Every finding on record at Stonebridge Nursing & Rehab

Based on observation, interview, and record review the facility failed to serve foods in the texture directed by the physician for 15 (R3, R5, R6, R7, R12, R28, R29, R33, R36, R38, R42, R49, R50, R51, and R53) of 15 residents reviewed for receiving a mechanical soft texture diet in a sample of 36. Findings include: The facility document dated day 9 Monday titled, Diet Spreadsheet lunch documents: ground smothered chicken with gravy, chopped Brussel Sprouts, soft and buttered dinner roll, canned fruit (no pineapple or fruit cocktail) and beverage. The facility document dated day 9 lunch titled, Chopped Brussel Sprouts documents: 3. cut/chop the number of servings need into bite-sized pieces. The facility document dated day 4 lunch titled, chopped peach parfait documents: 1. cut/chop the number of servings needed into bite-sized pieces. On 12/15/25 at 12:05 PM while observing trays being plated in the kitchen the brussel sprouts were served whole, approximately one inch in diameter or larger and the peach slices were over an inch to over two inches in length for the resident who were being served a mechanical soft diet. On 12/18/25 at 12:39 PM, V3 (Dietary Manager) stated the brussel sprouts and peaches that were served on 12/15/25 for the lunch meal should have been chopped before serving for the mechanical soft diet. The facility document dated 12/18/25 titled, Diet Roster - by Texture provided by V3 (Dietary Manager) documents: R12, R3, R28, R29, R6, R7, R33, R36, R38, R42, R5, R49, R50, R51, and R53 receive diet with a texture of dental soft (mechanical soft). V3 confirmed these residents received would have received the brussel sprouts and peaches on 12/15/25. The policy dated 10/2017 titled, Therapeutic Diets documents: 3. diet order should match the terminology used by the food and nutrition services department. 4. a therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or the alter the texture of a diet, for example: d. altered consistency diet. 5. if a mechanically altered diet is ordered, that provider will specify the texture modification.

Based on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 4 of 4 residents (R12, R18, R21, R38) reviewed for room size in a sample of 36.On 12/17/25 at 11:34 AM, V1 (Administrator) stated that rooms 1-14 on the North Hall and rooms 1, 3, 6-20 on the South Hall provide less than 80 square feet per resident bed and are all Medicaid Certified rooms.On 12/17/25 at 11:38 AM, V8 (Maintenance) measured R18 and R21's room on the south hall with a measuring tape, the bedroom measured 12.4 feet by 11.8 feet equaling 146 square feet, which is approximately 73 square feet per resident. R18 and R21's room contained 1 dresser, 2 beds and 2 nightstands. On 12/17/25 at 11:39 AM, R18 and R21 were in their room. The room was a smaller sized bedroom with two beds, 2 night stands and an inset dresser in the room. at that time R18 who was alert to person, place and time stated she does not have any concerns with the room size. R21 was in the room but was not able to be interviewed.On 12/17/25 at 11:44 AM, V8 measured R38 and R12's room on the north hall. This room was measured with a measuring tape and measured 12.4 feet by 11.8 feet equaling 143 square feet total space, which is approximately 71.5 square feet per resident. This room contained 1 inset dresser, 2 beds, and 2 nightstands. There were no concerns observed with space in this waivered room.On 12/17/25 at 11:45 AM, R38 stated she does not have any concerns with her room size. R38 was alert and oriented to person, place, and time.On 12/17/25 at 11:48 AM, R12 was in the room but was not able to be interviewed.The facility Daily Roster, dated 12/15/25, documents R12, R18, R21, and R38 reside in the rooms observed and measured by V8.Observations of the waivered rooms, from 12/15/25 through 12/18/25, show these rooms provide adequate space to meet the medical and personal needs of these residents.The Resident Council Meeting Minutes, dated 9/25 through 11/25, documents no complaints regarding the waivered room space.

Based on observation, interview, and record review the facility failed to maintain a safe, functional, and sanitary environment by allowing a wall behind the washer to fall apart from water damage and allowing for an increased risk of mold growth. This failure has the potential to affect all 53 residents residing in the facility.The findings include:On 11/17/25 at 6:05AM, observed behind the washer in laundry room and saw what appeared to be a black mold-like substance on the wall next to the hoses. Also observed along the bottom part of the wall, that the wall was falling apart and damp with the cove base trim lying down over the top of a grate that had water in it. The grate appeared to be where the water from the washer would drain. A moldy like substance was also noted to the wet broken wall area. On 11/18/25 at 9:02AM, V17 (Laundry) stated that the wall behind the washer has been falling apart and had that mold looking stuff on it for a very long time. V17 said that she didn't know for sure if that black stuff on the wall behind the washer was mold or what it was. V17 said that the wall has gotten wet several times. V17 said that she really couldn't say for sure what was causing the wall to fall apart on the bottom or what the substance was on the wall. V17 said V18 (Maintenance Director) did come back today and look at the wall and was talking about finally fixing the wall this week sometime. On 11/18/25 at 9:51AM, V18 (Maintenance Director) stated that he didn't know how long the wall behind the washer in the laundry room had been falling apart. V18 said that he did know that there was a water leak behind the washer because he had to change some hoses. V18 said that he doesn't think that it is black mold on the wall behind the washer, but he wasn't sure. V18 said that they are replacing the wall behind the washer this Friday on 11/21/25. V18 said that he thinks the wall is falling apart from water damage. V18 said that they are replacing the dry wall with green board which is meant for areas that have water. V18 said that he kind of inspects that laundry area on occasion to check if anything needs replaced, it's not a routine inspection. On 11/18/25 at 12:35PM, V1 (Administrator) stated that the laundry room wall behind the washer has been damaged most likely due to water damage from the washer leaking or the drain overflowing. V1 said that he does not think that the stuff on the wall is black mold, he thinks it is a discoloration from when they had other pipes on the wall, and it left a dark discoloration. V1 said that he doesn't see any mold to the bottom of the wall either where the wall is falling apart. V1 said that V18 will be replacing the wall this week on 11/21/25. The facility policy titled Quality of Life- Homelike Environment with a revised date of 05/2017 documents under policy statement Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belonging to the extent possible under policy interpretation and implementation #6. The maintenance staff to maintain the grounds, facility, and equipment in a safe and efficient manner in accordance with current federal, state, and local standards, to ensure that a successful maintenance program is maintained at all times. The daily census dated 11/16/25 documents a total census of 53 residents living in the facility.

Based on observation, interview, and record review the facility failed to ensure sufficient staff to meet the needs of the residents timely. This has the potential to affect all 58 residents currently residing at the facility. Findings include: 1. R13's admission Record documents an admission date of 2/9/25 with diagnoses including in part: altered mental status, anxiety disorder, diabetes, disorder of muscle, unsteadiness on feet, other lack of coordination, and unsteadiness on feet. R13's MDS dated [DATE] documents a BIMS of 14, indicating R13's cognition is intact. On 8/26/25 at 11:54 AM, R13's was sitting in his wheelchair in the doorway to his room with his call light on, this surveyor asked if his call light had been on a while, and he stated yes it has been. The call light was already on when the observation began. During constant observation, R13's call light was answered by V3 (Corporate Nurse) at 12:16 PM. 2. R8's admission Record documents an admission date of 9/11/23 with diagnoses including in part: diabetes, anxiety, chronic obstructive pulmonary disease, chronic pain syndrome, nicotine dependence cigarettes, and difficulty in walking. R8's MDS dated [DATE] documents a BIMS of 15, indicating R8's cognition is intact. R8's current Care Plan documents R8 uses tobacco with interventions including in part: orient R8 to smoking times and procedures. On 8/26/25 at 10:57 AM, R8's call light was on, and he stated he turned his call light on about 30 minutes ago about 10:30 AM because that was the smoking time for residents. There was a digital clock with large print that was next to R8's bed that he looked at when he stated what time he put his call light on. R8 stated it can take an hour at times to get his call light answered because there isn't enough help. On 8/26/25 at 11:49 AM, R8 is still in bed, stated he is still waiting for someone to get him up. V1 (Administrator) came to the room to answer the call light and stated he would go find the sit to stand to get him up. On 8/26/25 at 12:31 AM, R8 was still in bed. R8 stated V1 told him again that he was going to get the sit to stand and find the Certified Nursing Assistants (CNA) to get him up. R8 stated he has now missed the 10:30 AM smoke break. R8 said he thinks the next one is after lunch around 1:00 PM. 3. R3's admission Record documents an admission date of 8/7/25 with diagnoses including in part: cellulitis of buttock, muscle weakness, unsteadiness on feet, cognitive communication deficit, reduced mobility, need for assistance with personal care, and dementia severe. R3's MDS dated [DATE] documents a BIMS of 13, indicating R3's cognition is intact. R3's current Care Plan documents R3 has a selfcare deficit with interventions including in part: assist with meals as needed. On 8/26/25 at 12:38 PM, R3 was lying in bed with her lunch tray sitting on the bedside table, next to the bed. The tray was untouched. This surveyor asked R3 if she was hungry and she said yes, this surveyor told R3 her lunch was sitting beside the bed for her. On 8/26/25 at 1:33 PM, R3 was lying in bed with her lunch try sitting on bedside table next to bed, tray is untouched. On 8/26/25 at 1:38 PM, This surveyor asked R3 if she needed assistance eating and she replied Yes. On 8/26/25 at 1:42 PM, R3's V7 (Family Member) and V6 (Speech Pathologist/Director of Rehab) went into R3's room and V6 told V7 that R3 wasn't having a very good day today. On 8/26/25 at 1:47 PM, V6 stated R3 doesn't usually need assistance eating but she isn't having a very good day today, so she was going to try and get her to eat some. On 8/26/25 at 2:02 PM, V8 (CNA) stated R3 usually feeds herself but she has been struggling lately and hasn't been eating much. V8 stated she hasn't checked on her since her tray was delivered because she has been shaving 3 other residents and hasn't had time. 4. R11's admission Record documents an admission date of 12/5/23 with diagnoses including in part: fracture of lower end of right tibia, obesity, chronic pain syndrome, primary osteoarthritis, muscle weakness, other abnormalities of gait and mobility, unsteadiness son feet, and need for assistance with personal care. R11's MDS dated [DATE] documents a BIMS of 15, indicating R11's cognition is intact. The same MDS documents R11 is dependent for chair/bed-to-chair transfers. The MDS documents depends as, helper does all the effort and resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On 8/26/25 at 9:20 AM, R11 stated she is a mechanical lift now because she fell about 2 months ago while being transferred and broke her knee. R11 stated she usually has a long wait for her call light to be answered, sometimes 30 minutes or longer and stated she has urinated on herself before because she had to wait so long. On 8/26/25 at 12:40 PM, R11 said the CNAs usually get her up with one assist using the mechanical lift. On 8/26/25 at 12:40 PM, V4 (CNA) stated she got R11 up today with the mechanical lift by herself. This surveyor asked V4 why she did it by herself and V4 stated because there wasn't anyone else to help. 5.R12's admission Record documents an admission date of 7/18/25 with diagnoses including in part: displaced intertrochanteric fracture of left femur, anxiety, restlessness and agitation, major depressive disorder, dementia severe with other behavioral disturbance, and sensorineural hearing loss. R12's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 99 indicating the interview was not completed. The same MDS documents R12 is supervision or touching assistance for toilet transfer and sitting to standing. R12's current Care Plan documents R12 is at risk for fall with interventions including in part: call light within reach and observe for unsafe actions and intervene. The same Care Plan documents R12 has a self-care deficit with interventions including in part: assist with toileting and showers/bath. On 8/26/25 at 12:02 PM, constant observation, R12's bed alarm was going off at 12:02, R12 was yelling for help stating he needed to urinate and was going to urinate in his pants because he had to go so bad, there was no staff in the hallway. R12's call light was laying over the nightstand, out of reach. At 12:04 R12 reached for his trashcan and pulled it over to him, pulled down his pants and was trying to urinate in the trashcan, there was still no staff in the hallway until 12:08 PM. At 12:08 V5 (Activities Director) walked past R12's room then turned around and came back and told R12 she would get someone to help. At 12:09 V3 (Corporate Nurse) came down the hall to give this surveyor a document and heard the bed alarm and went into R12's room to assist. V3 came out of the resident's room and was asked who would have answered that bed alarm if she wasn't coming to find this surveyor and V3 stated I would hope the staff would.6. R4's admission Record documents an admission date of 9/30/24 with diagnoses including in part: atherosclerosis of aorta, difficulty in walking, other abnormalities of gait and mobility, history of falling, and tobacco use. R4's MDS dated [DATE] documents a BIMS of 08, indicating moderately impaired cognition. On 8/26/25 at 8:47 AM, R4 stated call light wait time can be long at times. R4 stated I am concerned if there was a real problem I might be dead before they get to me to answer my call light. On 8/26/25 at 11:04 AM, V9 (CNA) stated she feels like residents to not get the care they when they are short staffed, and V9 stated she feels like they are short on staff now. V9 stated they only have 4 CNA's working today and she doesn't think that is enough. V9 stated she can't always get to the residents right away when they need something. On 8/26/25 at 11:06 AM, V10 (CNA) stated she feels like residents are not getting the care needed when they are short staffed, and she stated there is only 4 CNAs working today and she doesn't think that is enough. V10 stated she doesn't think she is able to provide the best care when they don't have enough CNA staff, and she feels that is true right now. V10 was asked about 2 call lights that were currently on, and she stated they are on all the time, but we have higher priority things that need done right now. On 8/26/25 at 11:56 AM, V4 (CNA) stated there are days they have enough staff and days they don't. V4 stated weekends seems to be worse. V4 stated there are times she can't give showers due to not enough staff. V4 stated she feels like residents are not getting the care needed on days they are short staffed because they might not get their showers. V4 stated there are only 4 CNAs working today. On 8/26/25 at 1:13 PM, V1 (Administrator) stated there is someone from the management team here during the day 7 days a week, but not at night unless it is needed. V1 stated ideal staffing is 6 CNAs from 6am-2pm, 5 CNAs from 2pm-10pm, and 4 CNAs from 10p-6a. V1 stated they are having some difficulties with staffing right now due to staff being out with COVID. V1 stated the CNAs shifts were switched to 12 hour shifts to help cover. V1 stated all mechanical lift transfers should be completed using 2 staff assist. A facility document titled Daily Census dated 8/25/25 documents total number of residents that reside in the facility is 56. A facility policy titled Staffing dated October 2017 documents under Policy Statement: 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 and under Policy Interpretation and Implementation: 5. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee.

