordered. This entry on R49's Treatment on the TAR was scheduled for 8:00 PM. All administration boxes are marked out. On 12/14/22 at 11:30 AM, V11 (LPN/Wound Nurse) stated The order with the (Sodium Chloride Dressing) and Dakin's solution for (R49) is for his sacral wound and that should be getting done every day. The order should read daily and as needed until healed. V11 confirmed that the treatment had not been signed off as completed for the entire month of December (12/1/2022-12/14/2022). R49's TAR dated November 2022 documents Collagen-Antimicrobial Sheet apply to right ankle topically three times a week on Monday, Wednesday, and Fridays for pressure wound. The November Treatment Administration Record was timed for 9:00AM and 6:00PM on Monday, Wednesday, and Fridays. On 12/14/22 at 11:30 AM, V11 (LPN/Wound Nurse) stated No they should not have been done twice a day every three days, I don't know why it is on there (Treatment Administration Records) like that. 2. R70's Wound Evaluation and Management Summary dated 11/30/22 documents R70 has a wound to his left posterior thigh measuring 1.2 centimeters (cm) x 15.0 cm x 0.1 cm. On 12/14/22 it documents the wound measurement at 1.9 cm x 10 cm x 0.1 cm. R70's physician order sheet (POS) and TAR dated 11/18/22 documents Collagenase Powder: Apply to left posterior thigh topically one time a day for wound healing collagen powder, mix with hydrogel, apply to wound bed, cover with dry dressing. R70's TAR dated 12/1/22 through 12/31/22 documents R70's treatment to his left posterior thigh documents a code nine (Other/See progress notes) on 12/1, 12/5, 12/7, 12/9, and 12/13. R70's medical record dated 12/1/22 through 12/14/22 does not document treatment notes for the days coded as a nine as indicated on the TAR. On 12/14/22 at 12:19 PM, V3, Registered Nurse (RN), verified he entered code nine on 12/5, 12/7, 12/9, and 12/13 and then looked at R70's medical record and stated Let me see why I entered a code nine for those days. Oh, ok, so he didn't get a treatment those days. No, it's not documented in the progress notes, but I remember I didn't complete his treatments because he was gone for therapy. His therapy and treatment are both scheduled at 12:00 PM. Yeah, like yesterday (12/13) I didn't do the treatment because he was at therapy. They take him to therapy every day when his treatment window is so I can't change it if he's gone. No, I didn't change it when he got back. I don't know why I didn't change it. On 12/14/22 at 12:47 PM, V11, Wound nurse, stated Having therapy and a treatment order at the same time is not an excuse of why he should have missed a wound treatment. If (R70) was at therapy, then it should have been completed when he got back or before he even left. On 12/15/22 at 11:43 AM, V5, Wound Doctor, stated There was no change in R70's wound over the last few weeks. I don't think not changing his bandage a few days made a difference on the progression of his wound healing. It's better for the patient to get the wound treatments as ordered. Given (R70)'s diagnosis and non-compliance, I don't think it would have changed the outcome of the wound healing. On 12/15/22 at 12:15 PM, V1, Administrator, stated Yes, the wound treatments should have been completed every day as ordered by the physician. I'm looking for a policy that states they (Nurse) must follow a physician order, but I don't see one. 41869

Based on interview, observation and record review, the facility failed to ensure that sufficient staff was available to meet the needs of residents. Between [DATE] - [DATE], the facility had multiple days of not meeting their minimum staffing requirements. On [DATE], the facility did not meet their minimum staffing requirements, R1 was put to bed around 8:30 PM, did not get checked on by staff for nearly 12 hours, and was subsequently found deceased in bed the following morning. R1 was found in a state of rigor mortis (stiffening of the joints and muscles of a body after death) on discovery. These failures have the potential to affect all 76 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level II as the facility implements the following: re-educate staff members responsible for the facility's staffing schedules on the minimum staffing requirements per Illinois guidelines; perform daily audits of the schedules to ensure minimum staffing requirements are met or exceeded; review applications daily that have been submitted for a job posting listed on an employment website and track application statuses; utilize the staffing agencies contracted with the facility to aid in meeting or exceeding the minimum staffing requirements; increase Certified Nursing Assistant wages to assist with retention and recruitment of new staff; schedule management staff to fill open shifts to ensure minimum staffing requirements are met; and develop a Quality Improvement and Performance Improvement (QAPI) plan after a QAPI meeting is held. Findings include: The facility's Staffing policy (revised ,d+[DATE]) documents the following: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. The Facility Assessment (dated [DATE]) documents the following: Staffing: Review current census daily to ensure staffing needs are adequate for patient care. Due to the unique lay out of the building additional staff are needed above what would be typical for census. On [DATE] at 10:30 AM, V10 (Certified Nursing Assistant) stated she worked second shift on the second floor on [DATE]. V10 stated, First shift said (R1) had not eaten anything and had been drooling. We tried to get her to eat dinner. We tried applesauce, and she just wouldn't take anything. She was drooling quite a bit. It just kept coming out of her mouth. I kept grabbing towels and (R1) would spit into them. After dinner, the drool had color. It was darker. It almost looked like coffee grounds. I told the nurse we should probably get (R1) checked because there is probably something wrong since this had been going on all of my shift. The nurse never sent her out. She didn't really say anything. She just told me to put (R1) in bed. By that time, (R1) had vomited a large amount and had a brownish drool. The nurse just commented on the color and said she needs cleaned up. So I took (R1) to her room and cleaned her up and then put her in bed. I went back to the nurse and told her (R1) should probably get checked out. The nurse seemed very busy with paperwork. There is a lot of charting and paperwork on the second floor since it is the Medicare floor. The nurse should of at least called and had (R1) sent in to get looked at, but she stayed behind the desk and did paperwork. I never saw her go check on (R1). On [DATE] at 10:35 AM, V15 (Certified Nursing Assistant) stated she worked the second floor for night shift beginning at 10:00 PM on [DATE]. V15 stated, I heard (R1) passed away. I didn't even know she was on the second floor that night. She was on the third floor the last I knew. I never even saw her or went in her room that night. I worked by myself that night too. I was the only aide on the second floor. On [DATE] at 2:25 PM, V16 (Licensed Practical Nurse) stated the following: [DATE]st was supposed to be my night off. (V3, Assistant Director of Nursing) was the nurse working on the second floor, called and begged me to come in, and I agreed. (V3) had already left the building when I arrived and she had given the nurse's keys to (V17, Licensed Practical Nurse) who was working on the third floor. I never received any report when I arrived since (V3) was already gone. There was only one CNA (Certified Nursing Assistant) on the floor, and she left early around 5:30 AM. I had no one come to replace me when I was supposed to be off at 6:00 AM, and no CNAs had come in either. (V5, Agency Registered Nurse) showed up to relieve me at 7:30 AM, and after giving him report, I left. There were still no CNAs that had shown up when I left. Since [DATE]st was the last day of the month, I had to do changeover of the MARs (medication administration records). This is very time consuming. The second shift nurse on the third floor (V17) stayed over to do the third floor changeover and then she left. (V17) gave me her keys when she left and then I was responsible for covering the second floor and the third floor. I spent the majority of the night busy doing changeover, so I was not involved in much resident care. I can tell you that (R1) was never looked at. This is the CNA's failure. Bed checks are supposed to be done at least every two hours. A responsible aide would have caught this. The CNAs are taking advantage of the staffing shortage at the facility. They come and go when they please because they know they can get away with it. The facility has been very short staffed and a lot has been getting missed lately. I know a lot of the residents have said they have not been getting showers. On [DATE] at 10:12 AM, V17 (Licensed Practical Nurse) stated she was working second shift on the third floor on [DATE] and stayed over a few hours to do changeover for the third floor. V17 stated V3 (Assistant Director of Nursing) gave her the nurse's keys to the second floor around 11:00 PM and then left the facility. V17 then stated that V16 (Licensed Practical Nurse) arrived to pick up the second floor's nurses keys around 11:45 PM. V17 stated she handed over the third floor's nurses keys to V16 when she left the building at 3:00 AM. V17 stated the facility has been short staffed lately, There have been a lot of call ins. On [DATE] at 12:00 PM, V11 (Certified Nursing Assistant) stated she is the restorative aide, and usually does not work on the floor. V11 stated she assisted cleaning R1 up after R1 had passed away. V11 stated, This place has been very short staffed, so I went to help clean up (R1). When I went in the room, her eyes and mouth were open, and her body was very cold. She was very, very stiff. It appeared she had been there dead for quite a while. On [DATE] at 12:40 PM, R3 stated the facility has been extremely short staffed. R3 stated, There was a time when I missed a shower for three weeks, and another time for two weeks. That is gross. I've been getting myself up. I do it on my own because there is no one to help me. The facility's Shower Schedule (undated) documents R3 is scheduled to receive a shower on Mondays and Fridays during second shift. R3's Shower Sheets (dated [DATE] - [DATE]) document R3 received a shower on [DATE], and then not again until 14 days later on [DATE]. On [DATE] at 12:50 PM, R2 stated, They are always running short. I pretty much do for myself because you have to wait so long to get help around here. On [DATE] at 3:20 PM, R8 stated things are, Terrible. This place is so short staffed right now. I have missed a few showers. This makes you feel so dirty. There is not enough help, and I see others that need help not get it, especially the ones who cannot speak for themselves. The facility's Shower Schedule (undated) documents R8 is scheduled to receive a shower on Mondays, Wednesdays and Fridays during first shift. R8's Shower Sheets (dated [DATE] - [DATE]) document the following: R8 received a shower on [DATE], and not again until 9 days later on [DATE]; R8 received a shower on [DATE], and not again until 10 days later on [DATE]. On [DATE] at 9:15 AM, R12 was propelling his wheelchair toward the exit to the smoking area on the first floor. R12's hair was unkempt and appeared greasy. R12 stated, I was supposed to get a shower yesterday, and did not. They are so short staffed. It is impossible to get the help you need around here. On [DATE] at 1:08 PM, R9 was sitting in a wheelchair watching television. A mechanical lift sling was in place underneath her. R9 stated, This place is pretty short staffed and at times it is hard to find help when you need it. I have missed a shower a time or two. I am a (mechanical) lift and two people are needed to use the lift to get me out of bed. I have to stay in bed sometimes because if there is only one aide on the floor, there isn't enough help to get me up. The facility's Shower Schedule (undated) documents R9 is scheduled to receive a shower on Sundays and Wednesdays during second shift. R9's Shower Sheets (dated [DATE] - [DATE]) document the following: R9 was not offered or received a shower on [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 1:10 PM, R10 was sitting in her wheelchair watching television. R10 stated, It is so short staffed around here. At times, I have to wait over 30 minutes for someone to answer my call light when I need help. The wait times seem to be longer recently. The facility's Shower Schedule (undated) documents R10 is scheduled to receive a shower on Sundays and Wednesdays during first shift. R10's (local hospice) Visit History Summary documents the following: R10 received a shower from the local hospice staff on [DATE], [DATE] (Shower offered but R10 declined), [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 10:50 AM, V1 (Assistant Administrator) stated that she could not provide any Shower Sheets indicating the facility has offered or given R10 a shower. V1 stated, (R10) is hospice, and hospice is doing her showers. On [DATE] at 1:15 PM, R11 stated, They just don't have enough help. This place needs more CNAs (Certified Nursing Assistants). On [DATE] at 1:17 PM, R13 stated, It is very short staffed here. They are short both CNAs and nurses. I have to wait such a long time for my call light to get answered. Sometimes it is at least 30 to 45 minutes. There is a lot of staff leaving, and this is very concerning. On [DATE] at 1:30 PM, R7 stated, It is pretty short staffed. I think third shift has been the worst. They get me up with a (mechanical) lift, and I have had to stay in bed a few times because they didn't have enough staff to get me up. It takes two people to use the lift and sometimes only one CNA is scheduled. I don't like being forced to stay in bed. I like being up and busy during the day. On [DATE] at 1:10 PM, V22 (Certified Nursing Assistant) stated, This place is so short staffed. It is not fair to the residents. The CNA shifts aren't getting filled. It is hard to be the only one on the entire floor working by yourself. The fourth floor has 7 (mechanical) lift residents. I will not put my license on the line and attempt to get them up by myself. So, if there isn't a good nurse working that is willing to help with the (mechanical) lift residents, they have to stay in bed some days. Resident Council Minutes (dated [DATE]) document the following concerns: Staff are burnt out; There needs to be ,d+[DATE] CNAs per floor, not just one; Call lights are not being answered in a timely manner; Upset that their cares are not being met because of no staff on the floors; Residents are concerned with staff have to work multiple floors during their shift; Residents think that the CNAs who have been working here a while need a raise so they won't quit. Resident Council Minutes (dated [DATE]) document the following concerns: Scheduling is messed up; When it is close to the end of their shift, some aides refuse to give cares; Suggested that there needs to be specific aides just for showers; Call lights are not being answered in a timely manner. A Grievance/Complaint form (dated [DATE]) documents the following: Resident called (V23, Social Service Director) upstairs to inform her that there is only one aide at this time on the floor. On [DATE] at 10:20 AM, V1 (Assistant Administrator) stated the following: At a minimum, on first and second shifts, the second floor needs one nurse and one CNA (Certified Nursing Assistant) staffed; the third and fourth floors should have one nurse and two CNAs staffed. On third shift, each floor should have one nurse and one CNA at a minimum. We do like to have two CNAs if possible on third shift but can get by with one. On [DATE], V1 (Assistant Administrator) provided the facility's daily staffing sheets (dated [DATE] - [DATE]) which document what staff members were working, and the location that they worked. V1 also provided the corresponding timesheets indicating when the employee clocked in and out for their shift. These sheets document the following: On [DATE], a nurse worked three hours of third shift on the third floor, leaving no nurse working for 5 hours of third shift; On [DATE], only one CNA was scheduled for second shift on the second and third floor; On [DATE] on third shift, a CNA worked for 15 minutes, leaving the fourth floor without a CNA for over 7.5 hours; On [DATE], [DATE], and [DATE], only one CNA was scheduled to work second shift on the second floor; On [DATE], the fourth floor only had one nurse working for the first hour, and then no nurse coverage for the remainder of the shift; On [DATE], the second floor and the fourth floor only had one CNA scheduled; On [DATE], the CNA working third shift on the second floor worked 6.5 hours, and there was no CNA scheduled for the last 1.5 hours of the shift; On [DATE], the facility's third floor had a nurse work for 4.75 hours, leaving the remaining 3.25 hours with no nurse working; On [DATE] and [DATE], no nurse was scheduled to work third shift on the second floor; On [DATE], only one CNA was scheduled to work second shift on the second floor; On [DATE], a nurse worked 2 hours of third shift on the third floor, leaving the third floor without a nurse for 6 hours, and a CNA worked 6.75 hours, leaving the floor without any direct care staff for 1.25 hours; On [DATE], only one CNA was scheduled to work second shift on the third and fourth floor; On [DATE], only one CNA was scheduled to work first shift on the second floor, and one CNA worked 6 hours of third shift on the fourth floor, leaving the fourth floor with no CNA coverage for 2 hours; On [DATE], only one CNA was scheduled to work second shift on all three floors, and one CNA worked 6 hours on third shift on the third floor, leaving the third floor without a CNA for 2 hours; On [DATE], no nurse was scheduled to work first shift on the fourth floor; On [DATE], no nurse was scheduled to work third shift on the third floor; On [DATE], no CNA was scheduled to work third shift on the third floor; On [DATE], only one CNA was scheduled to work second shift on the second floor; and on [DATE], a CNA worked 4.5 hours of third shift on the second floor, leaving no CNA for 2.5 hours. On [DATE] at 10:40 AM, V1 (Assistant Administrator) confirmed that the facility has been short staffed and confirmed that at times, the facility goes without Nursing and CNA coverage on the resident floors. V1 stated that she had received multiple concerns from the residents regarding the facility's staffing and direct care not being completed. V1 confirmed that several residents have missed showers due to limited staff. V1 stated, I do not do anything with the CNA schedule. (V21, Administrator/Owner) has not allowed me to touch it. I haven't dealt with the nurse's schedule for at least 6 months. (V2, Director of Nursing) schedules the nurses. V1 stated that management can cover when there is a hole, and stated, They (management staff) can cover an open shift, but it doesn't make sense for management to come in on night shift and just sit there when the residents are sleeping, and then we do not have them in the building for their management duties the following day. The Resident Roster (dated [DATE]) documents 76 residents resided in the facility at the time of survey. The Immediate Jeopardy was identified on [DATE] at 2:00 PM to have begun on [DATE] when R1 displayed a change in condition and was not monitored for nearly 12 hours due to an inadequate amount of staff scheduled to work in the facility. V21 (Administrator) and V1 (Assistant Administrator) were notified of the Immediate Jeopardy on [DATE] at 2:10 PM. The surveyor confirmed through interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: Documentation provided on [DATE] indicates that on [DATE], V1 (Assistant Administrator) re-educated (V2, Director of Nursing), who is responsible for maintaining the licensed nurses schedule, on the minimum staff requirements per Illinois guidelines. Documentation provided on [DATE] indicates that on [DATE], V1 (Assistant Administrator) re-educated (V30, Certified Nursing Assistant Supervisor/Scheduler), who is responsible for maintaining the Certified Nursing Assistants schedule, on the minimum staff requirements per Illinois guidelines. On [DATE] V1 (Assistant Administrator) provided a copy of the facility's Daily Staffing Assignment sheet (dated [DATE] and [DATE]) and indicated that audits had been conducted by V1 to ensure the minimum staffing requirements were met or exceeded. On [DATE] copies of signed contracts with three local staffing agencies were provided and reviewed. V1 indicated that the facility can utilize these agencies for staffing assistance to meet the minimum staffing requirements. On [DATE] copies of Ads that were placed on [DATE] on an employment website for certified and licensed staff were reviewed. V1 is to review applications daily with Human Resources and track application statuses. on [DATE] a copy of the facility's Certified Nursing Assistant Incentive Program (implemented on [DATE]) was provided, which documents a Certified Nursing Assistant will receive an hourly wage increase based on years of experience. On [DATE] at 2:30 PM, V19 (R1's Physician/Medical Director) stated that he participated in a Quality Assurance and Performance Improvement meeting that was conducted on [DATE] with facility administration and management members. On [DATE], the following facility staff members were interviewed and verbalized knowledge of the recent education and inservicing that was administered: V21 (Administrator), V2 (Director of Nursing), V30 (CNA Supervisor/Scheduler), V22, V27, V33 (Certified Nursing Assistants), V31, V32 (Licensed Practical Nurses), and V1 (Assistant Administrator). All staff interviewed indicated they were not able to begin working a shift until they had received the required education. Management staff interviewed and all indicated that in a recent meeting, it was discussed that they will be required to be placed in a rotation to fill an open shift that has been unable to be filled.

