Every finding on record at The Haven of Paris

Based on interview and record review the facility failed repeatedly, to obtain/purchase a resident's medication from the resident's preferred pharmacy in accordance with the resident /resident representatives' choice. This failure affects one of three residents (R5) reviewed for medication procurement on the sample list of 14.Findings include:R5's current Face Sheet documents R5's medications are to be ordered from the Veterans Administration.The facility Resident Grievance/Complaint Form dated 7/13/26, signed by V1, Administrator documents the following: (V8, R5's Family Member) was very upset her relative's (R5's) meds (medication) are being ordering (sic, ordered) from (Private Facility Pharmacy name), instead of VA (Veterans Administration Pharmacy) and (V8, R5's Family Member) gets large invoices (facility pharmacy). Told (V1) we will order meds from VA today (7/13/26) and return the used meds (remaining facility supply ordered from the facility pharmacy for R5) for credit. I (V1, Administrator) told (V8) we (facility) would then take care, to pay the invoices she (V8) had been sent. She (V8) did seem to agree to this.On 7/22/26 at 3:05 PM, V8, R5's Family Member stated Two weeks ago (V8 ) got a call about (R5's) blood thinner. It hadn't been refilled since February. Instead of alerting (V8) they (facility) had the house doctor (V20, Medical Director) order medication which is more expensive. When the bill came it was $120 versus $14. My (Family Member, R5) is a veteran, he uses the VA (Veteran Administration Pharmacy). This happened before and cost me $1000 (prior to admission). I got a call yesterday (7/21/26) stating he is out of Metoprolol (blood pressure medication) and Eliquis (blood thinner medication). They had sent all his meds back to the more expensive pharmacy (after V8 reported discrepancy the week before, according to other interviews and record review). VA mailed the Eliquis on July 17, 2026.On 7/24/26 at 11:00 am V2, Director of Nursing stated medications refills are always supposed to come from the correct pharmacy. R5's Facility Pharmacy Requisition Sheet documents the following medication were ordered on three separate occasions, from the facility (private name) Pharmacy instead of the Veterans Administration Pharmacy: On 7/13/26 the facility ordered 30, of R5's Finasteride five milligrams (MG) ( Benign Prostatic Hyperplasia medication) tablets.On 6/24/26 the facility ordered 28, of R5's Eliquis Oral Tablet 2.5 MG (Atherosclerotic Heart Disease medication) tablets.On 6/4/26 the facility ordered 60, of R5's Metoprolol, Succinate 25 MG tablets. (high blood pressure medication).The facility undated Ordering and Receiving Non-Controlled Medications From the Dispensing Pharmacy policy documents the following:Reordering of medications is done in accordance with the order and delivery schedule developed by the pharmacy provider(s). Quantities of medications sent from the pharmacy may vary in accordance with payer status, insurance plan, or law. Examples include Medicare A vs. (verses) Medicaid, plan limitations on quantities under Medicare Part D, and quantity ordered by the prescriber. Reorder medication four (4) days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand. When reordering medication that requires special processing [such as Department of Veterans Affairs prescriptions or mail order, or clozapine], order at least [five days] in advance of need.a. The refill order is called in, faxed, or otherwise transmitted to the pharmacy. When available and legible, the pharmacy label (including bar-code, is used) is pulled and transmitted to the pharmacy.b. For Same-Day delivery, refills received by 12:00 PM Monday through Saturday will be delivered on the nightly delivery.

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by another resident for two of four residents (R1 and R8) reviewed for abuse in the sample of fourteen residents.Findings include:The Facility Incident Log dated 7/23/26 documents a verbal altercation between R1 and R8 on 6/12/26.R8's MDS dated [DATE] documents R8 is cognitively intact.R1's MDS dated [DATE] documents R1 is moderately cognitively impaired. On 7/23/26 at 1:24 PM, R8 stated R1 threatened to hit R8 in the head and R8 told R1 if R1 did, R8 would turn R1 in. R8 stated R8 felt increased anxiety and still does when R8 sees R1. R8 became teary eyed when speaking to this writer.On 7/24/26 at 2:05 PM, V17 Activity Assistant stated V17 was in the activities room where the incident between R1 and R8 took place and overheard bickering with elevated volume of speech but was busy not paying attention to what exactly was said. V17 stated R8 was very upset in tears when V17 intervened.On 7/24/26 at 1:45 PM, V1 Administrator stated V1 would consider a verbal threat as abuse according to the reasonable person approach.On 7/24/26 at 1:15 PM, V1 Administrator/Abuse Prevention Coordinator stated the unwitnessed incident occurred over bingo prizes.The undated Resident Rights/Abuse Policy documents the facility affirms the right of the residents to be free from abuse by anyone including physically, verbally, mentally, or sexually. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation (42 CFR 483.12 Interpretive Guidelines).