Based on interview and record review, the facility failed to obtain and implement physician orders for wound care for 1 (R1) of 3 residents reviewed for wound care in the sample of 9. The findings include: R1's admission Record documented R1 was admitted to this nursing home on 9/20/2022 with diagnosis of stroke with right sided paralysis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 had a Brief Interview for Mental Status (BIMS) score of 01, indicating R1 has severe cognitive impairment. This MDS also documented R1 has one Stage IV Pressure Ulcer that was present on admission. R1's admission assessment titled Admit/Readmit Screener, dated 4/26/25 documented R1 was admitted via wheelchair from hospital and had a pressure area to his coccyx. There were no measurements or description of the wound documented on the Admit/Readmit screener or the nurse progress notes. R1's Order Summary Report with active orders as of 5/30/25 documented there were no orders for wound care from 4/26/25 until 5/2/25. R1's Treatment Administration Record (TAR) dated 4/1/30-4/30/25 indicated there were no treatments ordered for R1's coccyx wound to be done beginning on 4/26/25. The same TAR dated 5/1/25-5/30/25 documented a treatment to begin on 5/2/25 of cleanse area to sacrum (coccyx) then apply manukah honey absorbent dressing and cover with silicone border dressing every night shift for wound care. On 6/3/25 at 11:23am, V11 (Licensed Practical Nurse/LPN) said he was working on 4/26/25 when R1 returned to the facility from the hospital. V11 said that R1 had a wound on his sacrum/coccyx upon re-admission. V11 said all he was told from the out of state hospital that R1 was discharged from was that R1 had a non-blanchable area to coccyx. V11 said the wound had a wadded up dressing on it and the middle was deeper. V11 said he wasn't sure about the stage of the wound. V11 said they started off with Silvadene and calcium alginate dressing. V11 said that he believes either the doctor or the nurse practitioner okayed the calcium alginate, he does not remember. V11 said he did pass it on in report and thinks he wrote it on the 24-hour shift report. V11 said that V9 (Registered Nurse/RN) was helping him since he was new to the facility. On 6/3/25 at 2:55pm, V7 (LPN/Infection Preventionist/IP) said that R1 came back to the facility on 4/26/25 with the sacrum/coccyx wound. V7 said that the nurse that admitted R1 should have documented a wound note with measurements and R1 would have been seen the following Thursday. V7 said she was not notified about the wound on the sacrum/coccyx until 4/28/25. V7 said she got the order for treatments on the coccyx wound on 5/2/25. On 6/4/25 at 9:35am, V10 (RN) said she worked day shift on 4/27/25. V10 says it's usually after around 10am when she starts her treatments. V10 said that R1 did not have a treatment on the TAR to be done. V10 said she knew he came back with a wound and when she saw there was not a treatment, she knew it had to be cleaned. V10 said she went with what the wound doctor always orders which is cleanse, apply Silvadene, calcium alginate and cover with dry dressing. On 6/4/25 at 10:03am, V8 (RN) said that R1 had an area on his behind and when she looked at the TAR there was no treatment listed on there. V8 said she would never leave a wound without a dressing, and they had been putting Silvadene, calcium alginate and dry dressing on it. V8 said she does not remember if it was on the 24-hour report sheet or not. On 6/4/25 at 11:08am, V5 (Physician) said he thought he remembered staff calling for wound orders. V5 said he figured he would go ahead and do something until the wound physician could see R1. V5 said he thought he ordered calcium alginate with dry dressing, which is what wound care generally does. V5 said he does not remember which nurse called him. On 6/4/25 at 11:15am, V9 (RN) said she was told about R1's wound and did look at it. V9 said she put a treatment on it, cleansed, applied Silvadene, calcium alginate and a dry dressing. V9 said it was very hectic and she may have not put a note in on it. V9 said she also put in the order, she just wanted to put something on it. V9 said she didn't remember which doctor ordered it. On 6/5/25 at 11:46am, V14 (RN) stated that she worked the night of 4/26/25 after R1 had returned from the hospital earlier that day. V14 said there was no open area on R1's coccyx before he went to the hospital. V14 said she tries to do her treatments in the evenings after her medication pass, but V11 (LPN) took care of it on days so she didn't have to do it. V14 said an order will show on the TAR if she has to do one, but this happened with R1 a long time ago. V14 then said that an order did pop up for R1 to cleanse, apply Silvadene cream and apply calcium alginate and cover the wound with dry dressing. V11 said if the order was not put in, it would not show up for her to do. V14 said that usually it goes on the 24-hour shift report, but she does not remember if she put it on there or not. V14 said she also worked on 5/1/25 and she did a treatment on R1's wound but does not remember if it showed on the TAR for her to do. V14 said that R1 was able to make his needs known. V14 said she got to where she could understand R1, or he would shake his head yes or no. Facility Policy labeled Telephone Orders (undated) documents Verbal telephone orders may only be received by licensed personnel (e.g. (for example) RN, LPN, pharmacist, physician). Orders must be reduced to writing by the person receiving the order and recorded in the resident's medical record. Facility Policy labeled Medication Orders (undated) documents Treatment Orders- When recording treatment orders, specify the treatment, frequency and duration of the treatment. Facility Policy labeled Pressure Ulcers/Skin Breakdown- Clinical Protocol (undated) documents Assessment and Recognition In Addition, the nurse shall describe and document/report the following: Full Assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.

Based on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 4 of 4 residents (R20, R21, R27, R38) reviewed for room size in a sample of 32. Findings include: On 12/18/24 at 10:15 AM, V1 (Administrator) stated that rooms 1-14 on the North Hall and rooms 1, 3, 6-20 on the South Hall provide less than 80 square feet per resident bed and are all Medicaid Certified rooms. On 12/18/24 at 10:30 AM, V6 (Maintenance) measured R27 and R38's room on the south hall with a measuring tape, the bedroom measured 12.4 feet by 11.8 feet equaling 146 square feet, which is approximately 73 square feet per resident. R27 and R38's room contained 1 dresser, 2 beds and 2 nightstands. On 12/18/24 at 10:45 AM, R27 and R38 were in their room. The room was a smaller sized bedroom with two beds, 2 night stands and an inset dresser in the room. at that time R27 who was alert to person, place and time stated she does not have any concerns with the room size. R38 was in the room but was non-interviewable. On 12/18/24 at 11:40 AM, V6 measured R20 and R21's room on the north hall. This room was measured with a measuring tape and measured 12.4 feet by 11.8 feet equaling 143 square feet total space, which is approximately 71.5 square feet per resident. This room contained 1 inset dresser, 2 beds, and 2 nightstands. There were no concerns observed with space in this waivered room. On 12/18/24 at 11:45 AM, R20 stated she does not have any concerns with her room size. R20 was alert and oriented to person, place, and time. On 12/18/24 at 11:55 AM, R21 stated she does not have any concerns with her room size. R21 was alert and oriented to person, place, and time. The facility Daily Roster, dated 12/16/24, documents R20, R21, R27, and R38 reside in the rooms observed and measured by V6. Observations of the waivered rooms, from 12/16/24 through 12/19/24, show these rooms provide adequate space to meet the medical and personal needs of these residents. The Resident Council Meeting Minutes, dated 9/24 through 11/24, documents no complaints regarding the waivered room space.

Based on observation, interview and record review, the facility failed to ensure that 17 multiple bed resident rooms on the South hall and 14 multiple bed resident rooms on the North hall provided the required 80 square feet per resident bed for 41 of 41 (R19, R7, R14, R28, R3, R11, R5, R36, R33, R31, R4, R26, R20, R39, R22, R18, R8, R9, R21, R34, R38, R30, R15, R6, R17, R18, R29, R12, R24, R37, R35, R1, R16, R32, R195, R196, R146) residents reviewed for room size in the sample of 44. Findings include: On 11/28/23 at 9:10 AM, V1 (Director of Operations) stated, that all waivered rooms measure less than 80 square feet per resident and are Medicaid Certified. The waivered rooms on the south hall are rooms [ROOM NUMBER]-20; and north hall rooms 1-14. On 11/28/23 at 11:30 AM, V5 (Maintenance) measured rooms 1, 3, 6-20 on the south hall. Rooms 1, 3, 6-20 are certified 2 bedrooms measuring 12.4 feet by 11.8 feet equaling 146 square feet, which is approximately 73 square feet per resident bed. Rooms 1, 3, 10, 14, and 16 contained 1 dresser, 1 bed and 1 nightstand. Rooms 6, 7, 8, 9, 11, 12, 13, 15, 17, 18, 19, and 20 contained 1 dresser, 2 beds, 2 nightstands. There were no concerns observed with space in any of these waivered rooms. On 11/28/23 at 11:30 AM, R26 stated she does not have any concerns with the room size. R26 is alert and oriented to person, place, and time. On 11/28/23 at 11:40 AM, V5 measured rooms 1-14 on the north hall. Rooms 1-14 are certified 2 bedrooms measuring 12.4 feet by 11.8 feet equaling 143 square feet total space, which is approximately 71.5 square feet per resident per room. Rooms 1, 6, 7, 8, 9, contained 1 dresser, 2 beds, and 2 nightstands. Rooms 2, 3, 4, 5, 10, 11, 12, 13, 14, contained 1 dresser, 1 bed and 1 nightstand. There were no concerns observed with space in any of these waivered rooms. On 11/28/23 at 11:43 AM, R20 & R39 stated they do not have any concerns with the room size. R20 & R39 are alert and oriented to person, place, and time. On 11/28/23 at 11:45 AM, R9 stated she does not have any concerns with the room size. R9 is alert and oriented to person, place, and time. On 11/28/23 at 11:47 AM, R21 stated she does not have any concerns with the room size. R21 is alert and oriented to person, place, and time. On 11/28/23 at 11:50 AM, R30 stated she does not have any concerns with the room size. R30 is alert and oriented to person, place, and time. On 11/28/23 at 11:52 AM, R15 stated she does not have any concerns with the rooms size. R15 is alert and oriented to person, place, and time. On 11/28/23 at 11:54 AM, R146 stated she does not have any concerns with the rooms size. R146 is alert and oriented to person, place, and time. On 11/28/23 at 11:56 AM, R24 stated she does not have any concerns with the rooms size. R24 is alert and oriented to person, place, and time. On 11/28/23 at 11:58 AM, R16 stated she does not have any concerns with the rooms size. R16 is alert and oriented to person, place, and time. On 11/28/23 at 12:00 PM, R32 stated she does not have any concerns with the rooms size. R32 is alert and oriented to person, place, and time. On 11/28/23 at 12:03 PM, R19 stated he does not have any concerns with the rooms size. R19 is alert and oriented to person, place, and time. On 11/28/23 at 12:07 PM, R7 stated she does not have any concerns with the rooms size. R7 is alert and oriented to person, place, and time. On 11/28/23 at 12:09 PM, R14 stated she does not have any concerns with the rooms size. R14 is alert and oriented to person, place, and time. On 11/28/23 at 12:11 PM, R28 stated she does not have any concerns with the rooms size. R28 is alert and oriented to person, place, and time. On 11/28/23 at 12:13 PM, R195 and R5 stated they do not have any concerns with the room's size. R195 and R5 were alert and oriented to person, place, and time. On 11/28/23 at 12:17 PM, R11 stated she does not have any concerns with the rooms size. R11 is alert and oriented to person, place, and time. The facility Daily Roster, dated 11/27/23, documents R19, R7, R14, R28, R3, R11, R5, R36, R33, R31, R4, R26, R20, R39, R22, R18, R8, R9, R21, R34, R38, R30, R15, R6, R17, R18, R29, R12, R24, R37, R35, R1, R16, R32, R195, R196, R146 reside in rooms1, 3, and 6-20 on the south hall and rooms1-14 on the north hall. Observations of the waivered rooms, from 11/27/23 through 11/30/23, shows these rooms provide adequate space to meet the medical and personal needs of these residents. The Resident Council Meeting Minutes, dated 9/23 through 11/23, documents no complaints regarding the waivered room space.

Based on interview and record review, the facility failed to lock the wheels on a resident's bed and failed to provide the required level of assistance with bed mobility for 1 of 8 residents (R55) reviewed for falls in the sample of 55. This failure resulted in R55 falling out of bed, suffering a fractured left femur, and subsequently being admitted to the hospital for surgical intervention. Findings Include: R55's facility document titled, Face Sheet documents R55 was admitted to the facility on [DATE] with an admitting diagnosis of heart failure, muscle weakness, polyneuropathy, and type 2 diabetes mellitus. R55's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R55 is cognitively intact. This same MDS documents R55's Functional Status as requiring extensive assistance x 2 person physical assist with bed mobility. On 10/17/2022, at 8:50 a.m., R55 stated that on 6/27/2022, V23 (Registered Nurse/RN) came into her room to do her treatment on her bottom. R55 stated that V23 assisted in rolling her on her right side toward the wall. R55 stated she and V23 were the only ones in the room. R55 stated V23 turned away from her to get her treatment supplies and at that time, R55 stated the bed started to move away from the wall and before she could tell V23, she had fallen out of the bed onto the floor face-first between the wall and the bed. R55 stated that she started to have severe pain in her left leg and hit her head on the floor. R55 stated that V23 ran out of the room and V7 (Licensed Practical Nurse/LPN) came back into the room and looked her over. R55 stated she was sent out to the hospital and was told she had a broken leg and said she had a golf ball size bruise to the middle of her forehead. R55 stated that she had surgery on her left leg. R55 stated that at that time before she had her fall, she had one bed rail (1/2) on the upper left side of the bed. R55 stated she did not know why V23 rolled her to the other side that did not have a bed rail to hold onto. On 10/20/2022, at 10:00 a.m., V7 (LPN) stated that on 6/27/2022, 12:00 p.m., she was standing by the bathroom door outside of R55's room and heard a loud bang and then saw V23 (RN) come out of the room. V7 stated that she and V23 entered R55's room and rotated her onto her back and waited for the ambulance to arrive. V7 stated that there were no other people in the room when she entered to help V23 with R55. V7 stated that R55 was located between the bed and the wall when she and V23 repositioned R55 on her back. R55's medical records documents on 6/27/2022, at 4:20 p.m., local hospital history and physical, under section, Patient's Chief Complaint: Fall .Patient presented to local hospital emergency department due to fall. She states she has chronic wounds on her sacrum in dependent areas for which she was attempting to get wound care today. She states that she was rolled over and that the bed was not locked and slid away from the wall causing her to fall between the bed and the wall. Further x-rays and computed tomography (CT) revealed left distal femur comminuted fracture. Ortho was consulted and she will be admitted for further workup and treatment. Signed by V24 (local physician). R55's medical records, titled After Visit Summary dated 6/29/2022, under section, Surgical/Procedural Cases on This Admission, Open Reduction and Internal Fixation (ORIF), fracture, femur using intramedullary implant and interlocking screw by V26 (local surgeon). R55 returned back to the facility on [DATE]. R55's facility document titled, Resident Incident Report dated 6/27/2022, documents Resident side lying on right side during treatment. Bed raised approximately 3 feet, bed locked on bottom, checked with R55 to see if she was ok lying on her side. V23 (RN) turned around to get treatment supplies and R55 rolled out of the side of the bed landing on her stomach. R55 reported she hit her left leg and her head. R55 had a golf ball sized raised area on her head in the front middle area and reported pain in her left leg. Order obtained for transport to hospital to evaluate and treat. R55's facility document titled, Incident Investigation dated 6/27/2022, documents Full Investigation has been completed on this investigation. It was found that R55 was lying in bed and V23 (Registered Nurse) entered the room to do R55's treatment. R55 is independent with bed mobility and went to roll over so V23 could complete treatment and rolled off the side of the bed onto the floor. Interdisciplinary team (IDT) determined the root cause of this incident is R55's poor bed mobility and poor safety awareness. By V6, (Regional Administrator). On 10/18/2022 at 11:25 a.m., V20 (Director of Therapy) stated that R55 was evaluated for physical therapy on 7/19/2022 and R55's previous level of functioning was maximum assistance x 2 with rolling left to right with bed mobility. On 10/18/2022 at 1:55 p.m., V21 (Minimum Data Set/MDS Coordinator) stated that extensive assistance is 2 person physical assistance with bed mobility, transfer, walking, dressing, eating, toileting, and personal hygiene. At the time of this survey V23 was unable to be interviewed due to no longer being employed at the facility.