Based on interview, observation and record review, the facility neglected to identify, assess, and contact the physician of an acute change in a resident condition, and neglected to ensure a resident was checked every two hours as directed by the facility's policy. R1 displayed a change in condition on the afternoon of [DATE] that continued to decline into the evening. Facility staff put R1 to bed around 8:30 PM on [DATE], and R1 was subsequently found deceased in bed nearly 12 hours later. Rigor mortis of R1 was found on discovery. R1 was one of three residents reviewed for resident death in the sample of 13. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level II as the facility implements the following: administers education on a change in resident condition, physician notification, and shift report; develops a Quality Improvement and Performance Improvement (QAPI) plan after a QAPI meeting is held; and performs daily auditing to ensure that corrections are achieved. Findings include: The facility's Family and Physician Notification policy (undated) documents the following: Policy: To provide notification to family and physician of changes, resident needs. Procedure: Attending physician as well as Power of Attorney/representative shall be notified of health status changes in a timely manner. ie: falls, injuries, abnormal labs, continuous nausea/vomiting, unconsciousness, seizures, unusual bleeding, new or unmanaged pain, SOB (shortness of breath), chest pain, significant mental status changes, unmanageable behavior, medication errors, and all other conditions deemed necessary. Document time of call and results in chart. Notify POA (power of attorney) of any new orders obtained from physician. The facility's Repositioning and Check/Change policy (undated) documents the following: Repositioning and frequent changing is a common, effective intervention for prevention skin breakdown, promoting circulation, and providing pressure relief. Reposition and check or change residents every two hours or as needed. R1's Progress Notes document the following: On [DATE], R1 was sent to a local hospital after staff witnessed her have a grand mal [CONDITION(S)], was admitted to the hospital for care of a subdural hematoma and returned to facility on [DATE]. R1's Minimum Data Set Assessment (dated [DATE]) Section C, Cognitive Patterns, documents a Brief Interview for Mental Status could not be conducted due to R1 being rarely/never understood. This same section also documents the Staff Assessment of R1's Mental Status indicating a short-term and long-term memory problem, and R1 is severely impaired (never/rarely made decisions) in cognitive skills for daily decision making. On [DATE] at 1:55 PM, V9 (Housekeeping Supervisor) stated the following: On the morning of [DATE], I was delivering newspapers. I was on the second floor and was walking past (R1's) room. I always glance in the resident's rooms as I pass by. I stopped at (R1's) room because she didn't look right. You could tell that something was wrong. Her color was gray, her head was back, and her eyes and mouth were open. I went in and felt her. She was cold. I tried to find a pulse and one was not present. She was as stiff as a board. So, I went to (V5, Registered Nurse) and made him aware that one of his residents was dead. On [DATE] at 12:10 PM, V5 (Agency Registered Nurse) stated he was the nurse working day shift on [DATE]. V5 stated the following: Around 8:00 AM, (V9, Housekeeping Supervisor) came and told me that (R1) had passed away. I was passing morning medications and had not yet been in to see (R1). When I went in her room, she was very cold and rigor mortis had already set in. Her eyes were open, her mouth was open, and her head was tilted back. Both of her hands were grasping the bed sheet. I called the Power of Attorney, the doctor's office, the Coroner's office, and then the funeral home after getting the OK from the Coroner's office. V5 stated he was not aware of R1's recent hospitalization for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:35 PM, V6 (Licensed Practical Nurse) stated she was called to be the second nurse to confirm R1's time of death. V6 stated, I was in my office and got a call that they needed a second nurse to verify (R1's) death. V9 (Housekeeping Supervisor) called, and I went down to verify. I listened for a heartbeat and lung sounds and did not hear anything. I also watched for chest rise and fall and did not see any respirations. After doing this, I verified her time of death with (V5, Registered Nurse). Rigor had already set in. It appeared she had been dead for a while. We did not attempt CPR. It was past that point. On [DATE] at 2:40 PM, V3 (Assistant Director of Nursing) stated she was the nurse working second shift on [DATE]. V3 stated the following: (R1) was her normal self until dinner time. I saw that she had spit on the floor- it appeared to be clear sputum. Around 6:00 PM, one of the CNAs (Certified Nursing Assistant) grabbed a tray table and positioned it in front of (R1) and placed a basin on the table. (R1) was spitting in the basin. The CNA offered (R1) a banana, and she spit it out. (R1) was offered a glass of water. She did take a very small drink. V3 stated she was aware that R1 had a recent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 stated she reported off to V8 (Licensed Practical Nurse) on [DATE]. V3 stated, (R1) was in bed by 9:00 PM. V3 stated R1 did have a bruise present on her forehead, I asked about it because I didn't know how she got it. No one I asked knew anything about it. On [DATE] at 2:25 PM, V14 (Certified Nursing Assistant) stated she worked on the second floor from 7:00 AM - 8:30 PM on [DATE]. V14 stated, (R1) was sick from about 1:00 PM that day. I tried feeding her lunch and she spit it out. She kept spitting out a foamy spit substance. I gave her a shower around 4:00 PM that day because she was covered in the secretions she was throwing up. I took care of (R1) often and I've never seen her do anything like this. I am not aware that she has ever spit on the floor. I have never seen her do this or been told she does this. She just kept getting worse. She should have been sent to the hospital after throwing up for that long. I told (V3, Assistant Director of Nursing) that (R1) was ill multiple times. We put her to bed right before I went home. (R1) is usually up at night until at least 9:30 PM due to restlessness and wandering. I think she should have been sent in to get evaluated. There was clearly something wrong with her. (R1) is cognitively impaired so she couldn't tell you what was wrong. After so many hours of this, I just kept telling (V3) that (R1) was sick. On [DATE] at 10:30 AM, V10 (Certified Nursing Assistant) stated she worked second shift on the second floor on [DATE]. V10 stated, First shift said (R1) had not eaten anything and had been drooling. We tried to get her to eat dinner. We tried applesauce, and she just wouldn't take anything. She was drooling quite a bit. It just kept coming out of her mouth. I kept grabbing towels and (R1) would spit into them. After dinner, the drool had color. It was darker. It almost looked like coffee grounds. I told the nurse we should probably get (R1) checked because there is probably something wrong since this had been going on all of my shift. The nurse never sent her out. She didn't really say anything. She just told me to put (R1) in bed. By that time, (R1) had vomited a large amount and had a brownish drool. The nurse just commented on the color and said she needs cleaned up. So, I took (R1) to her room and cleaned her up and then put her in bed. I went back to the nurse and told her (R1) should probably get checked out. The nurse seemed very busy with paperwork. There is a lot of charting and paperwork on the second floor since it is the Medicare floor. The nurse should of at least called and had (R1) sent in to get looked at, but she stayed behind the desk and did paperwork. I never saw her go check on (R1). On [DATE] at 10:35 AM, V15 (Certified Nursing Assistant) stated she worked the second floor for night shift beginning at 10:00 PM on [DATE]. V15 stated, I heard (R1) passed away. I didn't even know she was on the second floor that night. She was on the third floor the last I knew. I never even saw her or went in her room that night. I worked by myself that night too. I was the only aide on the second floor. On [DATE] at 2:25 PM, V16 (Licensed Practical Nurse) stated the following: [DATE]st was supposed to be my night off. (V3, Assistant Director of Nursing) called and begged me to come in, and I agreed. (V3) had already left the building when I arrived and she had given the nurse's keys to (V17, Licensed Practical Nurse), who was working on the third floor. I did not receive any report when I arrived since (V3) was already gone. There was only one CNA on the floor, and she left early around 5:30 AM. No one came to replace me when I was supposed to be off at 6:00 AM, and no CNAs had come in either. (V5, Agency Registered Nurse) showed up to relieve me at 7:30 AM, and after giving him report, I left. There were still no CNAs that had shown up when I left. Since [DATE]st was the last day of the month, I had to do changeover of the MARs (medication administration records). This is very time consuming. The second shift nurse on the third floor (V17) stayed over to do the third floor changeover and then she left. (V17) gave me her keys and then I was responsible for covering the second floor and the third floor. I spent the majority of the night doing changeover, so I was not involved in much resident care. I can tell you that (R1) was never looked at. This is the CNA's failure. Bed checks are supposed to be done at least every two hours. A responsible aide would have caught this. The CNAs are taking advantage of the staffing shortage at the facility. They come and go when they please because they know they can get away with it. The facility has been very short staffed, and a lot has been getting missed lately. I know a lot of the residents have said they have not been getting showers. On [DATE] at 10:12 AM, V17 (Licensed Practical Nurse) stated she was working second shift on the third floor on [DATE] and stayed over a few hours to do changeover for the third floor. V17 stated V3 (Assistant Director of Nursing) gave her the nurse's keys to the second floor around 11:00 PM and then left the facility. V17 then stated that V16 (Licensed Practical Nurse) arrived to pick up the second floor's nurses keys around 11:45 PM. V17 stated she handed over the third floor's nurses keys to V16 when she left the building at 3:00 AM. V17 stated the facility has been short staffed lately, There have been a lot of call ins. On [DATE] at 9:50 AM, R2 was driving his electric wheelchair on the facility's first floor. R2 was dressed and groomed and stated, I am going to go to therapy in a few minutes. R2 stated that he has been very upset about R1's death. R2 stated that on [DATE] at approximately 7:30 PM, I was in the main hall on the second floor. (R1) was in her wheelchair and was coming toward me. They (facility staff) said she was spitting on the floor. I think it is gross, but the staff say she has done this before. I have been here for over a year and never seen her do this. When she got closer to me, I could see blood. It was a dark red substance with little coffee ground pieces in it. It was all over her face and gown. I told the nurse she needed help and the nurse said to me, It is probably just chocolate pudding. I am a grown man. I am [AGE] years old, and I know blood when I see it. (R1) looked bad. You could tell something was wrong with her. She was waving her arms around in the air, almost as if she was trying to say something. It was almost like she was choking, and I said that to the nurse. I don't think the nurse ever came out from behind the nurse's desk. One of the CNAs (Certified Nursing Assistants) took her to her room to clean her up and I think she put (R1) to bed afterwards. I don't think the nurse ever came out from behind the nurse's desk while all of this was going on, and I don't think they ever checked on (R1) because of the way she was found, stiff as a board. I just keep thinking about (R1), and she just had this panicked look on her face, and if you know (R1), you know that is not her normal demeanor. (R1's) was confused, so she could not tell you what was wrong, but you could tell something was wrong. She didn't have to die that day and shouldn't have died that way. R2 was visibly upset and tearful throughout the interview. On [DATE] at 2:35 PM, V18 (former Receptionist) stated the following: (R2) came and talked to me after (R1) had died . He was so upset and tearful. He felt like he should have done something for (R1). He said he wanted to call an ambulance for (R1) the night she was ill, but residents are not allowed to do this. He told me that he kept telling the nurse that (R1) needs help, and she is throwing up blood. He said the nurse looked at him and told him it was pudding. He was angry about this and told me that he is [AGE] years old, and he knows what blood looks like. I hugged him because he was so upset. He told me he had not been sleeping well because of what happened. On [DATE] at 2:00 PM, V13 (Licensed Practical Nurse) stated she learned of R1's death when she arrived at work on [DATE]. V13 stated, I work second shift and was told (R1) had died . She was a wanderer, and she had some behaviors. I never had seen her spit on the floor. (R2) was very upset by all of this. He told me that he felt like something was wrong and it appeared to him that (R1) was vomiting up blood. (R2) is completely with it, and I encouraged him to go to management with his concerns. He was so upset. On [DATE] at 12:00 PM, V11 (Certified Nursing Assistant) stated she is the restorative aide, and usually does not work on the floor. V11 stated she assisted cleaning R1 up after R1 had passed away. V11 stated, This place has been very short staffed, so I went to help clean up (R1). When I went in the room, her eyes and mouth were open, and her body was very cold. She was very, very stiff. It appeared she had been there dead for quite a while. On [DATE] at 12:20 PM, V12 (Certified Nursing Assistant) stated she and (V11) cleaned up R1 after she had passed away. V12 stated, (R1) was cold and stiff. Her eyes were open and so was her mouth. The head of her bed was elevated at approximately 30 degrees and her head leaned back. She was holding onto the bed sheet. R1's medical record did not contain any documentation of a change in condition, assessment conducted or physician notification prior to R1's death on [DATE]. On [DATE] at 12:50 PM, V1 (Assistant Administrator) confirmed nothing about R1's change in condition was charted in R1's medical record and stated, Our charting sucks. V1 stated that R1's physician should have been notified when R1 began displaying a change in condition on the afternoon of [DATE]. V1 stated that R1 should have been checked on at a minimum of at least every two hours. V1 stated the facility has been short staffed and it has been a challenge to fill the facility's schedule. V1 confirmed that several residents have missed showers as a result of the limited number of staff working. On [DATE] at 10:35 AM, V19 (R1's Physician) stated he was never made aware of R1's change in condition on [DATE]. V19 stated, This is neglect. They should have called me. I cannot do anything to address the situation if I am not made aware of it. (R1) should have been checked on throughout the night. They should have checked her at a minimum every two hours. The Immediate Jeopardy was identified on [DATE] at 11:00 AM to have begun on [DATE] when R1's change in condition was not addressed. V21 (Administrator) and V1 (Assistant Administrator) were notified of the Immediate Jeopardy on [DATE] at 11:05 AM. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: Documentation provided on [DATE] indicates that on [DATE], nursing staff were re-educated by V2 (Director of Nursing) on the following facility policies: Change in Resident's Condition or Status policy, Acute Condition Changes-Clinical Protocol policy, Family and Physician Notification policy, Guidelines for Shift Report policy. Documentation provided indicates that on [DATE], nursing staff was re-educated by V2 (Director of Nursing) on the facility's Narcotic Count protocol. Documentation provided on [DATE] indicates that on [DATE], CNAs (Certified Nursing Assistants) were re-educated by V30 (Scheduler/CNA Supervisor) on the following: nurse notification- any change in condition, two-hour rounds, and the facility's Repositioning and Check/Change policy. On [DATE] at 2:30 PM, V19 (R1's Physician/Medical Director) stated that he participated in a Quality Assurance and Performance Improvement meeting that was conducted on [DATE] with facility administration and management members. on [DATE] a copy of the facility's Daily QA (Quality Assurance) Audit Tool was provided and V2 (Director of Nursing) stated that this form will be completed daily to ensure all resident changes in condition have been addressed and appropriate follow up has been implemented. On [DATE], the following facility staff members were interviewed and verbalized knowledge of the recent education and inservicing that was administered: V21 (Administrator), V2 (Director of Nursing), V30 (CNA Supervisor/Scheduler), V22, V27, V33 (Certified Nursing Assistants), V31, V32 (Licensed Practical Nurses), and V1 (Assistant Administrator). All staff interviewed indicated they were not able to begin working a shift until they had received the required education.

Based on interview, observation and record review, the facility failed to ensure that emotional support was provided to a resident who became emotionally distressed after witnessing a resident's change in condition who later passed away. R2 observed R1 display a change in condition on the afternoon of [DATE] that continued to decline into the evening. R2 was made aware that R1 was found deceased in bed the following morning, which caused R2 emotional distress that continues. R2 was one of 13 residents reviewed for improper nursing care in the sample of 13. Findings include: R2's Minimum Data Set Assessment (dated [DATE]) documents a Brief Interview for Mental Status score of 15, indicating that R2 is cognitively intact. On [DATE] at 9:50 AM, R2 was driving his electric wheelchair on the facility's first floor. R2 was dressed and groomed and stated, I am going to go to therapy in a few minutes. R2 stated that he has been very upset about R1's death. R2 stated that on [DATE] at approximately 7:30 PM, I was in the main hall on the second floor. (R1) was in her wheelchair and was coming toward me. They (facility staff) said she was spitting on the floor. I think it is gross, but the staff say she has done this before. I have been here for over a year and never seen her do this. When she got closer to me, I could see blood. It was a dark red substance with little coffee ground pieces in it. It was all over her face and gown. I told the nurse she needed help and the nurse said to me, 'It is probably just chocolate pudding.' I am a grown man. I am [AGE] years old, and I know blood when I see it. (R1) looked bad. You could tell something was wrong with her. She was waving her arms around in the air, almost as if she was trying to say something. It was almost like she was choking, and I said that to the nurse. I don't think the nurse ever came out from behind the nurse's desk. One of the CNAs (Certified Nursing Assistants) took her to her room to clean her up and I think she put (R1) to bed afterwards. I don't think the nurse ever came out from behind the nurse's desk while all of this was going on, and I don't think they ever checked on (R1) because of the way she was found, stiff as a board. I just keep thinking about (R1), and she just had this panicked look on her face, and if you know (R1), you know that is not her normal demeanor. (R1's) was confused, so she could not tell you what was wrong, but you could tell something was wrong just by looking at her. She didn't have to die that day and shouldn't have died that way. They (facility staff) should have done something to get her some help. R2 was visibly upset and tearful throughout the interview. On [DATE] at 12:50 PM, R2 was lying in bed watching television. R2 stated that he was tired, I haven't been sleeping very much. I just keep thinking about (R1). She shouldn't have died that way. On [DATE] at 2:35 PM, V18 (former Receptionist) stated the following: (R2) came and talked to me after (R1) had died . He was so upset and tearful. He felt like he should have done something for (R1). He said he wanted to call an ambulance for (R1) the night she was ill, but residents are not allowed to do this. He told me that he kept telling the nurse that (R1) needs help, and she is throwing up blood. He said the nurse looked at him and told him it was pudding. He was angry about this and told me that he is [AGE] years old, and he knows what blood looks like. I hugged him because he was so upset. He told me he had not been sleeping well because of what happened. On [DATE] at 2:00 PM, V13 (Licensed Practical Nurse) stated she learned of R1's death when she arrived at work on [DATE]. V13 stated, I work second shift and was told (R1) had died . She was a wanderer, and she had some behaviors. I never had seen her spit on the floor. (R2) was very upset by all of this. He told me that he felt like something was wrong and it appeared to him that (R1) was vomiting up blood. (R2) is completely with it, and I encouraged him to go to management with his concerns. He was so upset. R2's current medical record including Progress Notes, Social Service Notes and Care Plan have no mention of any type of increased monitoring or follow up offered after R2 developed emotional distress from witnessing R1 display a change in condition and learning of her death. On [DATE] at 10:50 AM, V1 (Assistant Administrator) stated that she is aware that R2 has been having a difficult time coping after he witnessed R1 display a change in condition on [DATE] and learning she later passed away. V1 confirmed that no type of increased monitoring or follow up for emotional support has been offered to R2.