Based on interview and record review the facility failed to have sufficient number of nursing staff to provide nursing and related services to meet the activity of daily living needs of the residents who reside there. This failure has the potential to affect all 61 resident who reside in this facility. Findings included: On 10/17/2022 at 9:30am, V1 (Administrator) presented a facility document titled Resident Census and Condition. This document showed the facility has a census of 61 residents and of the 61 residents 59 of them require assistance of one or two staff for transferring and 42 residents require the assistance of 1 or 2 staff for personal hygiene needs. On 10/17/2022 at 3:30pm, V2 (Director of Nursing) said the CNAs (Certified Nursing Assistants) typically work 8 hours shifts which include 6am to 2pm for dayshift, 2pm to 10pm for evening shift and 10pm to 6am for night shift. After reviewing the evening shift schedule for 10/17/2022, V2 verified the facility had on schedule, 3 CNAs (V17, V31 and V32) and V30 NA (Nursing Assistant). V2 said she felt that was enough staff to provide care to all the residents who resided at this facility. On 10/18/2022, the shower schedule for the the evening shift of 10/17/2022 was reviewed with V6 (Corporate Administrator). R41, R18, R36, R50, R26, R44, R49, R7 and R8 were all scheduled to receive their showers per this schedule. V6 was asked to provide documentation of who received their scheduled shower on the evening of 10/17/2022. V6 provided a document titled Complete Care Details a summary lookback for 10/17/2022 for all units which listed the resident's who were bathed that day. This list documented 4 residents (R24 (not scheduled), R26, R44 and R7) received showers. V6 said she did not know why all the residents who were scheduled did not get showered. On 10/20/2022 at 11:00am, V32 (CNA/Certified Nursing Assistant) said she worked the evening shift on 10/17/2022 and she gave showers to R44, R24 and R26, which she documented. V32 said she was not sure if any other showers were given that evening. On 10/18/2022 at 9:00am, R36 said she was scheduled to get a shower on the evening of 10/17/2022 and she wanted her shower, but no one came to give her one. R36 said she misses a lot of showers because there is not enough staff to give her one. R36 said she needs extensive assistance for all personal hygiene tasks. On 10/19/2022 at 10:00am, R36 said she still had not received a shower and it had been over a week since she was last showered. R36's medical records under MDS (Minimum Data Set) dated 9/11/2022 documents R36's BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating R36 is cognitively intact and under section G of the MDS it documented R36 needs physical help in part for bathing. On 10/18/2022 at 12:15pm, R41 and R32 both alert to person, place and time were together in their room. Both said R41 was scheduled to get a shower the evening before (10/17/2022) but no one ever came and offered him to take a shower. Both said they are lucky to get even one shower a week and frequently don't get that because the facility is short of staff. R41's medical record under MDS under section G and dated 9/23/2022 documented R41 did not have the bathing activity occur or was provided by family 100 % in the previous 7 days. R32's most recent MDS documents R32 needs supervision with bathing. On 10/18/2022 at 12:30pm, R57 said the facility does not have enough staff. R57 said he and others do not get showers when scheduled and they have to beg to get showered. R57 said this issue has been brought up several times in resident council meetings but nothing is ever done about it. R57's medical records under MDS section C and G and dated 10/7/2022 documented R57 has a BIMS of 14 indicating R57 is cognitively intact and requires total assistance with bathing. On 10/18/2022 at 12:38pm, R54 said she does not get her scheduled showers and sometimes doesn't even get showered once per week. R54 said the facility needs more staff. R54's medical record under MDS section C and G, dated 10/05/2022 documents R54 has a BIMS of 14 indicating R54 is cognitively intact and needs physical help in part with bathing. On 10/18/2022 at 12:42pm, R51 said the facility does not have enough staff to give showers and provide proper care to the residents. R51 said she does not get her scheduled showers and often does not get showered once per week. R51's medical record under MDS sections C and G and dated 10/12/2022 documented R51 has a BIMS of 15 indicating R51 is cognitively intact and requires total dependence with bathing. On 10/18/2022 at 12:48pm, R 11' s' family member said she feels the facility is short of staff and needs more. R11's family member said some times when she comes to see R11, R11 is soaked with urine and needs her whole bed changed and it takes a long time to get the call light answered. On 10/17/2022 at 9:30am, R31 said there used to be 2 CNAs (Certified Nursing Assistants) assigned to work her hall on dayshift and on evening shift but for several weeks now there has only been one assigned. R31 stated she only gets a shower if she asks the staff for one otherwise she does not receive them. R31's medical records under tab titled MDS section C and G dated 9/16/2022 documented R31 has BIMS of 15 indicating R31 is cognitively intact and needs physical help in part with bathing. On 10/17/2022 at 10:01 am, R55 who was alert to person, place and time said there used to be 2 CNAs on her hall but that has not happened for a very long time. R55 said she feels there are a lot of residents on her hall who require extensive assistance and must be transferred with the patient lifting machine, which requires at least two staff members to use. On 10/17/22 at 10:33 AM, R29 stated that there is usually 2 CNAs working on her hall and lately there has only been 1 CNA working her hall. R29 stated that she needs 2 CNAs to get her out of bed. R29 stated she transfers using a patient lifting machine which takes 2 people to use and she must wait for another staff member to be found before she can be transferred or showered. R29's medical records under tab MDS sections C and G dated 8/31/2022 documented R29 has a BIMS of 15 indicating R29 is cognitively intact and needs extensive assistance of 2+ staff for transferring and is listed as total dependence of staff for bathing. On 10/18/2022 at 10:36am, V16 (Registered Nurse) said the facility is short staffed on all shifts especially CNAs (Certified Nursing Assistants). On 10/18/2022 at 10:39am, V15, V17 and V18 (Certified Nursing Assistants) all said the facility is very short of staff. V17 said she's worked at this facility for 2-3 years and she has always felt 3 care staff on the evening shift is not enough staff to provide care. V17 said it didn't used to be like that but has been for several months now. V15, V17 and V18 all said they can not complete the scheduled showers due to not having enough time or not enough staff, but they are doing the best they can.

Based on interview and record review the facility failed assistance with bathing for to 12 of 17 residents (R8, R18, R29, R31, R32, R36, R41, R49, R50, R51, R54, R57) reviewed for dependent care in a sample of 55. Findings included: On 10/17/2022 at 9:30am, V1 (Administrator) presented a facility document titled Resident Census and Condition. This document showed the facility has a census of 61 residents and of the 61 residents 59 of them require assistance of one or two staff for transferring and 42 residents require the assistance of 1 or 2 staff for personal hygiene needs. 1. On 10/18/2022, the shower schedule for the the evening shift of 10/17/2022 was reviewed with V6 (Corporate Administrator). R41, R18, R36, R50, R26, R44, R49, R7 and R8 were all scheduled to receive their showers per this schedule. V6 was asked to provide documentation of who received their scheduled shower on the evening of 10/17/2022. V6 provided a document titled Complete Care Details a summary lookback for 10/17/2022 for all units which listed the resident's who were bathed that day. This list documented 4 residents (R24 (not scheduled), R26, R44 and R7) received showers. This list showed R41, R18, R36, R50, R49 and R8 did not receive their showers as scheduled. V6 said she did not know why all the residents who were scheduled did not get showered. On 10/20/2022 at 11:00am, V32 (CNA/Certified Nursing Assistant) said she worked the evening shift on 10/17/2022 and she gave showers to R44, R24 and R26, which she documented. V32 said she was not sure if any other showers were given that evening. 2. On 10/18/2022 at 9:00am, R36 said she was scheduled to get a shower on the evening of 10/17/2022 and she wanted her shower, but no one came to give her one. R36 said she misses a lot of showers because there is not enough staff to give her one. R36 said she needs extensive assistance for all personal hygiene tasks. On 10/19/2022 at 10:00am, R36 said she still had not received a shower and it had been over a week since she was last showered. R36's medical records under MDS (Minimum Data Set) dated 9/11/2022 documents R36's BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating R36 is cognitively intact and under section G of the MDS it documented R36 needs physical help in part for bathing. 3. On 10/18/2022 at 12:15pm, R41 and R32 both alert to person, place and time were together in their room. Both said R41 was scheduled to get a shower the evening before (10/17/2022) but no one ever came and offered him to take a shower. Both said they are lucky to get even one shower a week and frequently don't get that because the facility is short of staff. R41's medical record under MDS under section G and dated 9/23/2022 documented R41 did not have the bathing activity occur or was provided by family 100 % in the previous 7 days. R32's most recent MDS documents R32 needs supervision with bathing. 4. On 10/18/2022 at 12:30pm, R57 said the facility does not have enough staff. R57 said he and others do not get showers when scheduled and they have to beg to get showered. R57 said this issue has been brought up several times in resident council meetings but nothing is ever done about it. R57's medical records under MDS section C and G and dated 10/7/2022 documented R57 has a BIMS of 14 indicating R57 is cognitively intact and requires total assistance with bathing. 5. On 10/18/2022 at 12:38pm, R54 said she does not get her scheduled showers and sometimes doesn't even get showered once per week. R54 said the facility needs more staff. R54's medical record under MDS section C and G, dated 10/05/2022 documents R54 has a BIMS of 14 indicating R54 is cognitively intact and needs physical help in part with bathing. 6. On 10/18/2022 at 12:42pm, R51 said the facility does not have enough staff to give showers and provide proper care to the residents. R51 said she does not get her scheduled showers and often does not get showered once per week. R51's medical record under MDS sections C and G and dated 10/12/2022 documented R51 has a BIMS of 15 indicating R51 is cognitively intact and requires total dependence with bathing. 7. On 10/17/2022 at 9:30am, R31 said there used to be 2 CNAs (Certified Nursing Assistants) assigned to work her hall on dayshift and on evening shift but for several weeks now there has only been one assigned. R31 stated she only gets a shower if she asks the staff for one otherwise she does not receive them. R31's medical records under tab titled MDS section C and G dated 9/16/2022 documented R31 has BIMS of 15 indicating R31 is cognitively intact and needs physical help in part with bathing. 8. On 10/17/22 at 10:33 AM, R29 stated that there is usually 2 CNAs working on her hall and lately there has only been 1 CNA working her hall. R29 stated that she needs 2 CNAs to get her out of bed. R29 stated she transfers using a patient lifting machine which takes 2 people to use and she must wait for another staff member to be found before she can be transferred or showered. R29's medical records under tab MDS sections C and G dated 8/31/2022 documented R29 has a BIMS of 15 indicating R29 is cognitively intact and needs extensive assistance of 2+ staff for transferring and is listed as total dependence of staff for bathing. On 10/18/2022 at 10:36am, V16 (Registered Nurse) said the facility is short staffed on all shifts especially CNAs (Certified Nursing Assistants). V16 said the residents in this facility are very elderly and need more assistance than a younger population would need. V16 said their skin is more fragile so staff cannot be rushed when caring for them because they can be injured more easily. On 10/18/2022 at 10:39am, V15, V17 and V18 (Certified Nursing Assistants) all said the facility is very short of staff and it is hard to complete all showers scheduled. V17 said she's worked at this facility for 2-3 years and she has always felt 3 care staff on the evening shift is not enough staff to provide all the care the residents need. V17 said it didn't used to be like that but has been for several months now. V15, V17 and V18 all said they can not complete the scheduled showers due to not having enough time or not enough staff, but they are doing the best they can.

Based on interview, observation and record review the facility failed to provide the mechanical soft diet texture as directed by the menu/recipe for 7 of 19 residents (R17, R30, R24, R45, R37, R13, and R15) reviewed for dining in a sample of 55. Findings Include: 1. The Facility document titled, Diet Spreadsheet dated week 3, Day 15 documents: Dental Soft (Mech Soft) - Ground Chicken Salad Sandwich, Cheddar Macaroni Salad - No raw Veg (vegetables), Diced Tomato Salad - No Raw Veg (d/s), and Pear Cobbler. The facility document titled, Ground Chicken Salad Sandwich documents: 4. Portion #10 dipper chicken salad on 1 sl (slice) bread. Top with 2nd slice of bread. On 10/16/22 between 12:00 PM and 2:00 PM, R17, R30, R24, R45, R37, R13, and R15 were observed with and eating the mechanical soft textured diet for lunch. On 10/16/22 between 12:00 PM and 2:00 PM, R17, R30, R24, R45, R37, R13, and R15 were observed with chicken salad sandwiches served on toast. 2. The Facility document titled, Diet Spreadsheet dated week 3, Day 16 documents: Dental Soft (Mech Soft) - Ground Hamburger on Bun, Soft baked french fries, creamed corn, and soft canned diced fruit. The facility document titled, Ground Hamburger on Bun documents: Portion #10 dip ground beef onto each bun. Top ground beef with 1-2 ounces of prepared gravy, as needed, to serve the meat moist. On 10/17/22 between 12:00 PM and 1:30 PM, R17, R30, R24, R45, R37, R13, and R15 were observed with and eating the mechanical soft textured diet for lunch. On 10/17/22 between 12:00 PM and 1:30 PM, R17, R30, R24, R45, R37, R13, and R15 were observed with ground hamburger on a bun with no gravy. On 10/17/22 at 11:23 PM, V20 (Therapy Director/ Speech Language Pathologist) stated, the residents with the mechanical soft diet should not receive their sandwiches on toast, that would be considered a regular diet food item. The directions on recipe for the item should always be followed. On 10/20/22 at 1:00 PM, V8 (Dietary Manager) stated, she did not realize the chicken salad was suppose to be served on bread and that the hamburger for the mechanical soft diet was suppose to have gravy on it. R17's Physician order sheet for 10/01/22 with a start date of 05/28/22 documents a Mechanical Soft diet. R30's Physician order sheet for 10/01/22 with a start date of 07/05/22 documents a Mechanical Soft diet. R24's Physician order sheet for 10/01/22 with a start date of 08/26/22 documents a Mechanical Soft diet. R45's Physician order sheet for 10/01/22 with a start date of 08/26/22 documents a Mechanical Soft diet. R37's Physician order sheet for 10/01/22 with a start date of 06/28/22 documents a Mechanical Soft diet. R13's Physician order sheet for 10/01/22 with a start date of 10/04/21 documents a Mechanical Soft diet. R15's Physician order sheet for 10/01/22 with a start date of 03/09/20 documents a Mechanical Soft diet.

Based on observation and interview, the facility failed to provide dining experience in a manner that maintains or enhances each resident's dignity for 41 of 41 residents (R2- R9, R13-R17, R19, R22, R24, R26-R28 ,R30, R33, R34, R36, R38-R40, R42-R45, R47-R50, R52, R55 ,R56 R58, R59, R110, R211) reviewed for dining in a sample of 55. On 10/16/2022 at 11:45am, residents were observed gathered in the dining room for the noon meal. On 10/16/2022 at 10:30am, V1 (Administrator) said the facility starts serving the residents their noon meal at 12:00pm. 1. On 10/16/2022 at 12:42pm, the first tray was observed being sent out of the kitchen to be served to a resident on the hall. R17 was quietly seated in the dining room, at the same table as R30 and R56. At 12:45, V56 received her tray while R17 and R30 remained waiting for their meal to be served. At 12:55pm, R17 began shouting I ' m hungry, can I have something to eat? and Please give me something to eat. and continued to cry out for her meal until she was served at 1:12pm. R56 was observed offering some of her food to R17 in an attempt to calm R17 down. At the table next to R17, R3 was served his meal at 12:42pm, while R45 and R59 continued to wait. At 12:59, R59 received his tray while R45 continued to wait to be served. R59 and R3 finished their meal and left the table before R45 was served at 1:10pm. While waiting R45 began to yell at staff to inquire about where his food tray was and that he had been forgotten, but staff would not stop to assist him with his question. 2. On 10/16/2022 at 1:22pm, R9 was observed wandering about the dining room in her wheelchair. R9 was observed eating food from the other resident's plates who had finished and left the dining room. V11 (Certified Nursing Assistant/CNA) also observed R9's activities. V11 was asked if R9 had been served yet and V11 did not know. V12 (Dietary Aide) said R9 had not been served yet. V12 was told about R9 eating off other residents plates due to be hungry and how much longer until R9's tray was served. V12 replied R9 does that all the time and her behavior was typical. Before being served her own meal tray, R9 was observed finishing a half eaten chicken salad sandwich which had first been served to R19. R9 had dropped a large chunk of sandwich onto the floor. R9 was observed picking the sandwich off the floor and eating it. V11 was observed watching R9 along with the surveyor. V11 was asked about R9 eating off the floor, but V11 did not attempt to stop R9 nor attempt to redirect R9 in any way. V11 would only answer (R9) had not been served her meal yet. 3. On 10/16/2022 at 1:06pm, R49 was observed sitting with two of her family members. All three were waiting to be served. R49 and her guests patiently waited to be served while all other members of the table were served, had eaten and left the table. R49 and her guests were finally served at 1:26pm. 4. On 10/16/22 at 12:25 PM, V12 (Dietary) stated, we are going to have to use disposable bowls and small bowls for the desserts because we do not have enough of the regular ones. On 10/16/22 between 12:25 PM to 1:50 PM the side salad, the diced tomato salad, and the sliced cucumbers were served in disposable bowls and the pear cobbler and the sliced pears were served in disposable small bowls to R2, R3, R4, R5, R6, R7, R8, R9, R13, R14, R15, R16, R17, R19, R22, R24, R26, R27, R28, R30, R33, R34, R36, R38, R39, R40, R42, R43, R44, R45, R47, R48, R49, R50, R52, R55, R56, R58, R59, R110, and R211. On 10/16/22 at 1:10 PM, V12 (Dietary) stated, We need some disposable spoons and knives, I don't have any left for the rest of the trays and four residents were served with plastic ware before they stopped serving lunch and washed some spoons so that non disposable spoons could be used. On 10/16/22 between 1:10 PM and 1:15 PM R38, R52, R43 and R5 were given disposable spoons and knives. On 10/17/22 between 12:00 PM and 1:15 PM, the creamed corn and the tropical fruit were served in disposable bowls to R2, R3, R4, R5, R6, R7, R8, R9, R13, R14, R15, R16, R17, R19, R22, R24, R26, R27, R28, R30, R33, R34, R36, R38, R39, R40, R42, R43, R44, R45, R47, R48, R49, R50, R52, R55 ,R56 R58, R59, R110, and R211. On 10/19/22 at 1:00 PM, R38 received her whole lunch on disposable ware. On 10/19/22 at 1:45 PM, V27 (Dietary) stated, R38 was served on disposable ware due to we did not have any regular dishware left. Small disposable bowls are used for desserts due to not having enough bowls to serve with and large disposable bowls are used sometimes because we don't have enough bowls to use either. Sometimes we do run out of regular silverware and have to use disposable. On 10/17/22 at 12:30 PM, R13 was sitting at a table with two other residents that were eating, he did not have his lunch yet and was heard repeating, please come to me, at 12:50 PM R13 wanted to go back to his room and was observed waving his arm towards any staff that came by him. At 12:59 PM, R13 received his lunch, the other two residents at his table had already finished their lunch and left the table. 5. On 10/17/22 at 12:20 PM, V22 (Laundry Aide) pushed a soiled linen cart through the middle of the dining room while residents were being served their noon meal. Soiled linen was stacked up approximately three feet above the lid of the soiled linen cart and a sheet was covering it. V22 had her hand raised above her head and resting on the sheet covering the pile of soiled linen while she pushed the soiled linen cart. Residents were being served lunch at the time the soiled linen cart was being pushed through the dining room. Multiple residents were seated at tables in the dining room while the cart was pushed through the dining room and about half of the residents were eating their meal.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 4 (R2) residents reviewed for abuse in the sample of 8. Findings Include: R2's facility Face Sheet dated 9/30/22 documents R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS (Minimum Data Set) dated 9/30/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R3's facility Face Sheet dated 9/29/22 documents R3 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS dated [DATE] documents R3 has a BIMS score of 00, which indicates R3 has a severe cognitive impairment. The facility Illinois Department of Public Health Report dated 9/4/2022 documents, On 9/4/2022 at approximately 9:15 am it was reported to Administrator that Resident (R2) made contact with resident R3 in his left shoulder and left arm. Residents were immediately separated and will remain separated for the remainder of the day. Nurse assessed for injures. Nurse noted an abrasion 6 cm x 7 cm to R3's left shoulder and a .1 cm x 2 cm skin tear to R3's left elbow. MD (physician), POA's (power of attorney), Ombudsman, and Police all notified. Full investigation has been initiated Final Report- Upon thorough investigation it was found that R3, who has a BIMS of 0 (Severe cognitive impairment), wandered into R2's room. R2, who has a BIMS of 15 (cognitively intact), reported he was awoken when R2 wandered into his room and made contact with him with a 3-pound hand weight. This awoke and frightened R2. R2 then attempted to assist R3 out of his room, causing him to fall to the floor. Both residents were immediately assessed. Nurse noted an abrasion 6 cm by 7 cm to R3's left shoulder and a .1 by 2 cm skin tear to his left elbow. R2 did not acquire any injuries. R3's abrasion and skin tear is healing well with no signs/symptoms of infection. Safety committee has decided to apply a mesh stop sign to R2's doorway to aid in preventing other residents wandering into rooms that are not their own. Additionally, a care plan meeting was completed with the resident's family and due to the progression in R3's dementia they requested a referral be sent to a Dementia/Alzheimer's behavior unit. MD was updated and agreed with this referral. The referral was sent to a facility in (local town) and they have accepted resident and will be picking him up 9/12/2022. MD, POA, ombudsman, and police all notified of interventions. On 9/29/22 at 1:04 PM, this surveyor reviewed the facility abuse/neglect allegations with V1 (Administrator). V1 stated the facility had a peer-to-peer abuse investigation dated 9/4/22 that involved R2 and R3. V1 stated the facility only had one other peer to peer investigation in the past 90 days and it did not involve R2 and R3. V1 stated R3 had not been physically aggressive with peers until the incident on 9/4/22. On 9/30/22 at 8:34 AM, R2 stated he had a man (R3) come into his room and picked up a chair. R2 stated he was in bed sleeping and when he woke up R3 was standing in his room, next to his bed, and had the chair in the air like he was going to hit R2. R2 stated he told R3 to put it down and he did. When asked what he thought R3 was going to do with the chair, R2 stated I thought he was going to hit me. R2 stated R3 told R2, get out of my room. When asked if there were any other incidents with R3, R2 stated, R3 came into his room again and picked up a 3-pound weight and hit R2 in the stomach with it. R2 stated the weight, and the chair were both located in R2's room. When asked if he was afraid of R3, R2 stated, Yeah he seemed violent. R2 stated if you talked with R3 in a calm voice R3 would be ok. When asked if he felt like the facility did everything, they could to keep him safe, R2 stated they did. R2 stated they kept an eye on R3 and then he moved to another facility. R2's progress notes document on 9/4/22 at 10:59 AM Res (R2) had another res (unidentified) come into his room and threaten him and tear stuff up per res. Other res (unidentified) proceeded to throw 3 pound hand weight at res (R2) so he pushed him. Res (R2) has no apparent injuries . R2's progress notes document on 9/4/22 at 12:49 PM Admin (Administrator) also notified on incident upon it happening. R2's progress notes do not document an incident with a peer holding a chair and standing over R2's bed. R3's facility progress notes document the following: On 8/30/22 at 2:36 PM Resident observed laying in another resident's bed. While staff was moving him to his own room, Resident hit, kicked, cursed and tried biting staff. Resident put in his own bed where he fell asleep. Resident less combative .this PM. On 8/31/22 at 10:52 AM Resident attempted to leave out of the back door @ 8 am center hall. CNA was able to get him before he went outside. Another resident was c/o (complains of) R3 standing over his bed in the morning with a chair over his head cnas were able to get resident out of the other resident's room before anything happened. R3's progress notes do not document behaviors or assessment of behaviors until 9/4/22 when they document at 11:04 AM Res (R3) went into another res room and was threatening him and threw a weight at him. Other res (R2) then proceeded to push him, and res (R3) fell out of doorway and landed on his side per CNA. Res (R3) presents with two skin tears near his left elbow that measure 0.2 cm x 0.2 cm and a 3.5 x 0.1 cm that both required 3 steri strips a piece. Res also presents with an abrasion that measures 7 x 6 cm on his left shoulder, res (R3) re-directed to his own room. R3's progress notes document on 9/4/22 at 12:32 PM R3's physician was notified of the incident and at 12:49 PM the Administrator was notified of the incident. On 9/5/22 at 1:14 PM a late entry was made in R3's progress notes for 9/4/22 at 11:30 PM that documents, Res (R3) up walking up and down center hall going in and out of every room on center hall over and over and over and waking up every resident on Center Hall. 1-1 and redirection attempted and ineffective D/T (due to) res confusion and uncooperative. Res given a bowl of cereal in an attempt to get him to stay off center hall and sit still. On 9/29/22 at 3:22 PM this surveyor reviewed R3's progress notes with V1 (Administrator) and she stated she was not aware of the incident on 8/31/22, but she would check with her Regional (V8) who covered for her when she was off work and see if she was aware of it. V1 then provided this surveyor with the facility Resident Incident Report dated 8/31/22 that documented, This resident (R3) went into another resident's (unidentified) room and was standing over the other resident's bed with a chair. CNA's (Certified Nursing Assistant's) immediately intervened and redirected resident out of the room .MD (physician) and POA (power of attorney) notified. R3's peer is not identified in this report. There is no notification to local law enforcement, or the state agency documented in this report. The facility Incident Investigation dated 8/31/22 documents Resident (R3) with DX (diagnosis) of traumatic-subdural hemorrhage, TIA, ([CONDITION(S)]/stroke) Alzheimer's Disease, anxiety, [CONDITION(S)], and bi-polar disorder was re-directed from a peer's (not identified) room when he was observed with a chair above his head in the peer's room. Resident's behavior tracking for wandering and aggression were reviewed and updated. Medication review by pharmacist to identify medication conflicts. Assess resident for an unmet physical need e.g. hunger, thirst, bathroom, fatigue. Provide assistance to help resident make social connections. Use of visual cues to help resident find their room. Engage resident in meaningful activities for them-continuing life events and roles from their past. Provide regular positive attention. Validate resident's feelings around any known concerns. Provide reassurance-resident's need for safety and security. This investigation does not identify who R3's peer is. It does not document the local law enforcement, or the state agency were notified. R3's one hour checks sheets titled One Hour Checks x 5 days document R3 was monitored by staff every hour beginning on 8/31/22. R3's Resident 15-minute check sheet documents every 15-minute checks were done from 9/4/22 until date of discharge on 9/12/22. R3's Care Plan Behavior Tracking Record documents R3 has behavior tracking in place from 8/15/22 (date of admission) for wandering and agitation. R3's behavior tracking log dated 8/2022 documents an incident of agitation on 8/31/22. R3's behavior tracking record dated 9/2022 documents an incident of agitation on 9/4/22. R3's wandering behavior tracking for 8/2022 and 9/2022 document the behavior of wandering at least daily. R3's care plan documents a Care Plan Description (start date 9/4/22) of Behavior: Physically aggressive behavior x (times)1. Resident wandered into peers' room with a hand weight and threw at peer. Interventions documented on this care plan with start dates of 9/4/22 are as follows: 1. Do not argue with resident, 2. Talk in a calm voice when behavior is disruptive. 3. Refer to Social Services for evaluation. 4. Remove from public area when behavior is disruptive and unacceptable. 5. Praise for demonstrating desired behavior. 6. Monitor and document target behaviors. 7. Identify causes for behavior. 8. Reduce factors that may provoke aggressive behaviors. 9. Administer behavior medication as ordered by physician. 10. Provide diversional activities. The care plan documents the following intervention with a start date of 9/6/22, Meeting held with family to discuss incident from 9/4. Please see care conference note. Family agreed with moving resident to a facility suited for residents with such behaviors. R3's care plan documents a Care Plan Description (start date of 8/15/22) of Potential Behaviors: Dx (diagnosis) Alzheimer's disease. The interventions documented are all dated 8/15/22 and include explain care prior to providing, maintain calm voice and environment, medications as ordered, observe behaviors, and try to determine cause, observe for signs and symptoms of acute episodes, redirect, and reorientate as needed, provide therapeutic communication as needed, provide, and encourage favorite activities. R3's care plan does not document the incident or new interventions for the peer-to-peer incident that occurred on 8/31/22. On 9/29/22 at 1:55 PM, V3 (CNA/Certified Nursing Assistant) stated she was working on 9/4/22. V3 stated R3 always roamed the hallways and thought other resident's rooms were his. V3 stated R2 told R3 it wasn't his room and when you tell R3 that he gets angry. V3 stated R3 picked up a weight R2 had in his room and threw it at him. V3 stated R2 pushed R3 out of his room and when he did R3 fell into the floor. When asked if R3 had been physically aggressive before, V3 stated R3 had not been physically aggressive with peers but had been with staff. When asked what they did to prevent R3 from entering other resident rooms V3 stated they had some stop signs up on some of the doors. When asked if R3 had attempted to enter R2's room before the incident V3 stated, they always caught R3 in R2's room. V3 stated R2 did not have a stop sign on his doorway and she wasn't sure why. V3 stated the stop sign did not keep R3 from entering other resident's rooms. V3 stated they also had an alarm on R3's room so they would know if he got up, and they would give him activities to do. V3 stated when the incident occurred, she was just down the hallway and got to the room as R2 pushed R3 out. When asked if either resident were on increased monitoring prior to the incident on 9/4/22 V3 stated they were not since either R2 or R3 had been physically aggressive with peers prior to 9/4/22. On 9/29/22 at 2:12 PM. V2 (LPN/Licensed Practical Nurse) stated she was working on 9/4/22 but did not witness the event. V2 stated she assisted with assessing R3 after the incident. V2 stated R3 was combative with care and thought the whole facility was his. V2 stated R3 could be in an empty room, or the dining room and it would still be his. V2 stated she had not been involved with any other peer to peer incidents with R3. On 9/30/22 at 9:48 PM, V4 (CNA) stated R3 would wander to and from rooms and would get violent when being redirected. V4 stated she would give R3 snacks, magazines, and activities to keep him from wandering. When asked if those things helped, V4 stated they would sometimes. V4 stated R3 had behavior tracking in place and she did not witness the peer-to-peer incidents. On 9/30/22 at 10:00 AM, V5 (RN) stated she did not witness the peer-to-peer incidents between R2 and R3. V5 stated R3 was combative with staff during care and wandered into other residents' rooms frequently. V5 stated R3 would lay in other resident's beds, and it was difficult to get him to move because he thought it was his bed. V5 stated R3 was very hard to redirect. V5 stated they would sit R3 in the dining room and offer him drinks and snacks. When asked if those interventions worked V5 stated, they did not. V5 stated she was not aware of the incident between R2 and R3 on 8/31/22. When asked if they were monitoring R3 for physical altercations prior to the incident on 9/4/22, V5 stated they were watching R3. When asked to explain what that meant V5 stated We would have him sit in the dining room by the nurse's desk. On 9/30/22 at 10:47 AM, V6 (CNA) stated she was working on 9/4/22 and was coming down the hall when she saw R3 coming out of R2's room backwards and R3 fell and landed on his bottom. V6 stated R2 told them R3 hit him while he was in his room. When asked if either resident appeared upset at that time, V6 stated R2 was a little bit upset, R3 was not. V6 stated that was the first incident that she was aware of between R2 and R3. V6 stated R3 would wander into other resident's rooms. V6 stated they tried to check R3 every 15 minutes. V6 stated when R3 would get aggressive they would talk to him calmly and redirect R3 to do something else. On 9/30/22 at 11:42 AM, V7 (LPN) stated she was working on 8/31/22 and R2 told her he opened his eyes and R3 was standing in his room with the chair over his head. V7 stated she documented it and made sure R3 stayed out of R2's room. V7 stated she didn't remember the specific details when asked if she reported the incident. V7 stated she knew she talked about it, but she didn't fill out an incident report and she should have. V7 stated there weren't any staff in R2's room at the time of the incident. V7 stated it was morning and she believed R2 was still sleeping but she wasn't sure if there were any staff in the room. V7 stated R2 reported the incident to her. On 10/04/22 at 9:22 AM, V1 (Administrator) stated the incident that occurred on 8/31/22 between R2 and R3 was not reported to the state survey agency or the local law enforcement. V1 stated she was wasn't sure why it wasn't reported. V1 stated she was in and out of work at that time with a sick baby. V1 stated she wasn't sure why the incident wasn't considered abuse. When asked if she would have considered it abuse she stated she would have consulted with someone else since she is new in her position. The facility Nursing and Rehab Abuse Prevention Policy and Procedures dated 8/16/2018 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion Under definitions the same policy documents, Abuse, is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse facilitated or enabled through the use of technology.