Based on observation, interview and record review, the facility failed to administer pain medication as ordered by the physician and failed to address a resident's need for pain reduction interventions for one resident (R1) out of three residents reviewed for pain medication in a sample of 12. This failure resulted in R1 having increased pain and prolonged untreated pain. Facility's Administering Medications policy revised 12/2012, documents Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one hour of their prescribed time, unless otherwise specified. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS dated 6/13/22 documents [MEDICATION(S)] patch 12 micrograms (mcg) applied to posterior flank every 72 hours. R1's POS dated 6/23/22 documents [MEDICATION(S)] patch 25 mcg. Place one patch on location close to pelvis that have fat - subcutaneous tissue every 72 hours. Discontinue [MEDICATION(S)] 12 mcg patch when 25 mcg arrive. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 received the [MEDICATION(S)] 25 mcg patch on 7/1/22. R1's current care plan documents I have (chronic) pain related to Arthritis. Administer analgesia as per orders. Give half an hour before treatments or care. Anticipate my need for pain relief and respond immediately to any complaint of pain. On 7/16/22 at 11:45 AM, V4, Licensed Practical Nurse (LPN), stated We're having a lot of staffing issues. The CNAs (Certified Nursing Assistant) are shorthanded, and things aren't getting done. They don't have the time. The call lights will go off for an hour sometimes, they can't get the residents repositioned when they need to, and they're double padding the (Incontinence pads) to prevent the urine from leaking through. On 7/16/22 at 12:05 PM, V5, CNA, stated There's no staff, so yeah, there are things that don't get done. I don't see how were supposed to turn and reposition the residents when there's only one CNA on the floor. There are days I don't even get a lunch break we're so short staffed. I hate to admit it, but they're double padding the residents, so they don't have to change them as often. On 7/16/22 at 2:55 PM, R1 sitting in recliner pushing herself up in the chair, grimacing and trying to shift her body to the other side of the recliner. R1 stated Oh good, you're finally here to move me to bed. My back is really hurting. You're not her to move me? I asked to be moved to my bed at 1:00 PM, which was two hours because I'm in a lot of pain and need to lay down. This happens all the time. They don't have enough staff to help me from the recliner to the bed and once I'm in bed, I'll stay there until the next morning. On 7/16/22 at 3:00 PM, R1 stated I had a fall last month (6/5/22) and my hip and back have been hurting really bad ever since. I had a pain patch the doctor ordered, but for some reason the facility wasn't giving it to me. The nurse kept saying We're waiting for it to come in. I was in a lot of pain and had to sit here like that until it came in. I don't think that's right. I shouldn't have had to sit here in pain like that. On 7/17/22 at 11:48 AM, R1 lying in bed in hospital gown and shifting body side to side. R1 stated I've been in bed since 3:00 PM yesterday. I need to get up, my back and hip hurt. I just need to sit up for a bit. Can you please help me or find someone who can get me up? I'm in a lot of pain. On 7/17/22 at 12:10 PM, V1, Administrator, verified R1 did not receive the [MEDICATION(S)] patch from 6/25/22 until 7/1/22 and stated The pharmacy never sent the patches to us. It's something that we should have definitely followed up on when we didn't get them. The residents should be turned and repositioned at least every two hours. On 7/17/22 at 1:00 PM, V8, CNA stated No, the residents aren't getting turned and repositioned every two hours. I don't know how we can when we don't have enough staff.

Based on observation, interview, and record review, the facility failed to immediately assess a resident for injury following a fall including neurological checks, implement fall interventions, and supervise a resident while they are showering for two of three residents (R1, R2) reviewed for falls. These failures resulted in R1's injury not being identified and treated immediately. R1 sustained a closed fracture of right radius and ulna (right wrist) as a result of her fall. R2 received a 1/2 inch abrasion to his right lower leg as a result of his fall. Findings include: The facility's Fall policy, no date available, documents, Policy: To provide for the investigation of all falls. To provide a safe environment for resident. Procedure: When a resident falls the nurse on duty will assess the resident for injury. 1. On 4/26/22 at 12:30 p.m. R1 alert sitting up in wheelchair. R1 had a hard cast on R1's right arm from right upper arm down to R1's hand. R1's fingers were swollen and light purple/green in color. R1 was pleasantly confused with garbled word salad. States, I fell pointing to her cast R1's Incident Investigation, dated 4/12/22 at 3:30 p.m., documents, I walked around to elevator and saw (V5 CNA) with R1 on the floor. She was sitting/leaning up against the wall reaching for the linen cart. The investigation also documents, Resident's verbal report of the fall and circumstances: (R1) unable to communicate verbally. (R1) was agitated at the time of fall. The report also documents, List the interventions you immediately put in place to provide resident safety and prevent another fall: Assisted (R1) in to chair to prevent (R1) from attempting to get up on her own. R1's Neurological Flow Sheet, dated 12/13/22, documents that R1 had neurological checks completed on 4/12/22 at 3:30 p.m., 3:45 p.m., 4:05 p.m., 4:20 p.m., and 4:40 p.m. signed by (V4 Licensed Practical Nurse). The entries also have a mark thru them and Hospital is written. The flow sheet documents that neurological checks were restarted when R1 returned from the hospital with the following checks: 10:40 p.m., 11:40 p.m., (4/13/22) 12:40 a.m., 1:40 a.m., 2:40 a.m., 3:40 a.m., 4:40 a.m., 5:40 a.m., 8:30 a.m., 2:30 p.m., and 6:30 p.m. On 4/27/22 at 2:40 p.m., V4 stated, I started doing neurological checks on (R1) when I saw her at 6:40 p.m. and that's when I did my first full assessment of her. I attempted to do her vital signs four different times at that time as well, but she was refusing. I did not do neurological checks at 3:30 p.m., 3:45 p.m., 4:05 p.m., 4:20 p.m., or 4:40 p.m. because I wasn't aware of the fall until 6:40 p.m. That is my signature on (R1's) form though. I think I messed up when I wrote 16:40 (4:30 pm) thinking it was 6:40 p.m. Facility Staff Statement, dated 4/12/22, documents, (V3 Assistant Director of Nursing) walked around to elevator and saw (V5 Certified Nursing Assistant-CNA) with (R1) leaning up against wall attempting to reach for a linen cart. (R1) was agitated at the time so I assisted (V5) in standing (R1) up to place her in a chair to be evaluated by floor nurse. Facility Staff Statement, dated 4/12/22, documents, (V3) and I (V5) picked (R1) up off the floor in the hallway. I asked (R1) if she was okay and she said yes. R1's Nurse's Note, dated 4/12/2022 at 6:40 p.m., documents, R1 complained of pain, held up her right arm. R1 sent to ER (emergency room ). R1's progress/nurses' notes have one entry prior to this dated 3/17/22. There is no other documentation regarding R1's actual fall. R1's 72 hour occurrence report, dated 4/12/22, documents, R1 was observed on the floor by the elevator. Staff assessed resident. ROM (Range of Motion) within normal limits. Neurological intact. R1 sitting by nurses' station. R1 didn't complain of any pain/discomfort. See neurological sheet for orders noted. On 4/27/22 at 2:40 p.m., V4 stated, I thought (V3) had done (R1's) initial fall assessment and neurological checks since she was with (V5) when (R1) was found on the floor. The entry I made on the 72 hour occurrence charting (dated 4/12/22) was information that I received from (V5). What I charted was not my assessment. I didn't assess her for ROM, and that entry was not put in until after (R1) went to the hospital. R1's Hospital X-ray results, dated 4/12/22, document, Impression: Displaced and angulated distal radial and ulnar fractures. R1's Hospital Progress note, dated 4/12/22, documents: Assessment & Plan: R1's wrist reduced and placed in short arm splint. R1's Emergency Department After Visit Summary, dated 4/12/22, documents, Reason for visit: wrist injury. Diagnosis: Closed fracture of right radius and ulna. The facility's 5 day report to the State Agency, dated 4/15/22, documents, R1 was observed on the floor in the the hallway on 4/12/22. R1 did experience swelling to her right wrist area. She was sent to the emergency room and returned the same date with a sling in place for a right radial and ulna fracture. R1's Fall care plan, dated 12/20/21, documents, I have risk factors that require monitoring and interventions to reduce risk for falls. History of falls. I can be noted to be impulsive with no regards to safety. The care plan also documents that on 4/13/22 it was revised with the new intervention was a therapy screen. This same care plan documents R1 requires 1:1 or 2:1 extensive assist with most ADL's (Activities of Daily Living) and mobility. On 4/26/22 at 12:34 p.m. V5 (CNA, Certified Nursing Assistant) stated, (R1) was wound up that day (4/12/22) trying to leave the floor. She was agitated. I was the one who found her on floor by the elevator. Myself and (V3 Assistant Director of Nursing, ADON) helped her up from the floor. I don't think (V3) did anything with her. (R1) was combative and fighting us. I walked her to a chair at the nurses' station, and (V3) left. When I took (R1) to the nurses' station, I reported to (V4 LPN-Licensed Practical Nurse) that (R1) had fallen, but she didn't do anything. (V4) didn't assess her or anything. At approximately 6:45 p.m. that night, (R1) was walking in the hallway complaining of her wrist and that's when (V4) sent her to the emergency room . On 4/26/22 at 1:35 p.m., V4 (LPN) stated, (R1) fell by the elevators (V3, ADON) and (V5, CNA) picked her up. (V3) didn't tell me anything before she left. I wasn't aware of the fall until the assessment I did. I assessed her around 6:40 p.m., and her wrist was blue and swollen. When I saw her wrist I sent her to the emergency room . On 4/27/22 at 11:35 a.m., V3, (ADON) stated, I was leaving work that day when I walked around the corner and saw (R1) on the floor. (V5) was already there with (R1). (R1) was agitated and grabbing onto the laundry cart trying to stand herself up. I looked over (R1) really quick to make sure she didn't have any obvious injuries. I didn't notice anything, but I didn't do a full head to toe assessment because that's the floor nurse's job. I didn't see any bruising or swelling on (R1's) arm, but she was swinging and agitated with us. I also feel like her adrenaline was pumping so much I don't know if she would have noticed the pain. She isn't really verbal enough to verbalize her pain consistently. The agitation could have been a nonverbal sign of pain. (V5) and I lifted (R1) into a chair at the nurses' desk, (V5) told me she would report it to the floor nurse. So, I left and went home. (V1 (Administrator) called me later that night telling me I need to do (R1's) report. I wasn't even there to get all of the details for the fall report. It should have been the floor nurses that completed this. I helped (V5) with (R1) that was it. This is why I left the facility. Had I felt it was my responsibility, I would have never left but there was two floor nurses present so this was the floor nurse's responsibility. The following morning, they threatened me into doing the fall report. (V5) gave me a written statement that she had reported the incident to (V4), but (V4) wasn't going to do anything with it. Once (V5) got (R1) to the nurses' station they should have done a set of vitals, and started neurological checks. We do neurological checks if it was unwitnessed, and unable to tell us what happened. On 4/27/22 at 3:10 p.m., V2 (Director of Nursing) stated, When (V3) found (R1) on the floor with (V5) she should have immediately assessed (R1) and do the fall paperwork or tell the floor nurse so the floor nurse could have taken over. (V3) did not do a full assessment of (R1) or start neurological checks. V2 confirmed that a full head to assessment nor neurological checks were done immediately after (R1) fell . V2 also stated, No one noticed any pain or swelling until (V4) sent (R1) out to emergency room . If (R1's) ROM (Range of Motion) was assessed the nurses may have noticed (R1's) injury sooner. Our facility neurological check policy is to start neurological checks when fall happens and the resident has hit their head or they don't know if they've hit their head. The checks are to be started immediately, and the frequency is what is documented on our neurological check form of every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, and then every four hours for 24 hours. After (R1's) fall we put an intervention in for therapy to evaluate (R1). However, because of (R1's) insurance we didn't get a therapy evaluation. So, there was no intervention put into place in order to prevent (R1) from falling again. 2. R2's Care plan, dated 12/29/20, documents, I am at risk for falls related to history of prior to admission, ataxic, and gait/balance problems. R2's Cognition care plan, dated 12/29/20, documents, I have impaired cognitive function/dementia or impaired thought processes related to Dementia. R2's ADL (Activities of Daily Living) care plan, dated 6/28/21, documents, (R2) presents functional deficits in self care. (R2) requires limited-moderate assist with most ADL's and mobility. (R2) demonstrates impaired decision making skills, short attention span, generalized weakness, functional ROM limitations in left upper extremity. R2's Fall Risk Evaluation, dated 4/22/22, documents a score of 13 putting R2 at risk for falls. The evaluation also documents the following risks that contribute to R2's risk for falls: Intermittent confusion; Chair bound; Balance problem while standing; Decreased muscular coordination; Requires use of assistive devices. R2's Incident Investigation Quality Improvement Process, dated 4/22/22, documents, Observed sitting on the floor in the shower room trying to transfer himself from shower chair to his wheelchair. R2's Quality Assurance Fall Report, dated 4/22/22, documents, Resident's verbal reports of the fall and circumstances: trying to transfer from shower chair to his wheelchair. Environmental status at time of fall: Floor wet. Immediate cause of fall: fall due to environmental. Injury as a result of fall: Minor-1/2 inch long on right lower leg. List the interventions you immediately put in place to provide resident safety and prevent another fall: All residents need supervision/assistance in the shower room, can not be left unattended. On 4/26/22 at 1:15 p.m., R2 was sitting up in a wheelchair in his room. R2 stated, I was in the shower on my own, like usual, when I fell . I was sitting in the shower chair on the shower side. When I was done, I needed to get to the other side of the shower room to get into my wheelchair and dry off. My feet don't touch the ground while I'm in the shower chair, so in order to move around in the chair I rock my body to scootch (move) the chair to where I want to go. There is an incline between the two areas of the shower room. So I have to go up and over that incline. When I tried to go up the incline the shower chair tipped over on me. I cut up my leg pretty good. R2 raised his pant leg where multiple scabbed over abrasions were scattered over the majority of R2's right lower leg. On 4/26/22 at 1:25 p.m., the facility shower room was a small area separated into two areas that was completely tiled. There is a separation between shower and entrance area, that is a raised incline. In order to get over the incline from either side of the shower you must go up and then down it. V9's (Certified Nursing Assistant) Facility Corrective Action Notification, dated 4/22/22, documents, On 4/22/22 you were giving (R2) a shower and you left the shower room and floor. Even though you reported to the nurse you were doing so, it is not acceptable to ever leave a resident unattended in the shower room. If the resident is independent and requests privacy you must stay in the shower area. This behavior is completely unacceptable as a caregiver. This also creates a hardship for the rest of your team in providing caring, quality care for our residents. On 4/26/22 at 2:35 p.m., V1 (Administrator) stated, The staff education that was provided in response to (R2's) fall was to remind them that no resident is to be left alone in the shower. We have one resident that is able to independently shower, and that is not (R2). (R2) shouldn't have been left alone. On 4/27/22 at 3:10 p.m., V2 (Director of Nursing) stated, (V8) took (R2) to shower in the shower room. (V8) left (R2) to shower on his own and left. (R2) fell while in the shower room alone. (R2) should not have been in shower alone.