Based on interview and record review, the facility failed to implement their Abuse Policy and Procedure to notify the state agency of a resident-to-resident abuse allegation for 1 of 4 (R2) residents reviewed for abuse investigations in the sample of 8. Findings Include: R2's facility Face Sheet dated 9/30/22 documents R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS (Minimum Data Set) dated 9/30/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R3's facility Face Sheet dated 9/29/22 documents R3 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS dated [DATE] documents R3 has a BIMS score of 00, which indicates R3 has a severe cognitive impairment. On 9/29/22 at 1:04 PM this surveyor reviewed the facility abuse/neglect allegations with V1 (Administrator). V1 stated the facility had a peer-to-peer abuse investigation dated 9/4/22 that involved R2 and R3. V1 stated the facility only had one other peer to peer investigation in the past 90 days and it did not involve R2 and R3. V1 stated R3 had not been physically aggressive with peers until the incident of 9/4/22. On 9/30/22 at 8:34 AM R2 stated he had a man (R3) come into his room and pick up a chair. R2 stated he was in bed sleeping and when he woke up R3 was standing in his room, next to his bed, and had the chair in the air like he was going to hit R2. R2 stated he told R3 to put it down and he did. When asked what he thought R3 was going to do with the chair, R2 stated I thought he was going to hit me. R2 stated R3 told R2, get out of my room. When asked if there were any other incidents with R3, R2 stated, R3 came into his room again and picked up a 3-pound weight and hit R2 in the stomach with it. R2 stated the weight, and the chair were both located in R2's room. When asked if he was afraid of R3, R2 stated, Yeah he seemed violent. R2 stated if you talked with R3 in a calm voice R3 would be ok. When asked if he felt like the facility did everything, they could to keep him safe, R2 stated they did. R2 stated they kept an eye on R3 and then he moved to another facility. R2's progress notes document on 9/4/22 at 10:59 AM Res (R2) had another res (unidentified) come into his room and threaten him and tear stuff up per res. Other res (unidentified) proceeded to throw 3 pound hand weight at res (R2) so he pushed him. Res (R2) has no apparent injuries . R2's progress notes document on 9/4/22 at 12:49 PM Admin (Administrator) also notified on incident upon it happening. R2's progress notes do not document an incident with a peer holding a chair and standing over R2's bed. R3's facility progress notes document the following: On 8/31/22 10:52 AM Resident attempted to leave out of the back door @ 8 am center hall. CNA was able to get him before he went outside. Another resident was c/o (complains of) R3 standing over his bed in the morning with a chair over his head cnas were able to get resident out of the other resident's room before anything happened. On 9/29/22 at 3:22 PM this surveyor reviewed R3's progress notes with V1 (Administrator) and she stated she was not aware of the incident on 8/31/22, but she would check with her Regional Nurse (V8) who covered for her when she was off work and see if she was aware of it. V1 then provided this surveyor with the facility Resident Incident Report dated 8/31/22 that documented, This resident (R3) went into another resident's (unidentified) room and was standing over the other resident's bed with a chair. CNA's (Certified Nursing Assistant's) immediately intervened and redirected resident out of the room .MD (physician) and POA (power of attorney) notified. R3's peer is not identified in this report. There is no notification to local law enforcement, or the state agency documented in this report. The facility Incident Investigation dated 8/31/22 documents Resident (R3) with DX (diagnosis) of traumatic-subdural hemorrhage, TIA, ([CONDITION(S)]/stroke) Alzheimer's Disease, anxiety, [CONDITION(S)], and bi-polar disorder was re-directed from a peer's (not identified) room when he was observed with a chair above his head in the peer's room. Resident's behavior tracking for wandering and aggression were reviewed and updated. Medication review by pharmacist to identify medication conflicts. Assess resident for an unmet physical need e.g. hunger, thirst, bathroom, fatigue. Provide assistance to help resident make social connections. Use of visual cues to help resident find their room. Engage resident in meaningful activities for them-continuing life events and roles from their past. Provide regular positive attention. Validate resident's feelings around any known concerns. Provide reassurance-resident's need for safety and security. This investigation does not identify who R3's peer is. It does not document the local law enforcement, or the state agency were notified. On 9/30/22 at 11:42 AM, V7 (Licensed Practical Nurse/LPN) stated she was working on 8/31/22 and R2 told her he opened his eyes and R3 was standing in his room with the chair over his head. V7 stated she documented it and made sure R3 stayed out of R2's room. V7 stated she didn't remember the specific details when asked if she reported the incident. V7 stated she knew she talked about it, but she didn't fill out an incident report and she should have. V7 stated there weren't any staff in R2's room at the time of the incident. V7 stated it was morning and she believed R2 was still sleeping but she wasn't sure if there were any staff in the room. V7 stated R2 reported the incident to her. On 10/04/22 at 9:22 AM, V1 (Administrator) stated the incident that occurred between R2 and R3 on 8/31/22 was not reported to the state agency or local law enforcement. The facility Nursing and Rehab Abuse Prevention Policy and Procedures dated 8/16/2018 documents in part, The Administrator is required to report to (the department), immediately, or within one hour, the alleged crime or abuse . Under section V. Protection of Residents, the policy documents, .All Resident to Resident abuse allegations will be reported to IDPH, Ombudsman, and the local police. Under section VI. Internal Investigation of Abuse, Neglect or Misappropriation Allegations and Response the policy documents, 1. All incidents will be documented, whether or not abuse occurred, was alleged, or suspected. 2. Any incident or allegation involving abuse, neglect or misappropriation will result in an abuse investigation .

Based on interview and record review the facility failed to report the incident of resident to resident abuse to the state agency for 1 of 4 (R2) residents reviewed for abuse investigations in the sample of 8. Findings Include: R2's facility Face Sheet dated 9/30/22 documents R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS (Minimum Data Set) dated 9/30/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R3's facility Face Sheet dated 9/29/22 documents R3 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 3' s' MDS dated [DATE] documents R3 has a BIMS score of 00, which indicates R3 has a severe cognitive impairment. On 9/30/22 at 8:34 AM, R2 stated he had a man (R3) come into his room and pick up a chair. R2 stated he was in bed sleeping and when he woke up R3 was standing in his room, next to his bed, and had the chair in the air like he was going to hit R2. R2 stated he told R3 to put it down and he did. When asked what he thought R3 was going to do with the chair, R2 stated I thought he was going to hit me. R2 stated R3 told R2, get out of my room. When asked if he was afraid of R3, R2 stated, Yeah he seemed violent. R2 stated if you talked with R3 in a calm voice R3 would be ok. When asked if he felt like the facility did everything, they could to keep him safe, R2 stated they did. R2 stated they kept an eye on R3 and then he moved to another facility. R2's progress notes document on 9/4/22 at 10:59 AM Res (R2) had another res (unidentified) come into his room and threaten him and tear stuff up per res. Other res (unidentified) proceeded to throw 3 pound hand weight at res (R2) so he pushed him. Res (R2) has no apparent injuries . R2's progress notes document on 9/4/22 at 12:49 PM Admin (Administrator) also notified on incident upon it happening. R2's progress notes do not document an incident with a peer holding a chair and standing over R2's bed. R3's facility progress notes document the following: On 8/31/22 10:52 AM Resident attempted to leave out of the back door @ 8 am center hall. CNA was able to get him before he went outside. Another resident was c/o (complains of) R3 standing over his bed in the morning with a chair over his head cnas were able to get resident out of the other resident's room before anything happened. On 9/29/22 at 3:22 PM this surveyor reviewed R3's progress notes with V1 (Administrator) and she stated she was not aware of the incident on 8/31/22, but she would check with her Regional Nurse (V8) who covered for her when she was off work and see if she was aware of it. V1 then provided this surveyor with the facility Resident Incident Report dated 8/31/22 that documented, This resident (R3) went into another resident's (unidentified) room and was standing over the other resident's bed with a chair. CNA's (Certified Nursing Assistant's) immediately intervened and redirected resident out of the room .MD (physician) and POA (power of attorney) notified. R3's peer is not identified in this report. There is no notification to local law enforcement, or the state agency documented in this report. The facility Incident Investigation dated 8/31/22 documents Resident (R3) with DX (diagnosis) of traumatic-subdural hemorrhage, TIA, ([CONDITION(S)]/stroke) Alzheimer's Disease, anxiety, [CONDITION(S)], and bi-polar disorder was re-directed from a peer's (not identified) room when he was observed with a chair above his head in the peer's room. Resident's behavior tracking for wandering and aggression were reviewed and updated. Medication review by pharmacist to identify medication conflicts. Assess resident for an unmet physical need e.g. hunger, thirst, bathroom, fatigue. Provide assistance to help resident make social connections. Use of visual cues to help resident find their room. Engage resident in meaningful activities for them-continuing life events and roles from their past. Provide regular positive attention. Validate resident's feelings around any known concerns. Provide reassurance-resident's need for safety and security. This investigation does not identify who R3's peer is. It does not document the local law enforcement, or the state agency were notified. On 9/30/22 at 11:42 AM, V7 (Licensed Practical Nurse, LPN) stated she was working on 8/31/22 and R2 told her he opened his eyes and R3 was standing in his room with the chair over his head. V7 stated she documented it and made sure R3 stayed out of R2's room. V7 stated she didn't remember the specific details when asked if she reported the incident. V7 stated she knew she talked about it, but she didn't fill out an incident report and she should have. V7 stated there weren't any staff in R2's room at the time of the incident. V7 stated it was morning and she believed R2 was still sleeping but she wasn't sure if there were any staff in the room. V7 stated R2 reported the incident to her. On 10/04/22 at 9:22 AM, V1 (Administrator) stated the incident that occurred between R2 and R3 was not reported to the state survey agency. V1 stated she was wasn't sure why it wasn't reported. The facility Nursing and Rehab Abuse Prevention Policy and Procedures dated 8/16/2018 documents part, The Administrator is required to report to (the department), immediately, or within one hour, the alleged crime or abuse. Under section V. Protection of Residents, the policy documents, .All Resident to Resident abuse allegations will be reported to IDPH, Ombudsman, and the local police .

Based on interview and record review the facility failed to ensure the physician was notified of a significant change in condition for 1 of 3 (R3) residents reviewed for wounds in the sample of 3. Findings Include: R3's facility face sheet dated 10/08/21 documents R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's facility wound assessment report dated 8/31/21 documents a venous ulcer on R3's right lateral shin measuring 2.4 x 2.0 x 0.0 cm (centimeter) with 90% epithelial tissue and no signs of infection documented on the assessment this assessment is signed by V8 (Licensed Practical Nurse/LPN). R3's facility wound assessment report dated 9/9/21 documents the venous ulcer on R3's right lateral shin measures 5.0 x 2.5 x 0.3 cm with 50% slough and 50% eschar and purulent drainage. Under physician notified the assessment documents V7 (Physician) was notified on 9/9/21. This assessment is also signed by V8. R3's medical record did not document changes to the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/08/21 at 2:17 PM V8 (LPN) confirmed R3's wound assessment dated [DATE] was accurate and the wound had increased in size and had purulent drainage. When asked if R3's physician had been notified of the change in R3's venous ulcer V8 stated she did not call V7 but put R3 on the board to be seen by V7 when he came to the facility. V8 stated she believed R3 was to be seen by V7 on 9/10/21 but could not confirm that he had. Review of R3's record did not document he was seen by V7 until 9/17/21. On 10/08/21 at 2:29 PM V1 (Administrator) and V2 (Director of Nurses) confirmed R3 had not been seen by V7 until 9/17/21. On 10/08/21 at 10:05 AM V7 (Physician) stated R3 had probable [CONDITION(S)] when he was admitted to the facility and that he felt the treatments and dressings were administered as ordered by the facility. V7 stated he should have been notified of the purulent drainage on 9/9/21 and the treatment should have been been changed, however V7 stated the outcome would not have been any different if the treatment had been changed sooner.