Based on observation, interview, and record review, the facility failed to reheat food to the appropriate temperature to kill pathogenic microorganisms that may cause foodborne illness, maintain safe food temperatures of food being held on the steam table, cool food in a manner that prevents the growth of pathogenic microorganisms, and ensure the prevention of potential foodborne pathogens through the monitoring of the temperatures of the resident dishwasher. As a result of this failure, a serious adverse outcome is likely to occur in an outbreak of foodborne pathogen illness. These failures have the potential to affect all 74 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 10/27/21, the facility remained out of compliance at a Severity Level 2. The facility is ensuring that all dietary staff are in-serviced on the facility's policies and procedures regarding the cooling of cooked potentially hazardous foods, reheating foods, safe holding, high temperature dishwasher monitoring and manual three compartment sink sanitizing prior to returning to work. The facility is also in the process of implementing their audit tool to ensure that the two step food temperature cool downs are implemented accurately and consistently. The facility has also deemed the dishwasher out of service and began utilizing the three compartment sink for all washing of dishes until the facility's dishwasher can be serviced and placed back in operation. Findings include: The facility's Cooling Cooked PHF/TCS (Potentially Hazardous Food/Time Temperature Control for Safety) Foods policy, dated 2017, documents, Hot foods are cooled in the refrigerator from 135 degrees Fahrenheit (F) to 70 degrees F within two hours. Within four more hours the food is cooled to 41 degrees F. Cooling time from 135 degrees F to 41 degrees F does not exceed a total of six hours. The policy also documents, Food for which no temperatures have been taken is discarded. Time and temperature are recorded on labels affixed to the pan and/or on a Two-Step Cool-Down Temperature Monitoring log. The facility's Food Temperatures policy, dated 2019, documents, To ensure food safety, hot food is cooked to a minimum safe temperature and is held at no lower than 135 degrees F. Cold food is held at 41 degrees F or lower. The facility's Reheating policy, dated 2017, documents, Cooked food which is cooled in the refrigerator and is reheated for hot holding is reheated to 165 degrees F (Fahrenheit) for 15 seconds. Foods will be reheated rapidly to an internal temperature of 165 degrees F for fifteen seconds. If holding reheated food, the temperature will be maintained at 135 degrees F. The facility's Dishwashing Machine Operation (High Temperature Dishwashing Machine) policy, dated 2017, documents, Paper thermometers are used to determine correct rinse temperatures of the dishwashing machine. The policy also documents, If it is not possible to repair the dishwashing machine in time for the next meal one of two alternatives may be used: The dishes and flatware maybe washed and sanitized in the three-compartment sink following a standard procedure for manual sanitizing. The facility's Manual Sanitizing in Three-Compartment Sink policy, dated 2017, documents, A sink with three compartments is used for manually washing, rinsing, and sanitizing utensils and equipment that can be submerged. It may also be used for tableware. After washing and rinsing utensils and equipment are sanitized in the third sink by immersion in either: Hot water (171 degrees F for thirty seconds) or Chemical sanitizing solution used according to manufacturer's instructions. A test strip is used to accurately determine the concentration of the sanitizing solution. The policy also documents that when using Quaternary solution sanitizer the concentration should be 150-400 ppm (parts per million) or 200-400 ppm. The Facility Assessment, dated 3/2021, documents, Food and Nutrition Services: The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. The facility's Director of Dietary Job Description, dated 4/7/20, documents that V4 (Dietary Manager) started on 4/7/20. The job description also documents, Essential Job Functions: Establish departmental regulations and procedures, in conformance with administrative policies and state and federal regulations and develops standards for organization and supervision of dietary service. Develop and prepare policies and procedures governing handling and storage of supplies and equipment, sanitation and for records and compiling reports. The Director shall be conscious of safety hazards which pose a threat to self, employees, residents, and visitors and correct or report such hazards to appropriate personnel. On 10/24/21 at 9: 20 a.m., a shelf in the walk in cooler contained multiple metal serving pans including: chicken nuggets (10/22/21), meat sauce (10/21/21), turkey ham (10/21/21), barbeque pork (10/16/21), beef gravy (10/21/21), chicken noodle soup (10/23/21), hamburgers (10/22/21), taco meat (10/22/21), sausage (10/20/21), and [MEDICATION(S)] casserole (10/22/21). V4 (Dietary Manager) was present and confirmed these were leftovers. V4 stated, We don't have cool down logs. There is no formal cool down process for the leftovers. The only time I would do a cool down is if I cooked a roast or another big piece of meat the day before the actual meal. On 10/24/21 at 09:37 A.M., V6 (Cook) stated, I don't really have a cool down process. I take the food off of the steam table and let it cool down for a bit before I put it in the cooler. Normally I wait until the temperature is at least under 160 degrees. On 10/24/21 at 09:37 A.M., V6 was washing the breakfast dishes of pans, pots, cooking/serving utensils, and cookie sheets. V6 stated, Our dishwasher is a high temperature dishwasher. I check the temperatures by looking at the gauges on the outside of the machine. It should read a high of 190 degrees F when it rinses. At this time, V6 sent a tray of dishes through the machine two times. The rinse and the wash gauges did not move. They read 142 degrees F for the rinse and 118 degrees F for the wash. V6 confirmed these temperature readings. On 10/24/21 at 09:39 AM, V4 (Dietary Manager) presented paper temperature check strips. V4 attached a temperature strip to a plate and sent the plate through on a dish tray. While inside of the dishwasher, V4 pointed out a third gauge on the machine. V4 stated that this is the gauge the staff are supposed to watch for the temperature. V4 pulled the tray out of the dishwasher and the paper strip had not changed colors (to indicate that the machine reached an appropriate rinse temperature). V4 sent a second strip through the dishwasher, and again it did not change colors. V4 stated that maybe the strips were dysfunctional. V4 took the strip over to the hot water machine to see if the strips were dysfunctional. The temperature strip instantly turned black which indicates that the appropriate temperature has been reached. V4 stated, Ok, I guess the strips do work. V6 continued to wash the facility's breakfast dishes. On 10/24/21 at 11:35 AM, the food being served for lunch was in the steam table. V6 (Cook) stated that the food had been put onto the steam table at 11:00 a.m. V6 removed a thermometer from a cup of ice and stated it was at 0 degrees F to confirm it was calibrated. V6 stated the pureed options for lunch that day were sweet and sour chicken, rice, and green beans. V6 placed the thermometer in the pureed sweet and sour chicken. Its temperature was 90 degrees F. Next, V6 placed the thermometer in the pureed rice. Its temperature was 90 degrees F. V6 placed the thermometer in the pureed green beans. Its temperature was 90 degrees F. V6 placed the thermometer in the substitute chicken and noodle soup. Its temperature was 80 degrees F. Then, V6 checked the temperature of the fortified mashed potatoes which was 110 degrees F. V6 stated the food should have holding temperatures of at least 135 degree F. On 10/24/21 at 11:40 AM, V6 (Cook) placed the pureed sweet and sour chicken, pureed rice, pureed green beans, and potatoes back into the oven. The chicken noodle soup was put on the stove top. On 10/24/21 at 11:50 AM V7 (Maintenance Director) put a dish tray through the dishwasher. V7 stated, The dishwasher is running hot according to the gauge. That's what we go by to make sure it's working. I don't know what the policy is of the facility on how we should be monitoring the temperatures of the dishwasher. V7 confirmed that the dishwasher was a high temperature sanitizing dishwasher. On 10/24/21 at 11:55 AM, the reheated food was brought back to the steam table. V4 placed the thermometer in the pureed rice. Its temperature was 140 degrees F. Then, V4 placed the thermometer in the pureed sweet and sour chicken. Its temperature was 142 degrees F. Next, V4 placed the thermometer in the pureed green beans. Its temperature was 142 degrees F. Last, V4 checked the temperature of the chicken noodle soup which was 135 degrees F and fortified mashed potatoes which had a temperature of 140 degrees F. V4 stated, When we reheated the food from the steam table it only needs to be able to reach 140 because it was hot once and in the steam table. So we can reheat the food to only 140 and serve it. V4 stated that they will be serving the reheated food with today's lunch. On 10/24/21 at 12:00 PM, V7 (Maintenance Director) put a dish tray into the dishwasher. V7 checked the rinse temperature of the machine using wire probe thermometer. The rinse temperature was 123.5 degrees F. V7 stated the rinse temperature should reach 190 degrees F. On 10/24/21 at 12:25 PM, V1 (Administrator) was notified to enter the kitchen. V6 (Cook) was actively serving lunch. The pureed sweet and sour chicken, rice, and green beans, chicken noodle soup, and fortified mashed potatoes were on the steam table being served to residents. V6 stated she was continuing to serve the reheated food. At 12:30 p.m. V4 (Dietary Manager) entered the kitchen and stated that the reheated food was safe to serve. This surveyor had to inform the staff to stop serving the food that did not reach the appropriate temperature of 165 degrees F, and to throw away the food in the cooler that was not cooled down through the cool down process. V4 stated that the food was reheated to an appropriate temperature of 140 degrees F to be served to the residents. V1 stopped V4 and stated, No! We will remove all of this food that didn't reach the correct temperature and make all new. V4 (Dietary Manager) stated, The danger zone of food is 41-135 degrees F. V6 also stated, I washed all of the breakfast dishes this morning after we knew the dishwasher wasn't working correctly. On 10/24/21 at 12:45 a.m., V4 (Dietary Manager) stated, I've been employed here for a little over a year, and this whole time the staff have been checking the dishwasher temperatures by watching the gauges. They have not ever used the paper temperature check strips. On 10/25/21 at 09:35 AM, V4 stated, The dishwasher was shut down after lunch yesterday (10/24/21). We switched to using the three compartment sink. The staff should be testing the sanitizer level with the test strips before washing dishes. I do not have a log for checking the sanitizer levels. On 10/25/21 at 09:40 AM, V8 (Cook) was washing the breakfast dishes in the three compartment sink. V8 stated, (V6) checked the Quaternary solution before we started washing dishes, and she said it was 200 ppm. V8 removed a Quaternary solution test strip from the packaging and dipped it into the sanitizing compartment sink of the three compartment sink. The color of the strip did not change. V8 removed a new test strip and tested the sanitizer solution again. The test strip did not change colors again to indicate that there was an appropriate sanitizing concentration. V8 stated, The no color change means 0; no solution. The countertop held coffee pots and pitchers in the drying racks that had already been washed in the three compartment sinks. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 10/24/21 and signed by V1 (Administrator), documents that 74 residents reside in the facility. The Immediate Jeopardy situation was identified on 10/24/21. The Immediate Jeopardy began on 10/24/21, when the facility was holding pureed sweet and sour chicken, rice, and green beans at 90 degrees Fahrenheit. The food was reheated to 142 degrees Fahrenheit and placed back onto the steam table to be served. This surveyor had to stop the cook from serving the food that was not reheated to the appropriate temperature. The cook nor the dietary manager were aware that the food must be reheated to at least 165 degrees. The walk-in cooler contained nine metal pans of food that had been previously cooked including: [MEDICATION(S)] casserole, sausage, taco meat, hamburgers, BBQ pork, turkey/ham, chicken nuggets, beef gravy, chicken noodle soup, and meat sauce. No cool down logs were maintained. The cook nor the dietary manager knew they were supposed to be keeping a cool down log or even complete a cool down process. V4 (Dietary Manager) stated that she didn't need to keep a cool down log. V6 (Cook) stated that she takes the food out of steam table and lets it sit for a moment until it's at least under 160 degrees. If it's below 160 she puts it into the cooler and does nothing else. The high temperature dishwasher used for the resident dishware and cooking material did not reach the appropriate temperature with the use of a paper thermometer and thermometer with a wire sensor. The facility does not use the paper thermometers to determine the correct temperature according to their policy. The staff are only visually looking at the temperature gauges on the machine which displayed 190 degrees Fahrenheit. The staff and dietary manager were unaware of the facility's policy to use a paper thermometer. This procedure of only checking the gauges has been used since V4 (Dietary Manager) started on 4/7/20. On 10/26/21 at 9:45 a.m., V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy situation. On 10/27/21, the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 10/26/21, V1 (Administrator) educated V4 (Dietary Manager) on cooling of cooked potentially hazardous foods, reheating foods, safe holding, high temperature dishwasher monitoring and manual three compartment sink sanitizing. 2. On 10/27/21, V4 (Dietary Manager) educated all dietary staff on cooling of cooked potentially hazardous foods, reheating foods, safe holding, high temperature dishwasher monitoring and manual three compartment sink sanitizing. 3. On 10/25/21, V4 (Dietary Manager) implemented a food cool down log. 4. On 10/25/21, V7 (Maintenance Director) contacted local repair company to service the facility's dishwasher. The repair company deemed the dishwasher out of service, and the three compartment sink was put into place for all washing of dishes. 5. On 10/27/21, V4 (Dietary Manager) initiated the use of the appropriate cool down stickers to label all cooled down food and track the process. 6. On 10/27/21, V1 (Administrator) developed an audit tool to ensure two step cool down is performed properly and consistently. 7. On 10/26/21, a QAPI meeting was held with the following attendees: Medical Director, V1, V2 (Director of Nursing), and V4.

Based on interview and record review, the facility failed to protect a resident from sexual abuse for one (R1) of four residents reviewed for abuse in a sample of eight. This failure resulted in R1 being sexually abused on 6/12/21 by R2. Findings include: Facility Abuse Prevention Program Facility Procedures policy, undated, documents This facility desires to prevent abuse, neglect, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. Facility Final Incident Investigation Report, dated 6/16/21, documents On 6/12/21 it was reported that (R1) had been inappropriately touched by another resident (R2). Staff were playing music for the residents and all were dancing including (R1). (R2) approached (R1) and pressed his palm against her breast. Facility interview with R2, undated, documents (R1) seems like a nice woman, and I thought she would like it. She seemed to enjoy it. R1's face sheet documents R1 was admitted on [DATE] and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's face sheet documents R2 was admitted on [DATE]. R2's Minimum Data Set, dated dated [DATE], documents R2 is cognitively intact. R2's current care plan documents a focus of I have a behavior problem. (R2) is noted to make inappropriate sexual comments to staff and some other female residents and a goal dated 7/7/21 of I will not make inappropriate comments to staff or residents. R2's behavior monitoring for April, May and June 2021 documents R2 is being monitored for Socially Inappropriate Behavior and has instances of Socially Inappropriate Behavior documented for each month. R2's Psychological Services Progress Note, dated 2/11/21, documents (R2) would have stayed at (other facility), however was asked to move due to his inappropriate behavior of sexual nature with staff as he would touch or slap women's body parts. He says he must behave now. On 6/17/21 at 11:10am, V1 (Administrator) stated An abuse allegation report was made to me by V2 (LPN/Licensed Practical Nurse) on 6/12/11 regarding (R1) who is confused and (R2). At the time of the incident (6/12/21) both (R1) and (R2) were on the 4th floor. (R1) is a fairly young resident who has small perky breasts, and (R1) has advanced dementia. (R2) propels himself around the unit by his wheelchair. On Saturday (6/12/21), (R1) was dancing at the nurse's desk and (R2) went up to (R1) and touched (R1's) breast with his hand. (R2) did this in front of staff at the nurse's desk. When I interviewed (R2) he claimed he thought (R1) wanted the sexual advances. (R2) has been here about five years and always been in a private room because he has behaviors. On 6/17/21 at 11:50am, V4 (CNA/Certified Nurse Aid) stated I was working on 6/12/21, and (R1) was in the hallway and (R2) touched her breast. I told (R2) he couldn't do that and he went to his room. (R2) is inappropriate with staff verbalizing sexual comments but does not touch. I tell the nurse if we have any sexual verbalizations from (R2). On 6/17/21 at 12:31pm, V3 (CNA) stated I was working on 6/12/21 and was at the nurse's desk where (R1) was dancing in the hallway. (R2) came down the hallway in his wheelchair, and stopped in front of (R1) and put his hand on her breast. I and other staff immediately separated (R1) and (R2) and told (R2) to not touch (R1). (R2) put one hand on (R1's) breast. I reported it to V2 (LPN), and V2 documented and told management about the incident. On 6/17/21 at 2:30pm, R2 stated I got in trouble for touching a gal. At that same time, R2 verified he was not to touch people inappropriately or say sexual things to people. On 6/22/21 at 10:50am, V2 (LPN) stated (R2) does have sexual behaviors and (R1) has severe dementia. I was working 6/12/21 from 6-2:30pm when (R1) was dancing at the nurse's desk and (R2) came wheeling himself down the hall and reached out and grabbed (R1's) breast with one hand. I directed (R2) back to his room and (R1) was taken to the other end of the hall. I called V1 (Administrator/Abuse Coordinator) and I then spoke to (R2) that he couldn't touch residents and that it was inappropriate. (R2) acted deliberately to touch (R1's) breast at the nurse's desk, and (R1) was moved to a different floor that day.

Based on observation, interview and record review the facility failed to perform physician ordered wound care, implement interventions to prevent the worsening of a pressure ulcer, and follow the facility's wound policy for one of three residents (R3) in a sample of five. This failure resulted in R3's pressure ulcer worsening, increasing in size and eventually requiring R3 to be admitted to a local hospital for a surgical debridement and care of pressure ulcer. Findings include: The facility's Wound Care Policy, revised October 2010, documents to use a disposable cloth to clean off the overbed table, then place supplies on the table. Then wash and dry your hands thoroughly, put on gloves, loosen tape and remove dressing. Wash and dry hands again, apply PPE (personal protective equipment) as required. Use a no touch technique, sterile tongue blades or applicators to remove ointments from their containers, pour liquid solutions directly onto gauze on their papers. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Place one gauze to cover all broken skin. Remove the dry gauze, then apply treatment as indicated. This policy also documents that the following information should be recorded in the resident's medical record: type of wound care, date and time wound care was given, position the resident was in, person performing treatment, all assessment date (wound bed color, size drainage, ect.), the signiture and title of person recording the data. The facility's Pressure Ulcers/Wounds policy, 11/10/19, documents that a Wound nurse or designee will monitor all wounds and will obtain new treatment orders for wounds which have shown no improvement for two weeks in a row unless expected decline. A care plan will reflect skin issues and interventions will be put into place. R3's Braden score dated 5/29/20 and 6/19/20 document a score of 15, indicating that R3 is a high risk for pressure ulcers. R3's current care plan does not address R3's pressure ulcer at all. There are no interventions or goals put into place to prevent R3's pressure ulcer from worsening. R3's admission skin assessment, dated 5/29/20, documents a three inch round stage four pressure ulcer on his sacral area. R3's wound measurements dated 6/1/20 document the sacral wound measures 3cm (Centimeters) by 3.5cm by 1.7cm depth. On 6/8/20 the measurements were 5cm by 5cm by .5cm depth. On 6/15/20 R3's wound measured 5cm by 3.2cm by 3.5 cm. R3's medical record does not have documented measurements for the weeks of 6/22/20 and 6/29/20. R3's wound measurements on 7/7/20 were 10cm by 4.5cm by 3.4cm. On 7/13/20 the measurements were 10.2cm by 7cm by 3cm. No measurements were documented for the week of 7/21/20. R3's Admission Physician order [REDACTED]. This same form documents to do a body audit three times a day. R3's Treatment Administration Record dated 5/29/20-5/31/20 does not have any documentation that R3's wound care to his coccyx or skin audit was completed as ordered. R3's POS (Physician order [REDACTED]. with an ABD, tape securely, daily. This form also documents to do a body audit three times daily. On 6/8/20 the wound care order was changed to two times daily instead of daily. On 6/15/20, R3's POS documented to continue the same treatment to the wound, but added to check R3 frequently, so stool (feces) does not get on the skin or dressing. R3's 6/1/2020-6/29/2020's TAR (Treatment Administration Record) has no documentation that R3's wound care or skin audit was done at all on 6/1/20, 6/9/20, and 6/30/20. R3's treatment order to his coccyx/sacral wound was changed on 6/8/20 to two times daily; R3's TAR does not have the new treatment orders on it. R3's treatment was only done one time daily instead of the two times as ordered. This form also has only the order to do the skin audit one time daily. R3's Progress Notes dated 6/30/20, document to send R3 to to the emergency room for a rapid COVID 19 test, then to get a total debridement of his sacral wound. R3's emergency room Notes, dated 6/30/20 documents that R3's wound measured 10cm by 8 cm by 3.5cm with necrotic tissue on the top of sacrum/coccyx bone with fascia involved, and the wound is unstageable. R3 was readmitted to the facility on [DATE]. R3's readmission orders [REDACTED]. R3's TAR, dated July 2020, has no documentation that R3's wound was completed on 7/5/20, 7/6/20, 7/9/20 7/16/20, 7/19/20 and 7/25/20 on the 2:00pm - 10:00pm shifts and on 7/11/20, on the 10:00pm - 6:00am shift. R3's body audit was not done on 7/4/20 and 7/6/20. On 7/27/20 at 11:00am, V4 (Licensed Practical Nurse/LPN) removed R3's brief to assess his dressing to his coccyx/sacral area. The dressing was intact but had feces on it; the dressing was not dated or initialed. V4 and V5 (LPN) returned with the supplies to do R3's wound care. V4 and V5 applied PPE before entering the room. V5 set the treatment supplies on the foot of R3's bed (not on a overbed table), then removed the soiled dressing, including the medicated packing, placed in a plastic bag at the foot of the bed. V5 cleansed R3's wound with medicated solution, disposed of the medicated gauze, then with the same gloves on, applied the medicated cream to the outside of the wound with her finger tip. V5 then put an ABD dressing over the top of the wound, initialed and dated the dressing. V5 did not do any hand hygiene any time during R3's wound care and was not wearing sterile gloves as documented in the facility's wound policy. V5 did not follow the physician wound care order to pack R3's wound with the medicated solution on the 4x4's. On 7/27/20 at 2:00pm V3 (LPN/Wound Nurse) verified that hand hygiene is to be done when moving from a dirty area to a clean. V3 verified that at no time is the finger tip used to apply medications. V3 stated the medicated solution is to be packed into R3's wound and left there until the next treatment. V3 stated that if the TAR is not signed out, then the treatment is considered not to be done as ordered. V3 verified that wound measurements are to be done on a weekly basis. On 7/27/20 at 2:30pm, V1 (Administrator) verified that wound care and treatments are to be completed as ordered. V1 stated that if they are not signed out then they are not done. V1 could not provide any wound care measurements for R3 for the weeks of 6/22/20, 6/29/20 and 7/21/20. On 7/29/20 at 8:45am, V14 (R3's Primary Care Physician) verified that wound and physician orders [REDACTED]. V14 also stated that wound care interventions should be put into place and followed to prevent worsening of pressure ulcers. On 7/29/20 at 9:00am, V13 (Clinical Wound Care Nurse Consultant) verified that R3's treatment order is to soak 4x4 gauze in medicated solution, pack the wound with it, then cover with a dressing. Cleanse with normal saline prior to using the medicated solution. V13 stated that she is no longer working at the facility because the treatments were not being done as ordered. V13 stated that she was not notified of R3's pressure ulcer worsening between 6/15/20 and 7/7/20.

Based on observation, interview, and record review, the facility failed to ensure that care planned interventions of floor mats and a specialty bed were followed, new interventions added to a care plan after a fall, and the correct mechanical lift device was used for three (R5, R24, R27) of seven residents reviewed for falls in a sample of 29. This failure resulted in R27 being transferred to the hospital and receiving stitches to the right eye. Findings include: 1. The facility's (undated) fall policy documents Policy: To provide the investigation of all falls. To provide a safe environment for resident. This same policy documents Procedure: IDT (interdisciplinary team) to review fall during morning meeting. New interventions will be added to the care plan. On 1/21/20 at 11:35 AM, R27 was sitting in a chair in the dining room. R27 was pleasantly confused with conversation and had a reddened area containing stitches to her right eyebrow. R27's current care plan, dated 1/1/20, documents I have a history of falls with injury related. I have risk factors that require monitoring and interventions to reduce risk for falls. This care plan also documents the latest intervention was added on 1/1/20 to include mats on floor. R27's Incident Investigation Quality Improvement Process form, dated 1/14/20, documents at 3:50 PM (R27) was attempting to get out of bed and fell to the floor. This same form documents R27 suffered a Major Injury as a result of the fall. Laceration to right outer eyebrow. Sent to the emergency room for evaluation and treatment. R27's Incident Investigation Quality Improvement Process form, dated 1/16/20, documents at 4:20 AM (R27) removed bolster from bed, threw it on the floor and rolled out of bed. On 1/22/20 at 10:45 AM, V2 (Director of Nursing) stated, When someone has a high/low bed, the bed goes to the floor. Usually they're accompanied by floor mats. (R27's) fall on 1/14/20 resulted in a laceration and stitches to her eyebrow because staff working that day forgot to put down (R27's) floor mats. (R27) didn't have floor mats in place so she hit her eye on the floor. V2 confirmed that the care plan for R27 has not been updated and new interventions were not added after the falls in January. V2 stated, Nursing assistants and nurses should look at the care plan to know how to care for a resident. On 1/22/19 at 12:15 PM, V16 (Minimum Data Set assessment coordinator) confirmed R27's care plan has not been updated after two falls in January. V16 stated, We have not added any interventions after she fell [DATE] and 1/16/20 due to our team has not met to discuss the fall. 2. R24's current care plan, dated 1/22/20, documents (R24) has risk factors that require monitoring and interventions to reduce risk for falls. This same care plan documents an intervention of high/low bed. R24's current physician order [REDACTED]. On 1/21/20 at 10:50 AM, R24 was sleeping in bed in his room. R24 was not in a high/low bed. R24 did not have floor mats in the room. On 1/21/20 at 11:25 AM, V18 (Licensed Practical Nurse) stated, (R24) does not have a high/low bed but his bed is in the low position. On 1/22/20 at 12:20 PM, V2 (Director of Nursing) stated, Orders for a high/low bed should be communicated to me and I then let maintenance know and the bed would be delivered within the same day. I have not seen this order (high/low bed) for (R24). I didn't know it was an order in his chart because the nurse did not tell me. He should've had the high/low bed on the day it was ordered 1/15/20. 3. Facility Policy and Procedure for lift equipment, dated 2013, documents To be transferred with a sit to stand lift, the resident must be able to partially bear weight and hold on to the hand grips. R5's Minimum Data Set (MDS), dated [DATE] and 12/20/10, documents R5 is totally dependent on two people for transfers. R5's carecard, no date, in R5's room documents R5 is a two person mechanical lift. R5's Physical Therapy notes, dated 11/14/19, documents Transfers = Total Dependence without attempts to initiate. V5's (Certified Nurse Aid/CNA) incident investigation written statement, dated 11/26/19, documents I was helping (V15) CNA with (R5) and we put him in the sit to stand and he slid out of the sit to stand. V15's (CNA) incident investigation written statement, dated 11/26/19, documents Me and (V5) were transferring (R5) in the lift. He fell straight down out the lift and we got the nurse. On 1/16/20 at 1:05pm, V15 stated When he (R5) fell in (MONTH) (2019) we were using a sit to stand, he let go of the bars and he fell straight down out of the sit to stand. He was up and we told him to push up and use his knees and at times he was weak when using the sit to stand. On 1/16/20 at 1:15pm, V16 (Licensed Practical Nurse/MDS - Minimum Data Set Coordinator) verified there was no assessment performed on (R5) for the use of a sit to stand.

Based on observation, interview and record review the facility failed to follow its policy and wash hands in between glove changes, avoid touching clean items with soiled gloves, and avoid direct contact with a wound for one resident (R288) and failed to identify and assess a pressure ulcer wound for one resident (R31) of four residents reviewed for pressure wounds in the sample of 39. This failure resulted in a decline in R31's coccyx wound from incontinent [MEDICAL CONDITION] to an unstageable ulcerated wound. Findings include: 1. Physician order [REDACTED]. POS indicates order initiated on 10/8/19 to start Santyl (chemical [MEDICATION NAME] agent) to coccyx wound bed, apply Calazyme (protective cream) to periwound bed and cover with Xeroform (petroleum coated dressing) daily and as needed. On 10/24/19 at 9:40am V3 (Assistant Director of Nursing/Wound Nurse) changed the dressing on R31's coccyx. Coccyx wound was larger than a fifty cent piece, ulcerated with defined edges and thick layer of adherent yellow slough in the wound bed. After the wound was cleaned with normal saline, the layer of slough remained intact in the wound bed. At that time V3 stated (V11) is calling this incontinent [MEDICAL CONDITION]; that's not slough in the wound bed - it's Calazyme. V3 stated they are not staging or calling the wound a pressure ulcer. Weekly Pressure Ulcer Tracking Log does not include R31's ulcerated coccyx wound. Braden Score - Pressure Sore Risk assessment dated [DATE] indicates R31 at High Risk for developing pressure ulcers. On 10/25/19 at 8:50am V11 (Nurse Practitioner/Wounds) stated R31's coccyx wound started out as incontinent [MEDICAL CONDITION] and has declined to the wound it is now. V11 stated that the adherent coating in R31's wound bed is slough, which is why he ordered the Santyl, stating The appropriate treatment to debride the layer of slough. V11 stated that pressure is part of the problem as well as moisture. V11 stated that he has detailed typed notes after each wound round that include notes indicating that if the ordered treatment was in place and done as it should be the wound would not have declined as it did. V11 stated he has seen several times during rounds that R31's dressing was not in place and positioned off of the wound. V11 stated that it was avoidable for the wound to decline from [MEDICAL CONDITION] to what it is now. V11 agreed the wound is not stageable at this time due to the thick layer of adherent slough in the wound bed. None of V11's detailed wound notes were presented by the facility or found as part of R31's medical record. V3 presented unsigned, handwritten, abbreviated notes that V3 stated were written by V11. No weekly wound notes were presented documenting assessments of R31's coccyx wound. Facility Policy/Pressure Ulcers/Wounds (undated) indicates: Wound nurse will generate weekly wound report. Facility Policy/Wound Care dated 2010 indicates: The following information should be recorded in the resident's medical record: 6. All assessment data (i.e., wound bed color, size, drainage, etc.)obtained when inspecting the wound. 2. The facility's Wound Care policy, revised (MONTH) 2010, states, 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves . 7. Use no-touch technique . 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. The facility's Standard Precautions policy, revised (MONTH) 2007, states, Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. R288's current Physician order [REDACTED]. On 10/22/19 at 01:32 PM, V2 (Director of Nursing) entered R288's room to change a coccyx wound dressing. V2 removed R288's coccyx wound dressing, removed V2's soiled gloves and then placed on clean gloves with no handwashing occurring prior. V2 then cleansed the coccyx wound with gauze pads and normal saline. V2 removed V2's soiled gloves and placed on clean gloves, with no handwashing occurring prior. V2 then applied the Collagen powder with V2's gloved hand directly to R288's wound bed. After touching R288's wound bed directly, V2 reached into V2's right pocket with same soiled gloves to locate a marking pen to date R288's wound dressing. V2 again changed gloves without handwashing and disposed of R288's biohazard bag. V2 then washed V2's hands in the nearby sink. On 10/22/19 at 01:49 PM V2 (DON) stated, That would have been better; I should have washed (my hands in between glove changes). I shouldn't have reached into my pocket (with soiled gloves on). I hadn't used that powder. I used my fingers and probably shouldn't have. That makes more sense.

Based on observation, interview, and record review, the facility failed to monitor pain, establish control of severe pain, and administer pain medication for two of three residents (R91, R251) reviewed for pain in the sample of 24. These failures resulted in R251 experiencing uncontrolled, excruciating pain during wound treatments. Findings include: The facility's Pain Assessment and Management policy, dated 3/2015, documents, The pain management program is based on a facility-wide commitment to resident comfort. 'Pain Management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain; Effectively recognizing the presence of pain; Identifying the characteristics of pain; Addressing the underlying causes of the pain; Developing and implement approaches to pain management; Identifying and using specific strategies for different levels and sources of pain; Monitoring for the effectiveness of interventions; and Modifying approaches as necessary. 1. R251's Hospital History and Physical, dated 11/29/18, documents, Assessment/Plan: Bilateral lower extremity [MEDICAL CONDITION], continue IV (Intravenous) antibiotics with [MEDICATION NAME] (antibiotic), continue wound care daily, infectious disease is following up on recommendations. Continue pain medications to provide supportive care. R251's Hospital discharge orders, dated 12/3/18, document that R251 was discharged from the hospital with an order to receive [MEDICATION NAME] (narcotic pain medication) 7.5/325 mg (milligrams) one or two tablets by mouth every four hours as needed for pain. R251's Pain Questionnaire, dated 12/4/18, documents that R251 has daily severe pain. R251's Comprehensive Pain Assessment, dated 12/4/18, documents that R251 has chronic frequent pain rating at a 9 out of 10 in R251's bilateral lower legs. R251's Emergency Department After Visit Summary, dated 12/9/18, documents reason for visit: leg pain. The Summary also documents to stop taking [MEDICATION NAME] 7.5/325 mg and start taking [MEDICATION NAME] 5/325 mg every four hours as needed for pain. On 12/10/18 at 12:11 PM, R251 stated, I came in with [MEDICATION NAME] but (V14 Medical Director) cut it in half to 1 pill as needed for pain. The pain is really bad in my leg wounds. I need something more than just one. I went to the hospital last weekend because of the pain and they gave me a new prescription for [MEDICATION NAME]. I threw it away thinking I didn't need it because the facility already had the prescription for [MEDICATION NAME]; well that wasn't true so I haven't received any pain pills since last night, nothing even over the counter. The pain is 10+ (scale of 0-10) at this point. It's burning and excruciating pain. Just imagine burning your finger on a hot stove and it's all over your calf. The pain pill last night helped for a bit but its worn off. I didn't get a whole lot of sleep last night with the pain. If I can't get anything today there will be no sleep tonight. They aren't telling me anything of when I will be able to have something. On 12/11/18 at 11:45 am. R251 was up in his motorized wheel chair with his bilateral lower legs wrapped with ace bandages soiled with yellow drainage. R251 elevated his right leg on the bed. R251 stated, This is really going to hurt. V13 (Licensed Practical Nurse) began unwrapping R251's leg. R251 was grabbing the arm rests on his wheel chair jumping with each touch, furrowed brows, and closed eyes. R251 stated, I wish I had a leather belt to bite on so I don't scream. R251's entire right lower leg was reddened with scattered open areas actively draining a clear yellow liquid. V13 cleansed R251's leg with normal saline and R251 continued to jump and moan with furrowed brows. V13 applied four sheets of calcium alginate silver to R251's leg. V13 applied ABD (abdominal) pad and wrapped his leg with kerlix. R251 then propped his left leg onto the bed. R251 stated, I am so sorry; I'm not in a good mood. The pain is so bad its excruciating. A staff member knocked at the door and offered R251 his lunch tray. R251 stated, Please don't even bring it in here. I can't eat lunch. I am so nauseous from the pain. I haven't gotten my pain pills since Sunday after I got back from the hospital. V13 stated, I gave him a prn (as needed) Tylenol about 15 minutes before we started the treatment. V13 began removing the soiled dressing from R251's left leg. R251's entire lower leg was reddened with scattered open areas actively draining a clear yellow liquid. R251 stated, Just get it off this hurts so bad. V13 began cleansing R251's leg with normal saline. R251 stated, This hurts even more when you clean it. V13 stated, You should be glad we don't have to scrub it anymore. As V13 continued to cleanse it, R251 stated Oh my f***ing god this hurts. V13 responded back, Are you ok? R251 stated, No I'm not ok; this hurts like holy hell. V13 applied the calcium alginate silver, ABD pad, and wrapped his leg with kerlix. R251 continued to writhe with each touch and moaning. With tears in his eyes R251 said, I'm sorry; this just hurts. V13 removed a dry dressing from R251's right great toe. A round open area was on top of R251's toe. V13 cleansed it with normal saline and applied a gauze dry dressing. All of R251's treatments took approximately 45 minutes. On 12/11/18 at 12:35 PM, V13 stated, R251 was receiving [MEDICATION NAME] 7.5/325 mg two tablets every four hours until he went to the hospital Sunday night with uncontrolled pain. He was sent back actually with a reduction in his pain medication to [MEDICATION NAME] 5/325 mg one tablet every 4-6 hours as needed. He had the written prescription when he came back, but he claims he tore it up thinking that the medication he already had was the same thing. The order was changed so we couldn't give him the [MEDICATION NAME] 7.5/325 mg that we had. He has not received any [MEDICATION NAME] since Sunday. V13 also confirmed that it took 45 minutes to complete all of R251's treatments like usual. On 12/12/18 at 11:52 AM, R251 stated that he still hasn't received any PRN [MEDICATION NAME], and that his pain is currently at a 10. R251 stated, The pain is excruciating and burning. R251 also stated, It's awful during dressing changes. I'm in agony and its like a 17+ at that time. R251's MAR (Medication Administration Record), dated 12/2018, documents that R251 was receiving the prn [MEDICATION NAME] 7/325 mg on a daily basis prn and the last dose of prn [MEDICATION NAME] 7/325 mg R251 received was on 10/9/18. R251's MAR indicated [REDACTED]. There also is no documentation of R251 receiving any pain medication prior to R251's wound care on 12/11/18. R251's MAR indicated [REDACTED]. R251's Pain Care plan, dated 12/10/18, documents, Potential for ineffective pain management related to the following Diagnoses: [REDACTED]. However, R251's care plan has no documentation of interventions to address R251's pain. On 12/12/18 at 02:30 PM, V2 (Director of Nursing) stated, R251 went to the hospital Sunday and they discontinued the [MEDICATION NAME] 7.5/325 mg and wrote the script for the [MEDICATION NAME] 5/325. Generally we would medicate them before the dressing change but we have virtually no pain medication order. We should have called the physician (V14); he is our medical director. On 12/13/18 at 09:26 AM, V14 stated, R251 should not have gone without pain medication for that long without communicating with me. He needs a pain plan and this takes communicating with me everything he has going on so we can decide the appropriate treatment. I wasn't aware that he was having that much pain. 2. R91's current electronic Medical [DIAGNOSES REDACTED]. R91's current physician's orders [REDACTED]. On 12/10/18 at 11:00 AM, R91 was sitting in R91's wheelchair leaning against a cushion positioned on R91's left side. R91 stated that the facility does not do a good job of managing R91's pain. R91 stated that R91 has frequent pain to R91's right hip and does not get R91's pain medication on a consistent manner. R91's Medication Administration Record [REDACTED]. This record also documents the following statement on 12/7/18 and 12/10/18: [MEDICATION NAME] not available. On 12/12/18 at 1:45 PM, V10 (Licensed Practical Nurse) verified that R91's Medication Administration Records indicated that R91's [MEDICATION NAME] had not been administered from 12/7/18- 12/11/18. V10 stated, It (the [MEDICATION NAME]) has not been available due to insurance reasons. V10 verified that R91 had not received R91's prescribed pain medication and that alternative pain medication had not been given.