Based on observation, interview, and record review the facility failed to provide adequate staff to meet care needs of residents. This failure has the potential to affect all 49 residents residing in the facility. The Findings Include: 1. On 6/29/21 at 1:23 PM, while in R34's room, the call light was turned on due to an incontinent episode and the room having a strong smell of urine. R34's bed sheets were saturated along with the clothing he was wearing. R34 stated that it takes the staff a long time to get to those lights at times. R34's most recent Minimum Data Set (MDS) documents a BIMS (Brief Interview Mental Status) of 11 indicating that he is moderately impaired in cognition. At 1:55 PM, V10 (Certified Nurse Assistant) came to R34's room to answer the call light. V10 then had to go find out how many persons were needed to assist R34 out of bed to get him cleaned up. V10 went on to state that she doesn't normally work this hall, that is why she is not familiar with the resident. On 6/29/21 at 2:20 PM, V8 (CNA) stated that she is the aide that is assigned to R34's hall, but she works this hall alone and sometimes gets pulled to help on the other halls. There used to be two aides assigned to each hall, but recently that has changed. On 6/30/21 at 11:45AM, V1 (Administrator) stated that generally the residents get showers 2-3 times a week, with a minimum of 2. Resident council minutes and grievance log shows documented concerns of extended times for call lights to be answered as follows: In March of 2021 a grievance was documented regarding call light system not working and time taken to answer call lights. The resident council minutes for April 2021 meeting then has call lights taking too long to be answered as an old business item. The resolution to this is that administration is hiring new CNA positions. The May 2021 resident council minutes have an old business item listed as issues with CNA's and needing more help on the floor. Residents feel again like the call light time is too long. They feel with more CNA's this issue would get resolved. The June 2021 resident council minutes had a continued old business item of the call light system and administration stated they are working on getting a new one wired in. V8 (CNA) stated on 6/29/21 at 2:30 PM that the call light system does not make any sounds, you just have to see that it is lit up above the door or at the nurses station. V8 went on to state that they used to make a sound for the bathroom call lights, but they don't anymore and she is unsure why. A grievance was filed on 6/7/21 with a description of the issue states that residents state that the time for call lights is increasing. One stated that they waited two hours to get up. The steps to the investigation documented: Observe staff and acknowledge it's not a matter of neglect, it is just a lack of CNA's in the facility. Summary and Findings: Needs to be more CNA's in each hall and have set duties to accomplish. The recommendations/action taken documented by V1 states administration is actively looking to hire more CNA's. Administration did an audit of time it is taking to answer call lights. Average time is 2-5 minutes. Upon review of staffing, findings show building is adequately staffed. 2. On 6-30-2021 at 12:50PM, R17 stated that it can take up to an hour to get a call light answered at times and indicated that this happens on all shifts. R17 stated she sometimes uses her personal cell phone and calls the facility phone and tells whomever answers that she is needing some assistance. R17 stated she has reported this to administration on more than one occasion and is told the problem would be addressed. R17 stated it continues to be a problem and she feels it's because they need more staff to take care of everyone. R17's quarterly resident assessment documents R17 as cognitively alert and oriented with a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. 3. On June 29, 2021 at 12:15 PM, R28 said the facility does not have enough people to make sure residents don't get out of the building, and said he was outside of the building smoking and calls the facility on his cell phone when a resident leaves out of the building unnoticed. R28 says the resident walks down the driveway and gets pretty far from the building. R28 said he did not think anyone knows when she leaves but she goes out the door everyday. R28 also said there are times he must remain in bed because there is not enough staff to get him up. He said he does not like waiting for 45 minutes to an hour to get out of bed but that is the way it is. 4. On 06/29/21 at 9:59 AM, R20 said there is not enough CNA's on evening shift everyday, and not enough on the weekends for day shift. R20 said they don't answer call lights timely and they do not give showers. If you ask the staff about not getting the water cups filled with ice water, they will tell you they do not have time to do it. I have to ask for ice water and ask for the water to be refilled. R20 said the staff use to fill them up daily with ice water and would pick them up, clean them and return them with the ice water but they do not have time anymore. R20 also said her bed pan is not cleaned after each use, and she feels the oral care for dementia patients is not being completed. On 06/29/21 at 1:37 PM V9, Certified Nurses Aide (CNA) said she was assigned to L hall alone and she had to get another CNA from Washington hall to assist her when the residents needed two assist. She also said when she is assigned to a hall by herself she is not able to give showers and she felt other needs of the residents were more important and that is what she did. On 6/29/2021 at 1:38 PM, V7, CNA verified when she is assigned to a hall by herself she would be unable to give showers since she had to be on the hall to take care of other more important resident needs. V7 also said she did not believe evening shift CNA staff gave showers. No Showers were observed given during the survey time on 6/29/21, 6/30/21, or July 1, 2021. On July 1, 2021 at 4:02 PM V23, CNA said she had not had time to give any showers on her shift and she does not have time with her being the only CNA assigned to a hall. 4.On 06/29/21 at 10:49 AM, R21 stated he has had to wait for staff to answer his call light sometimes up to 1 to 1.5 hours. And it has been 14 days since his last shower and he is supposed to get one twice a week. On 06/29/21 at 1:37 PM, R35's call light was turned on and at 1:59 PM a housekeeping staff knocked on the door and picked up his tray and did not ask what his light was on for. R35 stated, Sometimes they come and sometimes they don't come it is according to who is working. At 2:04 PM V24 (CNA) answered the light and asked R35 what he needed. On 7/1/2021 at 2:45 PM, V18 (CNA) also stated they are frequently short of staff and it is difficult to give residents showers because they can not leave the other residents on the hall unattended, they have difficulty toileting people and giving showers at the same time when there is only 1 CNA on the hall. 07/01/21 8:40 AM, V9 (CNA) stated, I think we don't have enough staff, we can get most of the care done except for showers. It is hard to get to their showers sometimes because it does not leave anyone on the hall. If I don't get them done I just document this and tell the nurse. I don't know what they do after that. Resident Census and Conditions of Resident dated 6/29/21 documents that 40 residents are in a chair all or most of the time and require support from others, 8 residents that require oversight/cueing/physical assistance and/or assistive devices, and 1 resident that is in a chair all or most of the time and require assistance to pivot from bed to wheelchair or to transfer otherwise. This document also lists a total of 49 residents residing in the facility.

Based on observation, record review and interview the facility failed to properly maintain the dish machine and keep food contact surfaces clean and sanitary. This failure has the potential to affect all 49 residents in the facility. The Findings Include: On 6/29/21 at 9:30 AM, V6 (Dietary Supervisor) stated that the dish machine is new but there have been issues with the water temperature and sanitizer level, and they are waiting for parts to come in. V6 went on to state that the staff are to check the sanitizer level two times a day in the dish machine, and those times are at start of first and second shift. V6 went on to state that the bucket sanitizing solution should be changed every two hours to ensure that sanitizer level is adequate. At this time the dish machine was not registering any sanitizer after several attempts to check it, and the bucket of sanitizer water used to wipe down surfaces also had no sanitizer registering when checked. V6 attempted to make a new bucket of sanitizing water solution, and no level was registering with the new solution. V6 was going to put in a call to the service agency to come look at the machines as soon as possible. The protocol for the staff to follow if the sanitizer is not at the proper level is to use the three compartment sink, and she would use bleach water to ensure proper sanitization would occur in both the 3 compartment sink and bucket of sanitizing water to wipe down surfaces. On the dish machine was a form titled Daily Sanitizing Checklist Chemical Sanitizing Dish Machine for the month of June. June 1 2021 June 2 2021 had the sanitizer level checked two times a day as directed and was within acceptable range. On June 3rd no chlorine level was checked and a corrective action was written in that the service department and that the wrong strips were sent. On June 4th-June 22nd no chlorine levels were documented as being checked. On June 5th- June 9th corrective action was documented as 'waiting on a part'. On June 23rd-26th the chlorine level was documented as 75 parts per million (PPM) with no corrective action listed. No documentation was was logged for checking the machine on June 28-29th. V6 stated at 9:40 AM on 6/29/21 that the acceptable range for the chlorine is 100-150 PPM and that it appears no one has checked the level for the past two days and now the sanitizer level is at zero. The Resident Census and Conditions of Residents dated 6/29/21 documents 49residents reside in the facility.

Based on observation, interview, and record review the facility failed to provide a minimum of 2 weekly showers to residents per policy for 4 of 16 residents (R21), (R27), (R34), and (R44) reviewed for activities of daily living in the sample of 37. The Findings Include: 1. On 6/28/21 at 1:15 PM, R34 stated that he does not get showers 'all too often.' V1 at 2:57 PM on 6/29/21 stated that residents are to receive at minimum 2 showers per week. Shower sheets provided by V1 on 6/29/21 indicate that R34 has only received 4 showers in the month of June as of 6/29/21. The showers are recorded on 6/11/21, 6/16/21, 6/21/21, and 6/22/21. R34's admission Minimum Data Set, dated dated dated [DATE] indicates that he is an extensive one person physical assist with personal hygiene. 2. On 7/1/2021 at 8:30 AM, R21 stated he usually takes a shower twice a week, and finally got his shower last night after 15 days. On 7/1/2021 at 2:45 PM, V18 CNA stated, (R21) was given either a bed bath, or a shower on the dates she documented. V18 also stated, (R21) usually takes showers, he may have took a bed bath on the dates I documented on the shower sheets. If the resident refuses a shower I have them initial the bottom of the shower sheet. R21's shower sheets entitled, Skin observation: Comprehensive Certified Nursing Assistant (CNA) Shower Review, indicate shower was done on 6/11/2021, 6/16/2021, 6/19/2021, and 6/26/2021. R21's Assistance and Support Sheet dated June , documents bathing on 6/5/2021, 6/19/2021, and 6/22/2021. R21's Minimum Data Set (MDS) dated [DATE] documents cognitive intact with Brief Interview for Mental Status (BIMS) score of 13, and requires one person physical assistance with bathing. 3. On 6/30/2021 at 8:29 AM, R27 stated she has gone over 2-3 weeks with no shower. She's supposed to get them on Tuesday and Thursday's, and no one had offered to give her one until she reported it to Physical Therapy staff. On 7/01/21 at 1:30 PM, (V14) Physical Therapist Assistant (PTA) stated, About a week or two ago (R27) and (R33) both complained in therapy about not getting showers. I immediately reported this to (V1) and she took care of it and both got their showers. On 07/02/21 at 8:05 AM, V1 stated, On the ADL bathing sheets if it is marked 8 it means they did not receive a bath. About a week ago (V14) reported to me (R27) and (R33) said they had not been given showers for over a week. I immediately went to the CNA's and both residents were given a shower that day. I am aware of the shower issues, and have been working on a plan for improvement with nursing to get more accountability. I expect residents to get a bed bath every night. R27's shower sheets entitled, Skin observation: Comprehensive CNA Shower Review; indicate shower was done on 6/16/21, 6/21/2021, and 6/26/2021. R21's Assistance and Support Sheet dated June 2021, documents bathing was done on 6/10/2021, 6/15/2021, and, 6/28/2021. R27's MDS dated [DATE] documents she is cognitively intact with a BIMS score of 15 and requires one person physical assist with bathing. 4. On 06/29/21 at 12:07 PM, R44 was up in his wheelchair, mildly confused, and not shaven. His fingernails were long with brown material under the nails. On 06/30/21 at 10:37 AM, V21 stated, when she visited (R44) last time she noticed his nails were long and unkept, she was planning to ask the staff about this. On 7/1/2021 8:40 AM V9 (CNA) stated, she got (R44) up today and did not notice his fingernails needed trimmed. On 07/01/21 at 3:00 PM, V11 observed (R44)'s hands and feet with surveyor. R44's fingernails were still long with brown material under them. V11 stated, Yes, (R44)'s fingernails should have been cleaned and trimmed. The nursing staff should have found this when doing their assessments and addressed it then. R44's shower sheets entitled, Skin observation: Comprehensive CNA Shower Review; indicate bathing on 6/11/2021, 6/16/2021, 6/21/2021, & 6/26/2021. R44's Assistance and Support Sheet dated June 10th through June 30th 2021, documents no bathing on days, eves, or nights. R44's MDS dated [DATE] documents severe cognitive impairment with BIMS 00, and requires one staff assist with personal hygiene. Facility policy entitled Activities of Daily Living (ADL's), Supporting dated Revised March 2018 documents, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Facility undated policy entitled, Fingernails and Toenails Care documents, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and prevent infections.

Based on interview, observation and record review the facility failed to provide showers based on resident choice preference for three ( R20, R28, R29) of 16 residents reviewed for resident choice in a sample of 37. The findings include: 1. On 6/29/2021 at 2:28 PM, R29 said the facility was short staffed for Certified Nurses Aides (CNA) and said she had went for 16 days without a shower. R29 said on the 16th day, V23, CNA clocked out of work at 2 PM and came back in to work and gave her a shower on V23's own time. R29 said V23 did not get paid for giving her a shower. R29 said she wanted and was to get a shower on Tuesday's, Thursday's and Sundays. V23 also said her hair was so long two staff were needed to assist her with her hair. R29 said she was supposed to get a shower earlier today but was told they were short staffed again and she would not get a shower. A Minimum Data Sets assessment dated [DATE] lists R29's Brief Interview for Mental Status score as 15 indicating R29 as being cognitively intact. This same MDS lists R29's functional status as being totally dependent on two staff with transfers, bathing, and toilet use and lists R29 as always incontinent with bowel movements. R29's care plan lists no behavior issues and lists Hoyer Lift transfer and assist X 2 and the electronic record lists the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R29's Care Plan does not list any behaviors and lists it is important to her to choose between a tub bath, shower, bed bath or sponge bath. A document entitled ADL (activities of daily living) Assistance and Support for the month of June, 2021 lists R29 as receiving a bath on evening shift on June 1, June 18, and on night shift on June 6, June 10, June 22, and once on day shift on 6/21/2021. This document did not indicate if the bath consisted of a shower or bed bath. On 07/01/21 at 4:02 PM, when the ADL Assistance and Support document for June, 2021 was reviewed with R29, she said she had never received a shower or bath on evening shift or night shift and said she went 16 days without a shower in the month of June, 2021. R29 said she wants to get a shower three days a week and does not get them. 2. On 06/29/21 at 12:15 PM, R28 said the facility is short staffed and he only gets one shower a week and he prefers at least two. R28 said he only gets a shower on the weekend and has told the staff he needs a shower more often and he does not get them. A Quarterly MDS dated , 5/14/2021 lists R28 as having no behaviors, a BIMS score of 11 indicating moderate cognitive impairment. R28 needs extensive assistance of two persons for transfers, and bathing with impairment in range of motion on both upper and lower extremities. R28's Care Plan does not list any behaviors and lists it is important to him to choose between a tub bath, shower, bed bath or sponge bath. A document entitled ADL Assistance and Support for June 2021 lists R28 as receiving baths on June 1, June 5, June 12, June 19, June 22, June 23, and June 27, 2021 and does not indicate whether the baths were showers or bed baths. 3. On 06/29/21 at 09:59 AM, R20 said there is not enough CNA's on evening shift everyday, and not enough on the weekends for day shift and they do not give showers. R20 said she does not receive very many showers and would like to get more than she does. A quarterly MDS dated [DATE] lists R20 with a BIMS score of 15 indicating she is cognitively intact. The MDS lists no behaviors, and needs extensive assistance of two persons with transfers, and one person physically assisting with bathing. Documented that R20 has impairment with range of motion on both lower extremities, and occasionally incontinent of bowel and bladder. R20's Care Plan lists her with utilizing a sit to stand mechanical lift for transfers, and lists it is important to her to choose between a tub bath, shower, bed bath or sponge bath. On 06/29/21 at 01:37 PM, V9, Certified Nurses Aide (CNA), said she was assigned to L hall alone and she has to get another CNA from Washington hall to assist her when the residents needed two. She also said when she is assigned to a hall by herself she is not able to give showers and she felt other needs of the residents are more important and that is what she did. On 6/29/2021 at 1:38 PM, V7, CNA verified when she is assigned to a hall by herself she would be unable to give showers since she had to be on the hall to take care of other more important resident needs. V7 also said she did not believe evening shift CNA staff gave showers. There were no showers being given during the survey time on 6/29/21, 6/30/21, or July 1, 2021. On July 1, 2021 at 4:02 PM. V23, CNA said she had not had time to give any showers on her shift and she does not have time with only 1 CNA assigned to a hall.