Based on interview and record review, the facility failed to recognize an allegation of verbal abuse, failed to protect one resident (R1) from verbal abuse by E5 (C.N.A./Certified Nurse Aide), failed to investigate an allegation of verbal abuse and failed to report an allegation of verbal abuse to the State Agency. This failure resulted in E5 continuing to work and verbally abuse R1. This failure has the potential to affect all residents residing on the second, third and fourth floor (R1-R84) where E5 continued to work. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 11/13/17, the facility remains out of compliance at a severity level 2, as the facility is still educating management and staff on recognizing abuse, protecting residents during an allegation of abuse, investigating allegations thoroughly and reporting the allegations of abuse to the State Agency. FINDINGS INCLUDE: R1's facility Admission Record documents that R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Admission physician's orders [REDACTED]. R1's current Minimum Data Set assessment, dated 10/25/17, documents R1's Brief Interview for Mental Status (Cognition) as 15 (cognitively intact). R1's Care Plan, dated 10/17/17 documents, (R1) has a diagnosis/history of depression, personality disorder, [MEDICAL CONDITION] and anxiety with prior suicidal ideational. Interventions for staff to follow include, Administer medication as ordered. Allow for independence within safety bounds. Allow resident to express feelings. Approach resident in a calm manner, Assure resident that he/she is in a safe and secure environment with caring professionals. Monitor for signs/symptoms of depression (tearfulness, restlessness and anxiety). Monitor/document/report (as needed) any risk for harm to self: sense of hopelessness or helplessness. Use encouraging words when speaking with resident. On 11/7/17 at 10:05 A.M., R1 stated, I've been here about a month. From the minute I walked in, it felt like a different place than where I came from. It was calm and the staff were kind. Then I met (E5). (E5) is a CNA (Certified Nursing Assistant) on third shift and she usually works here (fourth floor). (E5) is so loud on third shift. (E5's) voice is loud, (E5) slams things around. I have even spoken to (E2) (Director of Nurses) about how loud (E5) is. Well evidently (E5) found out I complained about (E5) and one night (11/1/17), it was around 11:30 (at night) me, (E3) (Certified Nursing Assistant) and (E6) Licensed Practical Nurse were talking about something and laughing. (E5) got mad and started slamming a bedside table and chair and said, 'And you complain about me being loud.' Then (E5) started yelling at me. I was so upset. My anxiety was out the roof. Then (E5) said, 'I can't stand her (R1).' (E5) was pointing at me. I felt terrible about that. (E5) made me feel bad about myself. I came here to get help with my anxiety, not to get yelled at by the staff. (E6) Licensed Practical Nurse (LPN) was trying to calm me down. (E6) gave me the telephone number for (E2) Director of Nurses. I told (E2) about it and (E2) said (E2) would look into it. (E2) told all of us to write statements about what happened and give them to (E6). Then they made (E5) leave the floor and go work another floor. (E5) was mad. (E5) was yelling, 'I might be leaving now, but I will be back on Tuesday.' I haven't seen (E5) since, but tonight is Tuesday and (E5) is supposed to be back. I hope not. I don't want to be around (E5). When (E5) left that night, they sent (E10), (E5's daughter) up to work the floor. And (E5) even came back to the floor later to talk to (E10). I saw them outside of my door. It made me very uncomfortable. R1's Medication Administration Record, [REDACTED].M. due to anxiety. On 11/7/17 at 1:15 P.M., E3 Certified Nursing Assistant (CNA) stated, On that night (11/1/17), (E5) was being loud saying (E5) wasn't going to be sitting next to the nurse's station because (E5) didn't like (E6) LPN or (R1). At one point me, (E6) and (R1) were laughing at something. (E5) got mad and started dragging (E5's) chair very aggressively down the hall, away from the nurse's station. (E5) was being loud and disruptive. (E5) snatched (E5's) fan up and started yelling at R1, 'I don't even like you. I can't stand you.' I stepped in between (E5) and (R1) because (E5) was mad and I wasn't sure what (E5) was going to do to (R1). (R1) was very upset. (R1) called the On-Call nurse, who was (E2) (Director of Nurses). (E4) (Registered Nurse) came up and told (E5) to go to the third floor and (E10) (E5's daughter) came up and worked the fourth floor. (E6) LPN told me to write a statement of what happened and (E6) gave it to (E2) for me. I went outside to smoke and took (R1) with me. (R1) was very upset with (E5) talking to (R1) like that. (R1) was worked up. (R1) had to take an [MEDICATION NAME] (anti anxiety) to calm down. (E5) came back up to the fourth floor two more times that night after (E5) was told not to. On 11/8/17 at 5:50 A.M., E4 (Registered Nurse) RN stated, I remember an incident involving (R1) and (E5). It happened last week. It was around midnight. I got a call from (E2), the Director of Nursing. (E2) said there had been an altercation between (R1) and (E5) and I was to tell (E5) to move to the third floor and (E10) was to go to the fourth floor. I went to the fourth floor to tell (E5) to move. (E5) wasn't happy about it. (E5) has been here for awhile and (E5) always works the fourth floor. (E5) has a loud voice. (E5) told me that (E5) had gone back to the fourth floor because (E5) left (E5's) jacket there. On 11/8/17 at 6:10 A.M., E5 stated, I have worked here for the past six years. I work full time on the fourth floor. Things have been going pretty good until (R1) got here. (R1) is an instigator and a liar. (R1) and (E6) are always ganging up on me. I remember the night that (R1) and I got into it. I was sitting in the hallway. I had a bedside table in front of me so I could work. (R1), (E6) LPN, (E3) CNA and R2 were at the nurse's station laughing loudly. I knew (R1) had made a complaint to (E2) DON about me being too loud. Well I said something to them about being too loud. (R1) didn't like it and got mouthy with me. I got up and drug my chair and table further down the hall, to get away from them. All I know is I got yanked off the floor around midnight and made to work the third floor. I wasn't happy about that. I have the fourth floor organized and I know my people. I went back to the fourth floor around 1:30 or 2:00 o'clock to talk to (E10). I just ignored (R1). I had to go back up there again around 4:00 or 4:15 to get socks. I just got back from vacation and worked the fourth floor last night. On 11/8/17 at 6:20 A.M., E6/LPN stated, I was working the night of November first and I witnessed the altercation between (R1) and (E5). I have worked with (E5) many times. (E5) is loud and abrasive. On that night, before midnight, me, (E3) CNA, (R1) and (R2) were at the nurse's station. We were laughing at something (R2) said. (E5) was sitting across from the nurse's station with a bed side table in front of (E5), doing something. (E5) got mad because we were laughing and said something about, '(R1) reports me for being loud.' (R1) said, 'Excuse me.' And (E5) yells it then, 'You report me for being loud.' Then (E5) said to (R1), 'I can't stand you anyway.' (R1) got very upset. (R1) said it was embarrassing. (E5) jumped up and drug the chair, loudly, further down the hall. (R1) saw the On-Call Nurse's phone number on the wall and called (E2) DON. Evidently (E2) called back and talked to the second floor supervisor (E4) RN and told (E4) to move (E5) to the third floor. (E10) came up from the third floor to work the fourth floor. (R1) said (R1) was very uncomfortable with that. (R1) knew (E10) was (E5's) daughter. When (E5) got pulled off the floor around midnight, (E5) was yelling, 'I might have to leave now, but you can bet, I will be back here on Tuesday.' Me, (R1) and (E3) all wrote statements. I made copies of them because things have a way of disappearing around here. I put a copy of each of our statements under (E2's) door and (E1's) door. (E5) ended up coming back to the fourth floor twice that night. One time around 1:00 to talk to (E10). (R1) was still up at the nurse's station. (R1) said that it made (R1) very uncomfortable that (E5) was back. (E5) kept watching (R1). (E5) was very aggressive. (E5) was mad (E5) got pulled off the floor. (E5) came back again around 4:00 or 5:00 o'clock. (R1) was sleeping at that time. (E5) was back on the fourth floor last night and (R1) said (R1) was very uncomfortable with (E5) being there. Neither (E1) Administrator nor (E2) Director of Nursing have ever contacted me to talk about that incident of November 1st. On 11/8/17 at 9:50 A.M., E2 Director of Nurses (DON) stated, (R1) called me one night around midnight (11/1/17). (R1) had a concern with (E5). I was really upset that (R1) was calling me. I don't know how (R1) got my personal cell phone number. (R1) told me (E5) was being loud and yelling at (R1), something about (E5) not liking (R1). (R1) was pretty upset. I told (R1) I would call back to the facility and talk to the third shift supervisor (E4) and have (E4) check it out. I told (E4) to calm things down and move (E5) to another floor or send (E5) home. There has been on-going friction between the two of them. (R1) is talking about moving to another facility and we think that would be the best thing. (R1) causes a lot of problems. No, I did not talk to the nurse (E6) on duty about this or the other staff that was there. I don't have an investigation for this incident. I didn't talk later to (R1) about it either. I did not report this to the state (agency). I really don't consider this abuse. On 11/8/17 at 10:10 A.M., E1 Administrator stated, I am not aware of a situation involving (R1) and (E5), involving verbal abuse. This incident was not investigated or reported. (E5) should have been sent home that night and been fired for talking to a resident like that. On 11/8/17 at 2:15 P.M., E1 Administrator stated, I wanted to ask you, is verbal abuse really abuse? Does it justify firing this CNA (E5) and having (E5's) record marred? What would you do? Should I just have (E5) work on another floor? On 11/8/17 at 3:10 P.M., R1 stated, It was very awkward last night. (E5) came back from vacation and worked this floor. I tried to stay away from (E5) but (E5) kept saying to me, 'Are you going to go to bed yet. Aren't you ready to go to bed yet.' (E5) wouldn't leave me alone. (E5) got me so upset. How long is this going to go on? Don't I have the right to feel safe? Then the Administrator (E1) and the Director of Nurses (E2) just called me into the office asking me if I wanted (E5) to lose (E5's) job and leave here with a mark on (E5's) record. It's not up to me to decide. Don't they have rules in place? They shouldn't even be asking me what I want them to do. This whole thing is so upsetting to me. My anxiety is out the roof now. I'm trying to get better so I can go home. A month ago I was really depressed and wanted to end things. When I moved here, I thought things were getting better. Now I'm starting to slide down hill again. On 11/8/17 at 4:00 P.M., E9 Corporate Manager stated, (R1) needs to go. (R1) is nothing but a trouble-maker. The sooner we can get (R1) out of here, the better off we will be. The facility Time Card Report dated 11/7/17 documents that E5 punched in to work at 9:54 P.M. and punched out at 6:18 A.M. The facility Staffing Worksheet dated 11/7/17 documents (E5) was assigned to work as a CNA on third shift, on the fourth floor. This information was verified by E2 DON. The facility Time Card Report dated 11/8/17 documents that (E5) punched into work at 10:00 P.M. and punched out at 6:24 A.M. The facility Staffing Worksheet dated 11/8/17 documents that (E5) was assigned to work as a CNA on the third shift, on the second floor. This information was verified by E2 DON. The Facility Roster, dated 11/7/17 and verified by E2 Director of Nurses documents R10-R29 as residing on the second floor, R30-R59 as residing on the third floor and R1-R9, and R60-R84 as residing on the fourth floor. The Immediate Jeopardy was identified to have begun on 11/01/17 when E5 (C.N.A.) was verbally abusive towards R1 and the facility failed to recognize this as verbal abuse. The facility did not investigate the allegation, did not implement interventions to protect the residents and did not report the abuse to the State Agency. E1 Administrator was notified of the Immediate Jeopardy on 11/13/17 at 10:00 AM. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediacy: Actions Completed November 8th through November 10th, 2017 by E1 Administrator: * All staff were educated on the facility Abuse Policy, specific to the prevention of abuse, to identifying and investigating, the timely reporting of abuse and immediate discipline and/or removal of the perpetrator. * E5/Certified Nursing Assistant was suspended pending the outcome of the investigation. * A complete investigation into this allegation was completed by the facility with a preliminary and a final report to be forwarded to the State Agency (report received 11/13/17). * The facility Administrator received a complete copy of the facility Abuse Policy and was inserviced on this by the Regional Director of Operations, prior to the Administrator giving the staff in-service training. Actions Started on November 8th through 10th, 2017 by E1 Administrator and E2 Director of Nurses: * Continue 100% education with new hires during orientation (all departments) on the facility Abuse Policy specific to prevention of abuse, to identify/investigate, timely report, immediate discipline and/or remove said employee and/or resident. (Monitoring) Actions Started on November 8th through 10th, 2017: * The Administrator/designee will immediately investigate all allegations of abuse per the facility Abuse Policy specific to preventing, identifying, reporting timely and immediate removal of resident and/or employee. Actions Started on November 8th through 10th, until all staff are educated prior to returning to duty by E1 Administrator and E2 Director of Nurses: * Continue 100% education with all staff prior to their reporting to duty on Abuse Policy and Procedures related specifically to prevention of abuse, to identify/investigate, timely report, immediate discipline and/or remove said employee and/or resident. * Staff on vacation, leave of absence, new hires and PRN (as needed) staff will receive education prior to reporting to their area for work. * The QAPI (Quality Assurance and Performance Improvement) Committee will meet monthly to review any infraction in following the facility Abuse Policy and Procedure.

Based on interview and record review the facility failed to ensure that (R1) was not verbally abused by E5/Certified Nursing Assistant. This failure resulted in R1 having extreme anxiety requiring medication to alleviate R1's anxiety. FINDINGS INCLUDE: R1's facility Admission Record documents that R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Admission physician's orders [REDACTED]. R1's current Minimum Data Set assessment, dated 10/25/17, documents R1's Brief Interview for Mental Status (Cognition) as 15 (cognitively intact). R1's Care Plan, dated 10/17/17 documents, (R1) has a diagnosis/history of depression, personality disorder, [MEDICAL CONDITION] and anxiety with prior [MEDICAL CONDITION]. Interventions for staff to follow include, Administer medication as ordered. Allow for independence within safety bounds. Allow resident to express feelings. Approach resident in a calm manner, Assure resident that he/she is in a safe and secure environment with caring professionals. Monitor for signs/symptoms of depression (tearfulness, restlessness and anxiety). Monitor/document/report (as needed) any risk for harm to self: sense of hopelessness or helplessness. Use encouraging words when speaking with resident. On 11/7/17 at 10:05 A.M., R1 stated, I've been here about a month. From the minute I walked in, it felt like a different place than where I came from. It was calm and the staff were kind. Then I met (E5). (E5) is a CNA (Certified Nursing Assistant) on third shift and she usually works here (fourth floor). (E5) is so loud on third shift. (E5's) voice is loud, (E5) slams things around. I have even spoken to (E2) (Director of Nurses) about how loud (E5) is. Well evidently (E5) found out I complained about (E5) and one night (11/1/17), it was around 11:30 (at night) me, (E3) (Certified Nursing Assistant) and (E6) Licensed Practical Nurse were talking about something and laughing. (E5) got mad and started slamming a bedside table and chair and said, And you complain about me being loud.' Then (E5) started yelling at me. I was so upset. My anxiety was out the roof. Then (E5) said, 'I can't stand her.' (E5) was pointing at me. I felt terrible about that. (E5) made me feel bad about myself. I came here to get help with my anxiety, not to get yelled at by the staff. (E6) Licensed Practical Nurse (LPN) was trying to calm me down. (E6) gave me the telephone number for (E2) Director of Nurses. I told (E2) about it and (E2) said (E2) would look into it. (E2) told all of us to write statements about what happened and give them to (E6). Then they made (E5) leave the floor and go work another floor. (E5) was mad. (E5) was yelling, 'I might be leaving now, but I will be back on Tuesday.' I haven't seen (E5) since, but tonight is Tuesday and (E5) is supposed to be back. I hope not. I don't want to be around (E5). When (E5) left that night, they sent (E10), (E5's daughter) up to work the floor. And (E5) even came back to the floor later to talk to (E10). I saw them outside of my door. It made me very uncomfortable. R1's Medication Administration Record, [REDACTED].M. due to anxiety. On 11/7/17 at 1:15 P.M., E3 Certified Nursing Assistant (CNA) stated, (R1) called the On-Call nurse, who was (E2) (Director of Nurses). (E4) (Registered Nurse) came up and told (E5) to go to the third floor and (E10) (E5's daughter) came up and worked the fourth floor. (E6) LPN told me to write a statement of what happened and (E6) gave it to (E2) for me. I went outside to smoke and took (R1) with me. (R1) was very upset with (E5). talking to (R1) like that. (R1) was worked up, (R1) had to take an [MEDICATION NAME] (anti anxiety) to calm down. (E5) came back up to the fourth floor two more times that night after (E5) was told not to. On 11/8/17 at 6:10 A.M., E5 stated, I have worked here for the past six years. I work full time on the fourth floor. Things have been going pretty good until (R1) got here. (R1) is an instigator and a liar. (R1) and (E6) are always ganging up on me. I remember the night that (R1) and I got into it. I was sitting in the hallway. I had a bedside table in front of me so I could work. (R1), (E6) LPN, (E3) CNA and R2 were at the nurse's station laughing loudly. I knew (R1) had made a complaint to (E2) DON about me being too loud. Well I said something to them about being too loud. (R1) didn't like it and got mouthy with me. I got up and drug my chair and table further down the hall, to get away from them. All I know is I got yanked off the floor around midnight and made to work the third floor. I wasn't happy about that. I have the fourth floor organized and I know my people. I went back to the fourth floor around 1:30 or 2:00 o'clock to talk to (E10). I just ignored (R1). I had to go back up there again around 4:00 or 4:15 to get socks. I just got back from vacation and worked the fourth floor last night. On 11/8/17 at 6:20 A.M., E6/LPN stated, I was working the night of November first and I witnessed the altercation between (R1) and (E5). I have worked with (E5) many times. (E5) is loud and abrasive. On that night, before midnight, me, (E3) CNA, (R1) and (R2) were at the nurse's station. We were laughing at something (R2) said. (E5) was sitting across from the nurse's station with a bed side table in front of (E5), doing something. (E5) got mad because we were laughing and said something about, '(R1) reports me for being loud.' (R1) said, 'Excuse me.' And (E5) yells it then, 'You report me for being loud.' Then (E5) said to (R1), 'I can't stand you anyway.' (R1) got very upset. (R1) said it was embarrassing. (E5) jumped up and drug the chair, loudly, further down the hall. When (E5) got pulled off the floor around midnight, (E5) was yelling, 'I might have to leave now, but you can bet, I will be back here on Tuesday.' (E5) ended up coming back to the fourth floor twice that night. One time around 1:00 to talk to (E10). (R1) was still up at the nurse's station. (R1) said that it made (R1) very uncomfortable that (E5) was back. (E5) kept watching (R1). (E5) was very aggressive. (E5) was mad (E5) got pulled off the floor. (E5) came back again around 4:00 or 5:00 o'clock. (R1) was sleeping at that time. (E5) was back on the fourth floor last night and (R1) said (R1) was very uncomfortable with (E5) being there. Neither (E1) Administrator or (E2) Director of Nursing have ever contacted me to talk about that incident of November first. On 11/8/17 at 3:10 P.M., R1 stated, It was very awkward last night. (E5) came back from vacation and worked this floor. I tried to stay away from (E5) but (E5) kept saying to me, 'Are you going to go to bed yet. Aren't you ready to go to bed yet.' (E5) wouldn't leave me alone. (E5) got me so upset. How long is this going to go on? Don't I have the right to feel safe? Then the Administrator (E1) and the Director of Nurses (E2) just called me into the office asking me if I wanted (E5) to lose (E5's) job and leave here with a mark on (E5's) record. It's not up to me to decide. Don't they have rules in place? They shouldn't even be asking me what I want them to do. This whole thing is so upsetting to me. My anxiety is out the roof now. I'm trying to get better so I can go home. A month ago I was really depressed and wanted to end things. When I moved here, I thought things were getting better. Now I'm starting to slide down hill again.

Based on record review and interviews the facility failed to prevent a fall for one of three residents sampled for fall risk in a sample of three. (R1) On 9/114/17 R1 was left alone on the toilet and fell . R1 sustained a left distal femur fracture. Findings include: R1's fall risk sheet dated 9/1/17 noted R1 at High Risk for Falling. R1's current care plan dated 8/8/17 noted that R1 is at risk for cognitive function/dementia or impaired thought process related to disease process, urinary tract infections, and periods of confusion. R1's incident report form dated 9/14/17 notes that, Patient (R1) transferred to toilet per request, staff member (E4 Certified Nurse's Aide) remained with resident (R1) while on toilet. Upon completion of voiding, staff (E4) stepped out of bathroom to obtain additional staff to assist with transfer. When staff returned to bathroom, resident (R1) was noted in sitting position on the bathroom floor next to the toilet. Resident (R1) assessed and noted to have hip discomfort. Sent to ER per orders. X-ray at (local hospital) noted left distal femoral fracture, surgical intervention planned for Sept. 15, 2017. Immediate intervention put in place for patient (R1) not to be left unattended on toilet. Hospitalist note dated 9/15/17 reads, Impression: Left distal femur fracture secondary to a fall. On 10/13/17 at 11:44 A.M. E2 (Director of Nursing) stated that on 9/14/17 at approximately 2:00 P.M. R1 was left unattended on the toilet by E4 while E4 went to get help to transfer R1 off the toilet. When E4 returned to the bathroom R1 was on the floor. E2 stated that R1 should not have been left unattended on the toilet due to R1's confusion.