Based on record review, interview and observation the facility failed to assess, monitor and provide sufficient fluid to maintain proper hydration for 5 of 8 residents (R1, R4, R2, R6, R8) reviewed for dehydration in a sample of 8. This failure resulted in R2 being hospitalized for [REDACTED]. This failure resulted in an Immediate Jeopardy. . While the Immediate Jeopardy was removed on [DATE], the Facility remains out of compliance at severity level two, while the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication for hydration. The findings include: 1. R2 was admitted to the facility on [DATE] with diagnoses, in part, of depression, Alzheimer's, pneumonia, and muscle weakness. The lab values on [DATE] were documented as Blood Urea Nitrogen (BUN) at 11 (,[DATE] mg (milligrams)/dL (decaliter), creatinine at 0.9 (0XXX,[DATE].3 mg/dL, and sodium 137 (,[DATE] mEq (milliequivalents)/L (liter). The "Admission Assessment" dated [DATE] documented "Good" for "Turgor". The assessment also documented R2 had to be "Fed" and was oriented "To person". The hospital "Physician's Orders at Time of Transfer" on the "Nursing Home Transfer Form" dated [DATE] documented for R2 "Assist (with) meals" and "Between Meal nourishment". The nurses notes on [DATE] at 4:15 PM documented "Good skin turgor", "needs help (with) eating", "Appears in a pleasant mood. quiet-alert x 1 to person. noted some confusion". The nurses notes dated [DATE] documented R2 "needs help with eating". On [DATE] the nurses notes documented "fed by staff". On [DATE], "needs to be fed/assist". On [DATE] "Staff fed meals". The Care Plan dated [DATE] identified R2 as at risk for dehydration due to cognitive impairment, decreased thirst perception, lack of awareness of need to drink and inability to communicate. The care plan documented as interventions: Assess skin turgor over sternum or inner thigh, as aging skin loses elasticity; Assess urine for color, consistency , and odor, as frequent, clear urine is an indicator of hydration; Be alert for symptoms of dehydration: change in mental status/confusion, constipation/fecal impaction, dizziness/drop in blood pressure from baseline, fatigue/lethargy; Explain the importance of hydration to (R2): Staff to offer fluids frequently and explain the importance of drinking fluids; Encourage her to drink and offer assistance at each encounter or on a routine basis; and Staff to feed (R2) as needed. On [DATE], Z3, R2's Primary Physician, came to the facility to see R2 and ordered lab work to be completed on [DATE]. The lab results on [DATE] documented BUN at 20 mg/dL, creatinine at 1.1 mg/dL, and sodium 147 mEq /L. There was no other documentation that the physician was notified after [DATE] until [DATE]. On [DATE] the nurses notes documented at 11:00 PM that R2 had a "Lg (large) emesis x 2 undigested food". The next nurses note on [DATE] at 12:00 AM documented "loose stools x 2". Lab work was drawn and reported on [DATE] at 5:00 AM. At 2:30 PM the nurses notes documented "multiple loose stools-no emesis. Alert to person (with) confusion poor PO intake". On [DATE] the nurses notes documented at 12:55 PM "N+V+D (nausea, vomiting, diarrhea) noted today PO fluids enc. (encouraged)". The nurses notes documented "loose stool x 1" on [DATE]. On [DATE] the nurses notes documented "cont. (continue) to have loose stool. (No N/V (nausea/vomiting). Good appetite. Feeds self". At 3:15 PM the nurses notes documented "Did (not) get up for meals today". On [DATE] at 1:05 AM it documented "loose stools x 2". The temperature was 100 and Tylenol was given for increased temperature. At 5:00 AM on [DATE] the nurses notes documented "Respirations rapid and shallow-(left) leg mottled. The physician was notified (Z3) and "TO (telephone order) received to send to the hospital". The nurses notes documented that R2 expired at 11:30 AM at the hospital. There was no documentation in the nurses notes regarding monitoring and assessing skin turgor, urine, and indicators of dehydration according to the Care Plan. E2, Director of Nursing stated in an interview on [DATE] at 1:35 PM that the nursing staff would chart in the nurses notes any assessment for urine or skin turgor. E2 stated there was no intake and output documentation for R2. E2 stated there has been a lot of residents with the flu in the building. The hospital History and Physical dated [DATE] by Z2, Hospital Physician, documented R2's lab results on admission was BUN at 60, Creatinine 4.4, and Sodium was 179. R2 was admitted with chief complaint of altered mental status and respiratory distress. The History and Physical documented R2 was normally alert but not oriented appeared septic and was experiencing "Cheyne-stokes breathing pattern. Due to the patients critical condition she was admitted for palliative care. Z2 documented R2 had very poor skin turgor and "The patients oral mucous membrane appears dry with food particles and significant dry thick green exudates covering over the paraoral cavities as well as the tongue". Intravenous hydration was started due to "significant [MEDICAL CONDITION] with sodium of 172, suspected for lack of oral intake or oral feeding from the nursing facility". R2 expired shortly after her arrival to the medical floor of the hospital. The hospital "Discharge Summary" dated [DATE] documented the final [DIAGNOSES REDACTED]. Z2 stated in an interview on [DATE] at 10:36 AM that R2 had a severely high sodium level that was "incompatible with life". Z2 stated the severe dehydration and [MEDICAL CONDITION] was the cause of death which caused the organ failure. Z2 stated R2 could not have been given fluids or fed. Z3, Physician, stated in an interview on [DATE] at 9:35 AM, that the facility did not call him except on [DATE] to discontinue therapy. Z3 stated he was at the facility on [DATE]. Z3 stated he was not aware there was any problems until the sister of R2 called him the day after she died to tell him. Z3 stated no one called him to tell him of her loose stools or decline. Z3 stated he was in town that weekend and was not sure why they didn't call him. Z3 stated it was a "Sad case" with what transpired in a week. Z3 stated they should have called him to help alleviate her problems. 2. R1 was identified in the Care Plan dated [DATE] as at risk for Dehydration due to cognitive impairment. The interventions included "Assess skin turgor over sternum or inner thigh, as aging skin loses elasticity", Assess urine for color, consistency, and odor, as frequent clear urine is an indicator of hydration", Be alert for symptoms of dehydration: change in mental status/confusion, constipation/fecal impaction, dizziness/drop in blood pressure from baseline, fatigue/lethargy", and "Explain the importance of hydration to (R1): and clarify the relationship of fluids and incontinence". The Care Plan dated [DATE] also identified R1 with "Cognitive Loss/Dementia", "Disordered Thinking, Mental function varies", and Disordered Thinking, Easily Distracted". The facility Nurses Notes dated [DATE] at 1:25 AM documented R1 "continues to have loose stools x 3-fluids encouraged". On [DATE] at 3:00 PM the nurses notes documented "loose stools x 4 today" and "poor PO (passing orally) intake". On [DATE] at noon the nurses notes documented the physician was "notified of current condition loose stools x 2". A Z-Pack was ordered. On [DATE] at 12:30 PM, the nurses notes documented R1 refused liquids and refused to get out of bed. On [DATE], the nurses notes documented fluids were encouraged and "will monitor". The physician was not notified again until [DATE] at 12:30 PM due to [MEDICAL CONDITION] with oxygen saturation levels at 80%. The nurses note also documented poor oral intake and poor appetite. R1 was admitted to the hospital for dehydration and [MEDICAL CONDITION]. There was no documentation in the nurses notes regarding monitoring and assessing skin turgor, urine, and indicators of dehydration according to the Care Plan. E2, Director of Nursing stated in an interview on [DATE] at 1:35 PM that the nursing staff would chart in the nurses notes any assessment for urine or skin turgor. The hospital History and Physical dated [DATE] documented R1 was "positive for mental status changes, increased confusion". According to the History and Physical, "Per family, one week ago patient was able to communicate and understand and know his family. He was able to stand and was eating good". R1 was admitted with [DIAGNOSES REDACTED]. R1's lab results were: Blood Urea Nitrogen 65 , creatinine 1.2 , Sodium 151. R1 was readmitted to the facility on [DATE]. Z2, Hospital Physician, stated in an interview on [DATE] at 10:36 AM that R1 was dehydrated on admission to the hospital with sodium levels in the 150's. Z2 stated R1 received hydration and that was corrected. 3. R8's Care Plan dated [DATE] identified R8 as at risk for dehydration due to cognitive impairment, dysphagia, fluid restriction and restricting fluids to avoid incontinence episodes. The interventions were: "Assess skin turgor over sternum or inner thigh, as skin in the elderly loses elasticity", Assess urine for color, consistency, and odor, as frequent clear urine is an indicator of hydration", Be alert for symptoms of dehydration: change in mental status/confusion, constipation/fecal impaction, dizziness/drop in blood pressure from baseline, fatigue/lethargy", and "Explain the importance of hydration to (R8): and clarify the relationship of fluids and incontinence". There are no nurses notes from [DATE] to [DATE]. On [DATE] the nurses notes documented R8 had an 8 pound weight loss and "eats fair to good each meal". The note also states "Plan to have Dietitian review this weight loss". The last Dietitian documentation was on [DATE]. On [DATE] at the noon meal, R8 was observed to eat only 75% of his ice cream with no other food or fluids taken. On [DATE] at the noon meal, R8 was observed to drink 4 ounces of water only. E3, Certified Nurse Aide (CNA), confirmed R8 only drank 4 ounces of water in an interview on [DATE] at 1:50 PM. The Food Intake Record for R8 documented R8 as "Fair" or that he ate and drank ,[DATE]% of his food and fluids at the noon meal on [DATE] and [DATE]. E2, DON, was informed of the intake observation for R8 at the noon meals and the documentation in the Food Intake Record. E2 stated in an interview on [DATE] at 2:00 PM that she asked E3 why the Food Intake Record was marked as Fair. E2 stated E3 told her she had told E6, CNA, that R8 had 0% intake and was not sure why she marked it that way. At 2:10 PM, the Director of Nursing was observed to check R8's skin turgor by pulling the skin up on his chest and arms. The skin on the arm was slow to go back but did not tent when pulled up. E2 stated the turgor was 'not good, not bad, not tenting". E2 stated she was not aware R8 had only had 4 ounces of water at lunch and told the staff R8 has to drink. E2 stated she told the charge nurse to make sure it was documented in the shift report. E2 stated R2 would be put on intake and output sheets. At 3:20 PM R8 was observed still in the hallway in his geri chair. R8's eyes were sunken. When asked what the hydration plan for R8 was E2 stated they had made a new sheet to monitor fluid intake. E2 was not aware if R8 had any fluids since lunch. E2 confirmed in an interview on [DATE] at 10:30 AM that the physician was not notified of the low intake until the evening of [DATE]. E2 stated he ordered R8 to be monitored on an intake and output record and start weekly weight monitoring. 4. R6 was admitted to the facility on [DATE] with diagnoses, in part, of Alzheimer's, [MEDICAL CONDITION], Depression. The Care Plan dated [DATE] and [DATE] documented "Dehydration, at risk for, potentially related to diuretic medication and dependency. Risk factor: cognitive impairment." The interventions listed on the [DATE] Care Plan documented "Assess skin turgor over sternum or inner thigh, as aging skin loses elasticity.", Assess urine for color, consistency, and odor, as frequent, clear urine is an indicator of hydration", and "Be alert for symptoms of dehydration: change in mental status/confusion, constipation/fecal impaction, dizziness/drop in blood pressure from baseline, fatigue/lethargy". On [DATE] the following interventions were added: "offer fluids throughout the day and night", assist with all meals", "labs as ordered". On [DATE] the physician ordered lab work and to "push water". The lab work was not completed until [DATE] at 10:20 AM and reported to the facility at 10:30 PM on [DATE]. E5, Licensed Practical Nurse (LPN), documented on the lab report "MD (Medical Doctor) Notified [DATE]". The lab results were BUN 57, Creatinine 1.0, Sodium 178. The sodium level was designated as "RCH" or "Repeat Critical High". Z4, Lab technician, stated in an interview on [DATE] at 9:15 AM that the repeat critical high means it has been repeated to ensure the correct results. R6's intake was documented as below the estimated fluid requirement for R6. Fluid needs were calculated by the Registered Dietitian as 1458 cc's (cubic centimeters) per day on the [DATE] "Nutritional Assessment". This is for normal fluid needs at 30 cc's per kilogram of body weight. The Nutritional Assessment documented fluid needs for "UTI (urinary tract infection), HX (history) Dehydration" is 35 cc's per kilogram of body weight. This would increase R6's fluid needs to 1701 cc's of fluid per day. The "Physician Orders" documented R6 was started on [MEDICATION NAME] 20 mg twice a day on [DATE]. The Intake and Output documentation for R6 noted her daily fluid intake was below fluid requirements. On [DATE]-480 cc's; [DATE]-690 cc; [DATE]-530 cc; [DATE]-550 cc; [DATE]-190 cc's; [DATE]-260 cc's; and, [DATE]-560 cc's. There is no documentation the low fluid intake was reported to the physician. There is no documentation in the nurses notes from [DATE] through [DATE] regarding skin turgor or urine assessment for dehydration. E2, Director of Nursing stated in an interview on [DATE] at 1:35 PM that the nursing staff would chart in the nurses notes any assessment for urine or skin turgor. E5 stated in an interview on [DATE] at 3:10 PM that she would usually call the physician if the lab was critical and usually the lab call to tell us. E5 stated she could not recall that far back. On [DATE], E2 provided a written documentation by E5 of the [DATE] incident. There was no date on the documentation. E5 documented "On [DATE] I notified (Z1) about labs on R6. Unable to recall the specific details of this event. I do not recall a telephone conversation with the lab on this night. I do recall checking our facility fax between 8 PM and 10 P med pass. It was during this time I received the fax and notified (Z1)". E2 stated in an interview on [DATE] at 10:30 AM that E5 told her she had called the physician about R6 and he had told her to call the family. E2 stated E5 could not recall if she had. E2 stated the next morning on [DATE] they did call the family and told them if she wasn't sent to the hospital she would die. E2 stated she was not sure why they had not sent her out the evening of [DATE]. The nurses notes dated [DATE] documented at 4:00 PM and on [DATE] at 1:45 AM has no documentation the physician was notified of the lab results. The next nurses note on [DATE] at 9:40 AM documented "Labs drawn came back critical. (Z1, Physician) notified. Orders to send to ER (emergency room ) for IV (intravenous) fluids and evaluation". Z1, Physician, stated in an interview on [DATE] at 11:30 AM that he could not recall if he was notified regarding R6's lab values dated [DATE]. Z1 stated if they would have called that night on [DATE] about the sodium being 170 that he "hope you would have sent her in". Z1 stated a sodium of 170 was "sort of an emergency" and they "should have called me". Z1 stated a sodium of 155, 160, 170 was the "usual manifestation of not drinking". According to the History and Physical dated [DATE], R6 was admitted to the hospital for severe [MEDICAL CONDITION], hyperchloremia, erythrocytosis, probably secondary to dehydration. R6 was admitted to the medical floor for IV fluid hydration. The history and physical documented R6's catheter was draining "dark amber urine". R6 was readmitted to the facility on [DATE]. 5. R4 was admitted to the facility on [DATE] with diagnoses, in part, of mental [MEDICAL CONDITION], possible [MEDICAL CONDITION], altered mental status. On [DATE], R4's bun was 18, creatinine 1.1 and sodium 147. The nurses notes dated [DATE] documented R4 was having emesis and loose stools. Z1, Physician, was in the facility and documented in a progress note "One of the principal things is he is not eating and drinking enough and that does concern me. Today is Friday, CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel)next week along with pelvis and both hip X-rays. They must keep me posted about his eating". The nurses notes dated [DATE] documented at 2:00 PM that R4 refused breakfast and lunch. The next nurses note was dated [DATE] at 2:45 AM when R4 was found on the floor non-responsive. R4 was sent to the hospital where he was admitted . The History and Physical by Z2, dated [DATE], documented R4 was admitted due to fractured ribs, altered mental status, acute [MEDICAL CONDITION], hypovolemic, hyperosmolar, [MEDICAL CONDITION] secondary to volume depletion, metabolic acidosis secondary to prerenal azotemia, and [MEDICAL CONDITION]. The History and Physical documented R4 had significant altered mental status with minimal withdrawal to pain. The History and physical documented R4 was "significantly volume depleted with perioral mucous membrane dryness with crack in the lips. The patient was found to have significant poor skin turgor with poor capillary refill...". The History and Physical documented R4's BUN at 38, creatinine at 1.2 and sodium at 162. Z2 stated in an interview on [DATE] at 10:36 AM that R4 had been combative in the past and was unresponsive on admission. Z2 stated R4 had severe dehydration with cracked lips and dry mucous on the tongue. Z2 stated R4 was unkept and required IV fluids. R4 was readmitted to the facility on [DATE]. The nurses notes dated [DATE] documented "Plan: Encourage, persuade et insist ,[DATE] (with) this res. (resident) to consume food (and) fluids and to involve family to participate (with) eating or drinking". 6. The facility Policy and Procedure titled "Hydration-Clinical Protocol" states: "The staff, with the physician's input, will identify individuals with signs and symptoms (for example, [MEDICAL CONDITION], lethargy, increased thirst, etc) or lab test results (for example, [MEDICAL CONDITION], azotemia, etc.) that might reflect existing fluid and electrolyte imbalances". "They will report this information promptly to the Attending Physician". "The staff, with the physician's input, will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance, for example, those with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well "The Physician will manage significant fluid and electrolyte imbalances, and associated risks, appropriately and in a timely manner." "The staff will provide supportive measures such as providing fluids and adjusting environmental temperature". "The Physician will help monitor for the development, progression, or resolution of fluid and electrolyte imbalance in at-risk individuals". "The Physician will adjust treatments based on specific information (lab results, level of consciousness, etc.) relevant to the individual". The Immediate Jeopardy situation was identified to have begun on [DATE] when R2 expired from dehydration. E1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 12:30 PM. . On [DATE], through interviews with E1, Administrator; E2, Director of Nursing; E3, Certified Nurse Aide (CNA); E7, Regional Director; E8 and E9, Licensed Practical Nurse (LPN); and E10, E11, E12, E13, and E14, CNA's, and review of the facility policy and procedure and in-service records, it was determined the facility took the following actions to remove the Immediate Jeopardy: 1. All residents were assessed for signs and symptoms of dehydration. Completed [DATE] with dietitian review. 2. All Direct Care staff were inserviced on [DATE] in regards to intake and output, signs of dehydration, physician notification, meal intake, and provision of hydration. 3. All staff were inserviced [DATE] for hydration, signs and symptoms of dehydration, measures to take to ensure hydration, communication regarding residents at risk for dehydration, and monitoring residents with poor intake.