Based on record review and interviews, the facility failed to maintain a door alarm in the on mode for one (R1) of three residents sampled for fall risk. On 7/28/17 R1 wheeled self into the back stairwell on the third floor and fell down one flight of stairs. R1 suffered a Left parfalcine acute subdural hematoma and Intraventricular hemorrhage. Findings include: R1's current Minimum Data Set ((MDS) dated [DATE] notes R1 to have a [DIAGNOSES REDACTED]. MDS notes that R1 has a history of wandering and uses a wheelchair for means of mobility. R1 scored a five out of a total of 15 on the BIMS (Brief Interview for Mental Status) test, indicating that R1 is severely cognitively impaired. Facility incident report form dated 7/28/17 reads, Resident (R1) had fall evening of 7/28/17. Physician notified and order received to send resident (R1) to ER due to hip discomfort. Neuros and vitals WNL (within normal limits) immediately follow. Pelvic x-ray - (negative) at ER, however CT (Computed Tomography Scan) noted multiple hematomas/Hemorrhages. Hospital Neurological notes that R1 had, Fall with Left paragalcine acute subdural hematoma, Intraventricular hemorrhage. On 8/17/17 at 2:20 P.M. E6 (Certified Nurse's Aide) stated that on 7/28/17 at approximately 6:30 P.M., staff noticed that R1 was unable to be located. At that time a facility wide search began. At approximately 6:42 P.M. R1 was found by E6 in the back stairwell, lying at the landing of the stairwell and bleeding from R1's head. E6 stated that R1's wheelchair was at the top of the stairs and the alarm on the door to the stairs had been shut off. E6 stated that R1 was confused and unable to state what exactly had happened. E6 stated that the door alarm is never to be shut off in order to alarm if a confused resident was to open the door. On 8/11/17 at 11:10 A.M. E1 (Administrator) stated that through her questioning staff, E1 had found out that staff must have shut off the alarm prior to R1 opening the door and falling down the back stairwell. E1 stated that the door alarm should not have been turned off and that the alarm has been glued permanently in the On position.

Based on interview and record review, the facility failed to protect one resident (R1) from financial abuse by a staff member. R1 was one of three residents reviewed for abuse in a sample of three. This failure resulted in R1 being convinced to sell R1's home to a staff member's husband for significantly less then it's value; which caused emotional upset for R1. Findings include: The facility policy, Abuse prevention Program, dated (2/7/17) directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation , misappropriation of property and mistreatment of [REDACTED]. The resident gave something of value to someone, or entered into a legally binding promise to give the person something of value without getting fair value in exchange. R1's facility Admission Record, documents that R1 was admitted to the facility on [DATE], as Medicaid-pending, with the following Diagnosis: [REDACTED]. R1's Social Services Notes, dated 6/2/15 document, SSD (Social Services Director) contacted resident's mother per resident's request to set up a care plan meeting to discuss residents house and staying here long term. R1's Social Services Notes, dated 6/4/15 document, Had meeting with (R1) and the family to discuss that (R1) may be here long term due to (R1)'s needs, assists with transfers, is a fall risk. The BOM (E3/Business Office Manager) wanting (R1) to be aware that (R1) may have to sell (R1)'s house. (R1) was upset and is trying to get stronger so (R1) can go home. R1's Social Services Notes, dated 7/20/15 document, BOM (E3/Business Office Manager) stated to (R1) that (R1) is going to have to sell (R1)'s home due to (R1) not returning to the home. R1's facility financial file contains a Notice of Property Assessment, dated 2015 documenting R1's property as Full fair market value of the property is $82,769. R1's facility financial file contains a Real Estate Settlement Statement, dated 4/19/16 documenting the purchase price of R1's home as $10,000. On 7/5/17 at 9:55 A.M., Z1 (R1's mother) stated, I haven't heard that (R1's house) is sold. As far as I know, (R1) still owns it. On 7/5/17 at 2:35 P.M., E3/Business Office Manager stated, I had talked to (R1) and (R1)'s mother about selling (R1)'s home. (R1) knew it was coming. (R1) wasn't happy about it. I went to the house to show the realtor. The house was really bad. The realtor suggested it go through someone who could flip it. I can't remember the name of the realtor. I got ahold of (Z3), (E4/Social Services Director)'s husband. I have worked with (Z3) before selling houses. (Z3) said (Z3) had an attorney we could go through. The house was sold for $10,000. This is the amount that (Z3) and (Z3)'s attorney came back with. There was not an appraisal done on the house. (R1) did not have an attorney for the sale of the property. On 7/5/17 at 3:05 P.M., E1/Administrator stated, (E3/Co-Business Office Manager) told me (E3/Co-Business Office Manager) had done it before (sold another resident's house) with (Z3), when (E3/Co-Business Office Manager) was employed at another facility. On 7/5/17 at 3:10 P.M., Z2/County Assessor's Office stated, (R1's property) was sold in April 2016 for $10,000. The fair market value at that time was $82,769. That's what the property was worth. The property was recently sold again by (Z3) for $95,000. On 7/6/17 at 8:50 A.M., E1/Administrator stated, I saw (in the newspaper) where (Z3) had bought some property for $10,000 and the seller was (R1). E1/Administrator also stated, I thought it was another person. On this same date, at 10:15 A.M., E1/Administrator also stated, We do not have a policy prohibiting employees from entering into a business relationship with a resident. That is a given with employment. It should not happen. On 7/6/17 at 12:00 P.M., E5/Co-Business Office Manager stated, I heard (R1) was upset about the house being resold (in April 2017) for so much money. (R1) was crying that (R1)'s house was sold and (R1) couldn't go back home. On 7/6/17 at 2:45 P.M., R1 stated, (E3/Business Office Manager) said they would offer me $2,000 (for my house) and I took it. (E3) told me I could keep the money. (E3) told me I needed to sell it (my house). I didn't know there were other options, no one ever told me.

Based on interview and record review, the facility failed to have R1's wound assessed by the facility Registered Dietician and failed to follow facility policy and procedures for the assessment of pressure ulcers to promote the healing of after the development of a Stage IV pressure ulcer for one of three residents (R1) reviewed for pressure ulcers in the sample of three. This failure resulted in a worsening Stage IV pressure ulcer for R1. Findings include: The facility's undated Wound Care Policy documents the following: The facility wound care program takes into account the patient as a whole including - nutrition, Braden scale, Dietary supplements needed to heal wound, weight loss and changes seen in the wound each week. The facility's undated Braden Procedure policy documents the following: The Braden scale is reassessed and updated with any resident's change of condition. The facility's Dietary Consulting Services Agreement dated 2/27/14 documents the following: Whereas, the consultant provides consultation in the areas of regulatory compliance concerning food and nutrition services for skilled nursing and other health care facilities . R1's Nursing Note dated 8/14/16 documents, (R1's) coccyx area opened .(E3, Wound Nurse) was left message. Will see on rounds. R1's Wound Care Nursing Note dated 8/16/16 documents, Wound on coccyx .staged IV measuring 2.4 cm (centimeters) x 1.5 cm x 0.1 cm. 50% black, 25% yellow and 25% pink with large serosanguinous drainage . R1's Wound Care Nursing Note dated 8/30/16 documents, (E3) .assessed wound and measured. Wound deteriorated 100% eschar tissue with large serosanguinous drainage measuring 2.4 cm x 2.3 cm x 0.1 - 0.8 cm . R1's Braden Scale Assessment documents an assessment was last conducted on R1 on 8/4/16, 10 days prior to the discovery of R1's stage IV coccyx pressure ulcer. On 9/14/16 at 12:12 p.m., E3, Wound Nurse, confirmed that a Braden Scale Assessment was not conducted on R1 after the development of R1's stage IV pressure ulcer. R1's Quarterly Nutritional Assessment documents that R1 was last seen by Z1, Registered Dietician, on 5/23/16. On 9/13/16 at 11:58 a.m., Z1 stated that Z1 evaluates all residents who develop pressure ulcers at the facility. Z1 stated that Z1 comes to the facility twice a month, and was at the facility evaluating residents on the following dates: 8/9/16 and 8/23/16. Z1 stated that on 8/23/16, the facility provided Z1 with a list of residents with pressure ulcers. A copy of this list was provided by Z1, and R1 was not documented on this list. At this same time, Z1 verified that R1 was last evaluated by Z1 on 5/23/16 and that R1 was not seen when Z1 was at the facility on 8/23/16, after the development of R1's stage IV coccyx pressure ulcer on 8/14/16. On 9/13/16 at 11:56 a.m., E3, Wound Nurse, stated, (Z1) comes twice a month and sees all of the pressure ulcers. E3 then verified that R1 was not seen by Z1 after R1's stage IV coccyx pressure ulcer developed. On 9/14/16 at 9:22 a.m., Z2, Wound Physician's Assistant, stated that Z2 evaluated R1 twice. Z2 stated, The first time I saw (R1) I staged (R1's) coccyx pressure ulcer a stage IV. The following week it was a little better. And the following week I was out of town so I didn't see (R1) but apparently it (R1's pressure ulcer) was a lot worse. (R1) had poor nutritional intake. (R1) didn't eat or drink. I ordered (R1) a protein supplement, but it's always a good idea to be seen by a dietician. An appetite stimulant should have been offered at some point .Things like this shouldn't happen.

Based on record review and interviews the facility failed to monitor and catheterize one of three residents with [MEDICAL CONDITION]. This failure resulted in R3 being sent to hospital on [DATE] where R3 was noted to be in acute kidney failure. Findings include: According to facility Nurse's notes R3 was admitted to the facility on [DATE] and discharged on [DATE]. R3's physicians order sheet dated 9/15/15 notes that R3 had an order for [REDACTED]. On 10/2/15 at 1:00 P.M. E2 (Director of Nursing) stated that the facility was unable to provide documentation that they were monitoring R3's output of urine during the nine days R3 resided at the facility. E2 stated that the Intake and Output sheets should have been being done on R3, but were not. Nurse's note written by E5 (Licensed Practical Nurse) on 9/20/15 at 22:15 stated, No urinary output this 8 hour shift. On coming nurse advised. Will monitor. On 10/2/15 at 10:30 A.M. E5 stated that on 9/20/15 at the end of her shift E5 reported to E6 (Licensed Practical Nurse) that R3 had not urinated all shift. On 10/2/15 at 12:52 P.M. E6 stated she does not remember the night of 9/20/15 and verified that E6 did not follow up with a nurse's note regarding R3's [MEDICAL CONDITION]. On 10/2/15 at 1:00 P.M. E2 stated that E6 should have performed a intermittent catheterization on R3 since R3 had not urinated for over 8 hours. E2 stated that R3 was not catheterized during the nine days R3 resided at the facility. Facility treatment sheet dated 9/1/15 to 9/30/15 verified that R3 was not catheterized at the facility from 9/15/15 to 9/23/15. On 10/1/15 at 9:50 A.M. Z2 (R3's daughter) stated that due to R3's family being overall unhappy with the care at the facility, they transferred R3 to another Long Term Care facility on 9/23/15. Z2 stated that while R3 was being admitted to the new facility on 9/23/15, the new facility staff did a physical assessment on R3. The new facility staff found R3 to be in pain and to have a very distended abdomen. Z2 stated that the new facility staff got an order to catheterize R3 but found R3 to be in too much pain to catheterize. The new facility sent R3 to the hospital. The hospital emergency room notes from 9/23/15 note that R3 was catheterized for 2700 milliliters of urine. Hospital labs from 9/23/15 note R3 BUN (Blood Urea Nitrogen) level to be 104 mg/dl, with a normal range being 7 - 22 mg/dl. R3's Creatinine serum level was 13.57 mg/dl, with a normal range being 0.70 - 1.30 mg/dl. Hospital Clinical Impression was, Acute Kidney Injury. On 10/1/15 at 11:30 A.M. Z1 (emergency room Physician) stated that R3 had come to the emergency roiagnom on [DATE] with a distended abdomen and in pain. Z1 stated that after doing Laboratory results, it was evident that R3 was in Acute [MEDICAL CONDITION], which was due to a prolonged period of time without urinating.

Based on observation, interview and record review, the facility failed to provide unobstructed fire exits for three of four stairwell exits (Third Floor, Fourth Floor and Fifth Floor) used in fire evacuations. This failure resulted in potential harm for a total of 87 residents (R4, R9, R11 through R33, R91 and R92 residing on the Third Floor), (R8, R10 and R34 through R67 residing on the Fourth Floor) and (R23 and R68 through R90 residing on the Fifth Floor). These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 3/24/14, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. FINDINGS INCLUDE: On 3/24/15 at 9:43 A.M., a resident mechanical lift, three broken wheelchairs, a wooden chair, a broken recliner and two wooden tables were obstructing the fire exit door on the third floor of the facility, adjacent to the freight elevator. A lit sign above the door stated, "Fire Exit Door." A sign posted on the stairwell door read, "Do Not Block Fire Doors at Anytime." On 3/24/15 at 9:51 A.M., bedside tables, a floor model television, two wheelchairs, a broken high-back wheelchair, two upholstered chairs, a bed mattress, and a bariatric shower chair were obstructing the fire exit door on the fourth floor of the facility, adjacent to the freight elevator. A lit sign above the door stated, "Fire Exit Door." A sign posted on the stairwell door read, "Do Not Block Fire Doors At Anytime." On 3/24/15 at 10:51 A.M., a wheelchair, a high-back wheelchair, a padded restraint cushion and six broken over-bed tables were obstructing the fire exit door on the fifth floor of the facility, adjacent to the freight elevator. A lit sign above the door stated, "Fire Exit Door." A sign posted on the door read, "Do Not Block Fire Doors At Anytime." The facility form titled, "3rd Floor Evacuation Plan" instructs staff to evacuate residents residing in rooms 300, 301, 302, 308, 309, 310, 311, 312, 313, 314, 315, 316, 317, 318, 319, 320, 321, 322 and 322 via the stairwell, adjacent to the freight elevators, in case of an emergency. The facility form titled, "4th Floor Evacuation Plan" instructs staff to evacuate residents residing in rooms 400, 401, 402, 403, 404, 410, 411, 412, 413, 414, 416, 417, 418, 419, 420, 421, 422 and 423 via the stairwell, adjacent to the freight elevators, in case of an emergency. The facility form titled, "5th Floor Evacuation Plan" instructs staff to evacuate residents residing in rooms 500, 501, 502, 503, 504, 504, 511, 512, 513, 515, 516 and 517 via the stairwell, adjacent to the freight elevators, in case of an emergency. On 3/24/15 at 10:45 A.M., E6 (Licensed Practical Nurse/ Restorative Nurse) stated, " That (4th floor Fire Exit door) is an exit door to the stairwell. That door is not supposed to be blocked. This stuff shouldn't be here. For some reason staff keep throwing stuff back here." On 3/24/15 at 10:52 A.M., E14 (Certified Nursing Assistant) stated, "That stuff shouldn't be there. It is blocking the stairs (5th floor Fire Exit door). There is always stuff there. You couldn't get to those steps if you needed to." On 3/24/15 at 12:05 P.M., E23 (Certified Nursing Assistant) stated, " We always store stuff back here (3rd floor Fire Exit door). I have been here two years. It's always been like that." On 3/24/15 at 3:10 P.M., E3 (Maintenance Director) stated, "The fire exit doors should not be blocked. I don't know why staff keep putting stuff back there, blocking those doors. Those doors are fire exit doors. Each floor has a posted emergeny evacuation plan. Those are the resident rooms that evacuate to that stairway ( near the freight elevator). The (undated) facility policy, Code Red-Fire General Instructions for a Fire in the Facility directs staff, "Do not use elevators. Administration will call all elevators to the first floor and lock them off. Use the stairs only for evacuation of residents." The (undated) facility policy, Evacuation Plan directs staff, "There are three types of evacuation plans for (the facility): Horizontal, Vertical and Total Evacuation...Vertical Evacuation is the removal of residents, visitors, personnel from the emergency area to an area of refuge on another floor, preferably below the emergency, using appropriate stairwells...The order of evacuation will be as follows: All those in a life threatening situation. Ambulatory Residents...Wheelchair Residents...Bed Ridden Residents- These residents should be evacuated in the most appropriate of the following methods: Slide, Hip Carry, Packstrap Carry, Extremity Carry, Side-by-side. The facility roster, dated 3/24/15 includes the following 87 residents (R4, R9, R11 through R33, R91 and R92 residing on the Third Floor), (R8, R10 and R34 through R67 residing on the Fourth Floor) and (R23 and R68 through R90 residing on the Fifth Floor). On 3/24/15 at 4:00 P.M. an Immediate Jeopardy was identified to have begun on 03/24/15 when the facility failed to keep the fire exit doors unobstructed. On 3/24/15 at 4:10 P.M., E16 (Corporate Compliance Nurse) and E34 (Administrator) were notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the following actions to remove the Immediate Jeopardy: 1. Initiated 3/24/15, all facility staff have received education regarding the facility policy on Emergency Exit Policy and Procedure. Information covered includes: *Emergency exit doors will be monitored hourly by department heads when they are in the building. *When department heads are not here the nurses on each floor will monitor every two hours the emergency exit doors to ensure that they are kept clear of miscellaneous items. *If items are located in front of the emergency door they will be removed immediately to ensure that the emergency egress is kept clear. 2. Initiated 3/24/15, the facility Performance Improvement Risk Management Director in-serviced all department heads. 3. Initiated 3/24/15, Department heads in-serviced their employees. As of 3/25/15 84% of all facility employees had been in-serviced. 4. Initiated 3/24/15, staff will not be allowed to work until they receive the in-service.