Based on record review, interview and observation, the facility failed to notify the physician of a change or decline in a residents condition for 3 of 8 residents ( R2, R4, R6) reviewed for physician notification in a sample of 8. This failure resulted in R2 being hospitalized and expired. The findings include: 1. R2 was admitted to the facility on [DATE] with diagnoses, in part, of depression, Alzheimer's, pneumonia, and muscle weakness. The lab values on [DATE] were documented as Blood Urea Nitrogen (BUN) at 11 (,[DATE] mg (milligrams)/dL (decaliter), creatinine at 0.9 (0XXX,[DATE].3 mg/dL, and sodium 137 (,[DATE] mEq (milliequivalents)/L (liter). The nurses notes on [DATE] at 4:15 PM documented "Good skin turgor". The Care Plan dated [DATE] identified R2 as at risk for dehydration. On [DATE], Z3, Physician, came to the facility to see R2 and ordered lab work to be completed on [DATE]. The lab results on [DATE] documented BUN at 20 mg/dL, creatinine at 1.1 mg/dL, and sodium 147 mEq /L. There was no documentation that the physician was notified after [DATE] until [DATE]. On [DATE] the nurses notes documented at 11:00 PM that R2 had a "Lg (large) emesis x 2 undigested food". The next nurses note on [DATE] at 12:00 AM documented "loose stools x 2". Lab work was drawn and reported on [DATE] at 5:00 AM. At 2:30 PM the nurses notes documented "multiple loose stools-no emesis. Alert to person (with) confusion poor PO intake". On [DATE] the nurses notes documented at 12:55 PM "N+V+D (nausea, vomiting, diarrhea) noted today PO fluids enc. (encouraged)". The nurses notes documented "loose stool x 1" on [DATE]. On [DATE] the nurses notes documented "cont. (continue) to have loose stool. (No N/V (nausea/vomiting). Good appetite. Feeds self". At 3:15 PM the nurses notes documented "Did (not) get up for meals today". On [DATE] at 1:05 AM it documented "loose stools x 2". The temperature was 100 and Tylenol was given for increased temperature. At 5:00 AM on [DATE] the nurses notes documented "Respirations rapid and shallow-(left) leg mottled. The physician was notified (Z3) and "TO (telephone order) received to send to the hospital. The nurses notes documented that R2 expired at 11:30 AM at the hospital. The History and Physical dated [DATE] by Z2, Hospital Physician, documented R2's lab results on admission was BUN at 60, Creatinine 4.4, and Sodium was 179. Z2 documented R2 had very poor skin turgor and intravenous hydration was started due to "significant [MEDICAL CONDITION] with sodium of 172, suspected for lack of oral intake or oral feeding from the nursing facility". The "Discharge Summary" dated [DATE] documented R2 expired shortly after her arrival to the medical floor of the hospital due [MEDICAL CONDITION], acute cardiopulmonary arrest, acute [MEDICAL CONDITION] failure, acute [MEDICAL CONDITION], multisystem organ failure, hypovolemic, hyperosmolar [MEDICAL CONDITION] secondary to the severe volume depletion with dehydration and [MEDICAL CONDITION] of chronic disease. Z3, Physician, stated in an interview on that the facility did not call him except on [DATE] to discontinue therapy. Z3 stated he was at the facility on [DATE]. Z3 stated he was not aware there was any problems until the sister of R2 called him the day after she died to tell him. Z3 stated no one called him to tell him of her loose stools or decline. Z3 stated he was in town that weekend and was not sure why they didn't call him. Z3 stated it was a "Sad case" with what transpired in a week. Z3 stated they should have called him to help alleviate her problems. 2. R6 was admitted to the facility on [DATE] with diagnoses, in part, of Alzheimer's, [MEDICAL CONDITION], Depression. The Care Plan dated [DATE] and [DATE] documented "Dehydration, at risk for, potentially related to diuretic medication and dependency. Risk factor: cognitive impairment." The interventions listed on the [DATE] Care Plan documented "Assess skin turgor over sternum or inner thigh, as aging skin loses elasticity.", Assess urine for color, consistency, and odor, as frequent, clear urine is an indicator of hydration", and "Be alert for symptoms of dehydration: change in mental status/confusion, constipation/fecal impaction, dizziness/drop in blood pressure from baseline, fatigue/lethargy". On [DATE] the following interventions were added: "offer fluids throughout the day and night", assist with all meals", "labs as ordered". On [DATE] the physician ordered lab work and to "push water". The lab work was not completed until [DATE] at 10:20 AM and reported to the facility at 10:30 PM on [DATE]. E5, Licensed Practical Nurse (LPN), documented on the lab report "MD (Medical Doctor) Notified [DATE]". The lab results were BUN 57, Creatinine 1.0, Sodium 178. The sodium level was designated as "RCH" or "Repeat Critical High". Z4, Lab technician, stated in an interview on [DATE] at 9:15 AM that the repeat critical high means it has been repeated to ensure the correct results. R6's intake was documented as below the estimated fluid requirement for R6. Fluid needs were calculated by the Registered Dietitian as 1458 cc's (cubic centimeters) per day on the [DATE] "Nutritional Assessment". The "Physician Orders" documented R6 was started on [MEDICATION NAME] 20 mg twice a day on [DATE]. The Intake and Output documentation for R6 noted her daily fluid intake was below fluid requirements. On [DATE]-480 cc's; [DATE]-690 cc; [DATE]-530 cc; [DATE]-550 cc; [DATE]-190 cc's; [DATE]-260 cc's; and, [DATE]-560 cc's. There is no documentation the low fluid intake was reported to the physician. E5 stated in an interview on [DATE] at 3:10 PM that she would usually call the physician if the lab was critical and usually the lab call to tell us. E5 stated she could not recall that far back. On [DATE], E2 provided a written documentation by E5 of the [DATE] incident. There was no date on the documentation. E5 documented "On [DATE] I notified (Z1) about labs on R6. Unable to recall the specific details of this event. I do not recall a telephone conversation with the lab on this night. I do recall checking our facility fax between 8 PM and 10 P med pass. It was during this time I received the fax and notified (Z1)". E2 stated in an interview on [DATE] at 10:30 AM that E5 told her she had called the physician about R6 and he had told her to call the family. E2 stated E5 could not recall if she had. E2 stated the next morning on [DATE] they did call the family and told them if she wasn't sent to the hospital she would die. E2 stated she was not sure why they had not sent her out the evening of [DATE]. Z1, Physician, stated in an interview on [DATE] at 11:30 AM that he could not recall if he was notified regarding R6's lab values dated [DATE]. Z1 stated if they would have called that night on [DATE] about the sodium being 170 that he "hope you would have sent her in". Z1 stated a sodium of 170 was "sort of an emergency" and they "should have called me". Z1 stated a sodium of 155, 160, 170 was the "usual manifestation of not drinking". The nurses notes dated [DATE] documented at 4:00 PM and on [DATE] at 1:45 AM has no documentation the physician was notified of the lab results. The next nurses note on [DATE] at 9:40 AM documented "Labs drawn came back critical. (Z1, Physician) notified. Orders to send to ER (emergency room ) for IV (intravenous) fluids and evaluation". According to the History and Physical dated [DATE], R6 was admitted to the hospital for severe [MEDICAL CONDITION], hyperchloremia, erythrocytosis, probably secondary to dehydration. R6 was admitted to the medical floor for IV fluid hydration. The history and physical documented R6's catheter was draining "dark amber urine". R6 was readmitted to the facility on [DATE]. 3. R4 was admitted to the facility on [DATE] with diagnoses, in part, of mental [MEDICAL CONDITION], possible [MEDICAL CONDITION], altered mental status. On [DATE], R4's BUN was 18, creatinine 1.1 and sodium 147. The nurses notes dated [DATE] documented R4 was having emesis and loose stools. Z1, Physician, was in the facility and documented in a progress note "One of the principal things is he is not eating and drinking enough and that does concern me. Today is Friday, CBC and CMP next week along with pelvis and both hip X-rays. They must keep me posted about his eating". The nurses notes dated [DATE] documented at 2:00 PM that R4 refused breakfast and lunch. The next nurses note was dated [DATE] at 2:45 AM when R4 was found on the floor non-responsive. R4 was sent to the hospital where he was admitted . The History and Physical by Z2, dated [DATE], documented R4 was admitted due to fractured ribs, altered mental status, acute [MEDICAL CONDITION], hypovolemic, hyperosmolar, [MEDICAL CONDITION] secondary to volume depletion, metabolic acidosis secondary to prerenal azotemia, and [MEDICAL CONDITION]. The History and Physical documented R4 had significant altered mental status with minimal withdrawal to pain. The History and physical documented R4 was "significantly volume depleted with perioral mucous membrane dryness with crack in the lips. The patient was found to have significant poor skin turgor with poor capillary refill...". The History and Physical documented R4's BUN at 38, creatinine at 1.2 and sodium at 162. Z2 stated in an interview on [DATE] at 10:36 AM that R4 had been combative in the past and was unresponsive on admission. Z2 stated R4 had severe dehydration with cracked lips and dry mucous on the tongue. Z2 stated R4 was unkept and required IV fluids. 4. The facility Policy and Procedure titled "Hydration-Clinical Protocol" states: "The staff, with the physician's input, will identify individuals with signs and symptoms (for example, [MEDICAL CONDITION], lethargy, increased thirst, etc) or lab test results (for example, [MEDICAL CONDITION], azotemia, etc.) that might reflect existing fluid and electrolyte imbalances". "They will report this information promptly to the Attending Physician". "The staff, with the physician's input, will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance, for example, those with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well "The Physician will manage significant fluid and electrolyte imbalances, and associated risks, appropriately and in a timely manner." "The staff will provide supportive measures such as providing fluids and adjusting environmental temperature". "The Physician will help monitor for the development, progression, or resolution of fluid and electrolyte imbalance in at-risk individuals". "The Physician will adjust treatments based on specific information (lab results, level of consciousness, etc.) relevant to the individual".