Based on record review, observation and interview, the facility staff failed to follow their policy to report witnessed resident abuse by a staff member immediately to the facility administrator. E4 (Certified Nurse's Assistant) witnessed E3 (Registered Nurse) physically abuse R1 without protecting R1 from further abuse and failed to immediately report abuse of R1 to facility administrator. This failure resulted in R1 having bruising on R1's upper left cheek under left eye. This has the potential to affect all residents in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 02-24-15 when E3 (Registered Nurse) was terminated, the facility remains out of compliance at a Severity Level 2 as the facility requires additional time to complete staff education on abuse reporting . Findings Include: On 02/24/15 at 1:10 P.M. E4 (Certified Nurse's Aide/CNA) stated that on 02/21/15 "around 4:30 P.M." E4 witnessed E3 (Registered Nurse/RN) grab R1's face and "force medication into R1's mouth."E4 also stated that E3 (RN) told R1 to shut up multiple times. E4 stated that E3 was on the phone with E1 (Administrator/ADM) so E4 felt like E1 "obviously knew how unstable 'E3' was." On 02/23/15 at 4:30 P.M. Z1 (R1's family member) stated Z1 came to the facility and staff informed Z1 of E3 (RN) grabbing R1's face. Z1 stated that Z1 confronted E3 (RN) about the allegation and E3 told Z1 to "mind your business." On 2/24/15 at 9:10 A.M., R1 had a long purple bruise approximately 4 centimeters under left eye. On 02/24/15 at 9:55 A.M. E2 (Director of Nurses/DON), E1(ADM) and E6 (Social Service Director) all confirmed the presence of dark purple bruise approximately 3 centimeters long on R1's upper left cheek under left eye. On 02/24/15 at 11:00 A.M. E3 ( RN) confirmed that E3 did put E3's hand on R1's face while giving R1 the medication. On 02/24/15 at 1:10 P.M. E4 stated E4 reported the allegation to R9 (RN) on 02/22/15. On 02/24/15 at 10:30 A.M. E9 (RN) stated E9 called E2 (DON) on 02/22/15 around 5:00 P.M. to report allegations. E3's (RN) time card indicate that E3 continued to work for six hours after the abuse occurred on 02/21/15, clocking out at 10:30 P.M. E3 also worked on 02/22/15, clocked in at 2:02 P.M. and clocked out at 11:13 P.M. On 02/24/15 at 11:00 A.M. E2 (DON) confirmed that E9 called E2 "multiple times" on 02/22/15 in regards to E3's (RN) behavior. E2 stated E2 would handle it Monday morning. On 02/25/14 at 2:00 P.M. E1 (ADM) stated E1's expectations would have been for E2 (DON) to respond to the multiple phone calls from staff about E3 (RN) in person to assess the situation. The Abuse Prevention Program dated January 2009 states " All employees of this facility must immediately report any incident or suspected incidents of resident neglect,abuse or misappropriation of resident property to their supervisor or Administrator." The Abuse Prevention Program dated January 2009 states "the chain of command as established by this policy shall be followed by all personnel when filing ......complaints, and/or in emergency situation." This chain of command indicates that the administrator is the first person to be contacted. The Immediate Jeopardy situation was identified on 2/24/15 at 2:30 PM. The Immediate Jeopardy was determined to have begun on 2/21/2015 at approximately 4:30 P.M., when the facility failed to immediately report abuse for R1 to E1 (Adminstrator). E1 was informed of the Immediate Jeopardy on 2/24/2015 at 2:45 P.M. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1.E3 was terminated on 02/24/15. 2. E1 (Administrator) reviewed the abuse policy and procedure with al department heads on 02/24/15 at 2:55 P.M.. Copy of the policy was distributed to the department heads. 3. Department heads began reviewing the abuse policy and procedure with their staff as well as providing them a copy of the policy on 2/24/15 beginning at 3:30 P.M. until all staff were completed. 4. In service on the abuse policy and procedure was given on 10/31/14 to all staff. 5. All new hires are given a copy of the abuse policy and procedure and the policy reviewed in orientation before beginning their first shift of work. Audit was conducted on the last 10 new hires and 100% of the 10 initialed that received and reviewed the abuse policy and procedure.

Based on record review, observation and interview the facility failed to immediately report to the administrator the witnessed physical abuse involving R1 and failed to protect R1 from further abuse. This has the potential to affect one of six residents (R1) reviewed for abuse in the sample of six and 38 residents (R7-R44) on the supplemental sample who live on the fourth floor of the facility at the time of this survey. This failure resulted in R1 having bruising on R1's upper left cheek under left eye. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 02-24-15 when E3 (Registered Nurse/RN) was terminated, the facility remains out of compliance at a Severity Level 2 as the facility required additional time complete staff education on abuse reporting and investigation, policy, and resident rights. Findings Include: On 02/24/15 at 1:10 P.M. E4 (Certified Nurse's Aide/CNA) stated on 02/21/15 around 4:30 P.M., E4 witnessed E3 (Registered Nurse/RN) grab R1's face and hold it and "force medicine in 'R1' mouth." E4 also stated that E3 "kept telling 'R1' to shut up." E4 (CNA) stated E4 reported the incident to E9 (RN) the next day (02/22/15). On 02/23/15 at 4:30 P.M. Z1 (R1's family member) stated that Z1 came to facility "about 4:45P.M., and "staff" informed Z1 that E3 (RN) had grabbed R1's face and "forced" R1 to take medicine. Z1 stated during Z1's visit on 02/21/15 Z1 noted "redness" to both cheeks. Z1 also stated "approximately two hours after 'E3' gave R1 medicine on 2/21/2015, 'R1' started coughing and spit out a whole pill." Z1 stated Z1 then asked E3 (RN) why R1 was given whole medicine when it is supposed to be crushed and E3 told Z1 to "mind your own business" and "I don't have time to check and see who all gets crushed medicine." On 2/24/15 at 9:10 A.M., R1 had a long purple bruise approximately 4 centimeters under left eye. On 02/25/14 at 10:30 A.M. E9 (RN) stated that "just before 5:00 P.M." E4 (CNA) reported that E4 witnessed E3 (RN) grab R1's face the previous evening (02/21/15). E9 stated that E9 called E2 (Director of Nursing/DON) "around" 5:00P.M., on 02/22/15. E9 stated that E2 told E9 "we have 24 hours to report it, will take care of it on Monday." On 02/25/15 at 11:00 A.M. E2 (DON) confirmed E1 was called and texted "multiple times" on 02/22/15 in regards to E3 (RN) "having a meltdown....crying and swearing at nurse's desk and won't pass pills, won't do anything." E2 (DON) stated E2 was notified by E9 (RN) that Z1 (R1's family member) was at the facility and very upset. E2 stated that Z1could be provided E2's cellphone number if Z1 wanted to speak with E2. E2 stated that E9 called E2 in regards to E3's behavior "this nurse is crazy." E3 stated that E3 told E9 "to continue to do E9's work and 'E2' would take care of it on Monday." On 02/24/15 at 9:25 A.M. E1 (Administrator/ADM) stated that E3 (RN) called and left a voicemail for E1 on 02/21/15. E1 stated that E3 was "very upset" during the voicemail and said "'R1s' off 'R1's rocker." E1 indicates that E1 called E3 back approximately 15 minutes later and E3 was "calm/fine." E3's time card indicates E3 worked the entire shift on 02/21/15 from 2:03 P.M. until 10:30 P.M. and worked again on 02/22/15 from 2:02 P.M. until 11:13 P.M. On 02/24/15 at 11:00 A.M. E3 stated that E3 was "not suspended." E3 remained available to work until termination on 02/25/15. On 02/25/15 at approximately 1:30 P.M. E3 arrived at the facility in scrubs for E3's regularly scheduled shift. E1 immediately terminated E3 at that time. On 02/24/15 at 9:28 A.M. E1 stated that this abuse investigation began at 10:15 A.M. on 02/23/15. E1 stated that E1 will notify the local law enforcement if abuse is fully founded . The facility's February 2015 staffing sheet reports that E4 worked primarily on fourth floor with potential to affect residents R1-R44. The Immediate Jeopardy situation was identified on 2/24/15 at 2:30 PM. The Immediate Jeopardy was determined to have begun on 2/21/2015 at approximately 4:30 P.M., when the facility failed to immediately report abuse for R1. E1 (Administrator) was informed of the Immediate Jeopardy on 2/24/2015 at 2:45 P.M. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1.E3 (Registered Nurse) was terminated on 02/24/15. 2. E1 (Administrator) reviewed the abuse policy and procedure with al department heads on 02/24/15 at 2:55 P.M.. Copy of the policy was distributed to the department heads. 3. Department heads began reviewing the abuse policy and procedure with their staff as well as providing them a copy of the policy on 2/24/15 beginning at 3:30 P.M. until all staff were completed. 4. Inservice on the abuse policy and procedure was given on 10/31/14 to all staff. 5. All new hires are given a copy of the abuse policy and procedure and the policy reviewed in orientation before beginning their first shift of work. Audit was conducted on the last 10 new hires and 100% of the 10 initialed that received and reviewed the abuse policy and procedure. The facility completed the review of the abuse policy and procedure on 02/24/15 by 10:00 P.M. 136 out of 147 employees received the review of the abuse policy. The facility attempted to contact the remaining 11 employees,but were unsuccessful. These 11 employees will not return to work until they have received and review of the abuse policy and procedure.

Based on observation, interview and record review the facility failed to ensure R1 was not physically or verbally abused. This has the potential to affect one of six residents (R1) reviewed for abuse in the sample of six. This failure resulted in R1 having bruising on R1's upper left cheek under left eye. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 02-24-15 when E3 (Registered Nurse) was terminated, the facility remains out of compliance at a Severity Level 2 as the facility requires additional time to complete staff education on abuse reporting and investigation, policy, and resident rights. Findings Include: On 02/24/15 at 1:10P.M. E4 (Certified Nurse's Aide/CNA) stated that on 02/21/15, "during first medication pass about 4:30 P.M.," that E3 (Registered Nurse/RN) grabbed and held R1's face and "forced medicine into R1's mouth." E4 stated that E3 told R1 to shut up "multiple" times." On 02/23/15 at 4:30 P.M., Z1 (R1's family member) stated that Z1 came to facility "about 4:45P.M., and "staff" informed Z1 that E3 (RN) had grabbed R1's face and "forced" R1 to take medicine. Z1 stated during Z1's visit on 02/21/15 Z1 noted "redness" to both cheeks. Z1 also stated "approximately two hours after 'E3' gave R1 medicine on 2/21/2015, 'R1' started coughing and spit out a whole pill." Z1 stated Z1 then asked E3 (RN) why R1 was given whole medicine when it is supposed to be crushed and E3 told Z1 to "mind your own business" and "I don't have time to check and see who all gets crushed medicine." On 2/24/15 at 9:10 A.M., R1 had a long purple bruise approximately 4 cm (centimeters) under left eye. On 02/24/15 at 9:55 A.M. E2 (Director of Nurses/DON), E1(Admistrator/ADM) and E6 (Social Service Director) all confirmed the presence of dark purple bruise approximately 3 centimeters long on R1's upper left cheek under left eye. On 02/24/15 at 11:00 A.M. E3 ( RN) confirmed that E3 did put E3's hand on R1's face while giving R1 the medication. The Immediate Jeopardy situation was identified on 2/24/15 at 2:30 PM. The Immediate Jeopardy was determined to have begun on 2/21/2015 at approximately 4:30 P.M., when the facility failed to immediately report abuse for R1 to E1 (Adminstrator). E1 was informed of the Immediate Jeopardy on 2/24/2015 at 2:45 P.M. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1.E3 was terminated on 02/24/15. 2. E1 (Administrator) reviewed the abuse policy and procedure with all department heads on 02/24/15 at 2:55 P.M.. Copy of the policy was distributed to the department heads. 3. Department heads began reviewing the abuse policy and procedure with their staff as well as providing them a copy of the policy on 2/24/15 beginning at 3:30 P.M. until all staff were completed. 4. Inservice on the abuse policy and procedure was given on 10/31/14 to all staff. 5. All new hires are given a copy of the abuse policy and procedure and the policy reviewed in orientation before beginning their first shift of work. Audit was conducted on the last 10 new hires and 100% of the 10 initialed that received and reviewed the abuse policy and procedure.

Based on interview and record review, the facility failed to identify,assess and implement interventions for a resident at risk for developing a pressure ulcer. This failure resulted in R2 developing an unstageable pressure ulcer. R2 is one of two residents reviewed for pressure ulcers in the sample of eleven. FINDINGS INCLUDE: R2's physician's orders [REDACTED]. R2's orders included: PT (physical therapy) and OT (occupational therapy) to address NWB (non-weight bearing status), transfer training and wheel chair positioning. R2 also had a physician's orders [REDACTED]. R2's Admission assessment dated [DATE] documents that R2 was admitted with a full leg cast on the right leg. R2's Interim Care Plan dated 9/25/14 includes the following problems: Pain, Visual Function, ADLs (activities for daily living), Anticoagulant, Infections, and Cardiac. R2's skin risk and skin assessment are not addressed. R2's Minimum Data Set ((MDS) dated [DATE] documents that R2 scored a 14:15 on the Brief Interview for Mental Status (no cognitive impairment). R2's nurse's notes dated 10/23/14 document that R2 was seen by the Orthopedic Surgeon with thigh high brace to right leg and include the following physician's orders [REDACTED]. May remove brace for cleaning only. Leave brace on at all times except hygiene. Follow up in 3 weeks. Continue non-weight bearing status. R2's CNA (Certified Nursing Assistants) Bath and Shower Sheets dated 10/26/14, 10/29/14, 11/2/14, 11/5/14, 11/9/14, 11/12/14, 11/16/14 and 11/19/14 document "No skin concerns." R2's nurse's Treatment Record for October 2014 and November 2014 document no assessment of R2's skin condition for the right leg brace. R2's Doctor's Progress Note dated 11/20/14 from Z1 (Orthopedic Surgeon) documents, " Pt (patient) reports not having brace off. Skin wound lateral/distal leg is 5 CM (centimeters) in length..." R2's nurse's notes dated 11/20/14 at 4:00 P.M. document, "Informed earlier via ORA (Orthopedic Surgeon) phone call of right lower leg wound...Assessed wound to right lower leg outer aspect, wound is 1.7 cm (length) X 1.1 cm (width) X 0.1-0.2 cm (depth), black eschar covering wound." The facility policy titled Management of Wounds (dated 3/5/09) directs staff, "...all residents at risk for pressure ulcer development will receive a documented daily visual inspection of their skin by the RN/LPN or CNA delivering care." On 12/18/14 at 10:50 A.M., Z1 (Orthopedic Surgeon) stated, " We replaced (R2)'s cast with a long leg brace on (R2)'s right leg on 10/23/14. I wrote orders for the leg brace to be removed for hygiene. (R2) returned to the clinic on 11/20/14 and when we removed the brace, we discovered a 5 cm necrotic skin wound. I asked (R2) if the leg brace had been removed and her leg assessed and (R2) said the brace had never been off. Because the staff did not remove the brace and assess (R2)'s leg for circulation, (R2) developed a necrotic skin wound." On 12/18/14 at 8:20 A.M., E4 (Certified Nursing Assistant) stated, " (R2) had a black brace on (R2) right leg. I didn't take the brace off (R2) leg,no one told me to. I didn't know there was anything on the right leg. (R2) told me (R2) never had the brace removed. I never saw (R2) with the brace off." On 12/18/14 at 11:05 A.M., E6 (Certified Nursing Assistant) stated, "I didn't take the leg brace off (R2)'s leg during (R2)'s bed bath. I didn't know I was supposed to take it off." On 12/18/14 at 11:10 A.M., E7 (Certified Nursing Assistant) stated, " I removed the black strap by undoing the velcro and washing the top of (R2)'s leg. I didn't take (R2)'s leg out of it. I didn't see the back of (R2)'s leg." On 12/18/14 at 10:55 A.M., E5 (Licensed Practical Nurse) stated, " I am (R2)'s full time day shift nurse. I have never seen (R2)'s leg brace off. I never took it off, I thought the CNAs did." On 12/18/14 at 1:45 P.M., E2 (Director of Nurses) stated, " (R2)'s leg brace should have been removed on bath days by the CNA with the nurse present to assess the skin. The nurse should be the one to document it. (R2)'s leg brace didn't get removed and the skin assessed because the nurse thought the CNA did it and the CNAs thought the nurse did it and no one ended up doing it."

Based on interview and record review the facility neglected to follow physician's orders to remove a leg brace during hygiene and assess the skin. the facility also neglected to follow their policy on wounds. This neglect resulted in R2 developing an unstageable, necrotic pressure ulcer. R2 is one of two residents reviewed for pressure ulcers in the sample of eleven. FINDINGS INCLUDE: R2's Physician's Order Sheet dated 9/25/14 documents that R2 was admitted to the facility with the following Diagnoses: [REDACTED]. R2's orders included: PT (physical therapy) and OT (occupational therapy) to address NWB (non-weight bearing status), transfer training and wheel chair positioning. R2 also had a physician's order to follow up with the Orthopedic Surgeon. R2's Admission assessment dated [DATE] documents that R2 was admitted with a full leg cast on the right leg. R2's Minimum Data Set ((MDS) dated [DATE] documents that R2 scored a 14:15 on the Brief Interview for Mental Status (no cognitive impairment). R2's nurse's notes dated 10/23/14 document that R2 was seen by the Orthopedic Surgeon with thigh high brace to right leg and include the following physician's orders: Bunny boots to feet. May remove brace for cleaning only. Leave brace on at all times except hygiene. Follow up in 3 weeks. Continue non-weight bearing status. R2's CNA (Certified Nursing Assistants) Bath and Shower Sheets dated 10/26/14, 10/29/14, 11/2/14, 11/5/14, 11/9/14, 11/12/14, 11/16/14 and 11/19/14 document "No skin concerns." R2's nurse's Treatment Record for October 2014 and November 2014 document no assessment of R2's skin condition for the right leg brace. R2's Doctor's Progress Note dated 11/20/14 from Z1 (Orthopedic Surgeon) documents, " Pt (patient) reports not having brace off. Skin wound lateral/distal leg is 5 CM (centimeters) in length..." R2's nurse's notes dated 11/20/14 at 4:00 P.M. document, "Informed earlier via ORA (Orthopedic Surgeon) phone call of right lower leg wound...Assessed wound to right lower leg outer aspect, wound is 1.7 cm (length) X 1.1 cm (width) X 0.1-0.2 cm (depth), black eschar covering wound." The facility policy titled Management of Wounds (dated 3/5/09) directs staff, "...all residents at risk for pressure ulcer development will receive a documented daily visual inspection of their skin by the RN/LPN or CNA delivering care." On 12/18/14 at 10:50 A.M., Z1 (Orthopedic Surgeon) stated, " We replaced (R2)'s cast with a long leg brace on (R2)'s right leg on 10/23/14. I wrote orders for the leg brace to be removed for hygiene. (R2) returned to the clinic on 11/20/14 and when we removed the brace, we discovered a 5 cm necrotic skin wound. I asked (R2) if the leg brace had been removed and her leg assessed and (R2) said the brace had never been off. Because the staff did not remove the brace and assess (R2)'s leg for circulation, (R2) developed a necrotic skin wound." On 12/18/14 at 8:20 A.M., E4 (Certified Nursing Assistant) stated, " (R2) had a black brace on (R2) right leg. I didn't take the brace off (R2) leg,no one told me to. I didn't know there was anything on the right leg. (R2) told me (R2) never had the brace removed. I never saw (R2) with the brace off." On 12/18/14 at 11:05 A.M., E6 (Certified Nursing Assistant) stated, "I didn't take the leg brace off (R2)'s leg during (R2)'s bed bath. I didn't know I was supposed to take it off." On 12/18/14 at 11:10 A.M., E7 (Certified Nursing Assistant) stated, " I removed the black strap by undoing the velcro and washing the top of (R2)'s leg. I didn't take (R2)'s leg out of it. I didn't see the back of (R2)'s leg." On 12/18/14 at 10:55 A.M., E5 (Licensed Practical Nurse) stated, " I am (R2)'s full time day shift nurse. I have never seen (R2)'s leg brace off. I never took it off, I thought the CNAs did." On 12/18/14 at 1:45 P.M., E2 (Director of Nurses) stated, " (R2)'s leg brace should have been removed on bath days by the CNA with the nurse present to assess the skin. The nurse should be the one to document it. (R2)'s leg brace didn't get removed and the skin assessed because the nurse thought the CNA did it and the CNAs thought the nurse did it and no one ended up doing it."