Based on observation, interview, and record review, the facility failed to implement fall interventions for R4 and R6 who have a history of repeated falls. R4 and R6 are two of four residents reviewed for falls/accidents on the sample list of 18.Findings include:1.R4's Minimum Data Set (MDS) dated [DATE], documents R4's Brief Interview of Mental Status (BIMS) score of zero (0), out of a possible 15, indicating R4 has severe cognitive impairment.The facility fall log documents R4 had the falls on the following dates: 5/23/26, 5/28/26, 6/8/26, 7/1/26 (fractured hip) and 7/16/26.R4's current Care Plan documents one of R4's fall interventions as follows: Bed / Chair alarm. Check each shift for placement and function. Date Initiated: 05/05/2026.On 7/21/26 at 10:30 AM, R4 was up in the wheelchair in the hallway, unable to be interviewed.On 7/23/26 at 10:28 AM, R4 was seated in R4's wheelchair in the hallway. There were no staff present to observe R4 for safety. R4 had a safety alarm monitor that was attached to the back of the wheelchair. The safety alarm monitor had a string with a clip at the end. The clip was not attached to R4, to alert staff in the event R4 would try to get up out of R4's wheelchair. This surveyor alerted V9, Certified Nursing Assistant (CNA). V9, confirmed R4's safety alarm clip was not attached to R4, and therefore would not trigger the alarm to sound. V9, CNA said R4's alarm should be attached to R4's shirt to alert staff if R4 attempts to get up from R4's wheelchair. 2. R6's MDS dated [DATE] documents the following: BIMS score of four (4), out of a possible 15, indicating severe cognitive impairment.R6's Fall investigations document R6 had a fall on the following dates: 10/25/25, 11/30/25, 2/18/26, 3/13/26 and 7/05/26. R6's Current Care Plan documents one of R6's fall interventions as follows: Alarm while in chair and bed. Date Initiated: 02/18/2026. The same care plan was updated on 7/23/26 and reiterated the same intervention after R6 was observed by this surveyor, without the safety monitor proper placement, which was prevented the alarm function (noted below).On 7/23/26 at 12:15 pm V6, R7's Family Member stated V6 was in the facility and witnessed R6 fall on 7/05/26, at the side of R6's bed, and R6's alarm did not sound.On 7/23/26 at 2:55 pm R6 was seated in a wheelchair at the bedside. R6 was asleep. R6 had a wheelchair alarm attached to the back of her wheelchair. The alarm had a very long thick string/cord that dangled down the left back of R6's wheelchair that extended up to a clip that was attached to the back upper center area of R6's shirt. V16, Certified Nursing Assistant (CNA) stated she was just going to lay R6 down in bed for a nap before dinner. V 16, CNA asked R6 if she wanted to lay down in bed. R6 opened her eyes and said yes, that would be fine. V16, CNA stood in front of R6's wheelchair, applied a gait belt, and gave verbal cues to R6 to place her hands on the wheelchair arms. R6 could not follow the request (BIMS of four as documented above). V16, CNA then placed R6's hands on the arms of R6's wheelchair. R6 then responded to V16, CNA by standing. As R6 stood, her wheelchair alarm did not sound. While R6 was still in a standing position, V16 CNA pulled the excess (approximately eighteen inches) of alarm string slack, before the alarm sounded properly. V16, CNA stated (R6's) alarm is not sounding like it should, the string is way too long. She (R6) could run around the block before we knew she was up, out of her wheelchair, with the string this long. The facility Falls Guideline policy dated as revised, August 2024 documents the following: Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to:* To achieve each resident's maximum potential of physical functioning.* To prevent or reduce injuries related to falls.* To enhance residents' dignity and self-worth.* To rehabilitate residents to their fullest potential of function.:

Based on interview and record review the facility failed to protect a resident's right to for privacy. This failure affected two of three residents (R1, R6) reviewed for quality of care on the sample list of six. Findings Include: The facility's Resident rights Guideline policy dated October 2023 documents the facility will treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. All residents have the right to equal access to quality care regardless of a diagnosis, severity of a condition, or payment source. Each resident has the right to privacy and confidentiality as well as a safe environment for themselves and their personal possessions. The facility must take reasonable care to protect personal property from loss or theft. 1. R1's Medical Diagnoses List dated April 2026 documents R1 is diagnosed with Alzheimer's Disease and Vascular Dementia with Behavioral Disturbances. R1's Minimum Data Set, dated [DATE] documents R1 is severely cognitively impaired and requires supervision or touching assistance for transfers. R1 uses a walker and wheelchair for mobility. R1's Progress Notes dated 2/24/26 documents a resident (R2) entered R1's room and sat in R1's recliner. R1 yelled out, What the h*** (expletive)? This is my room, go on and get before I stand up! Please keep that damn lady out of my room. I feel like I have no privacy anymore! On 4/8/26 at 12:15 PM V3 (R1's Wife) stated R2 is constantly wandering the halls and comes into R1's room. R2 will sit on his bed or in his recliner and wander in and out. V3 stated R2 wanders in and out of other people's rooms as well and staff are not doing enough to protect the residents from R2's intrusions. On 4/9/26 at 10:36 PM V12 Registered Nurse (RN) stated R2 is always wandering into R1's room. V12 RN stated V3 told her she doesn't want to come to the facility to see R1 anymore because she is tired of R2 always coming into R1's room. 2. R6's Medical Diagnoses List dated April 2026 documents R6 is diagnosed with Cognitive Communication Deficit, Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. R6's Minimum Data Set, dated [DATE] documents R6 has mild cognitive impairment and independent with transfers and mobility with a walker. On 4/9/26 at 11:20 M R6 stated she is tired of R2 coming into her room and she had to place a Stop sign on her door and keep her door closed to protect her things and have privacy. Staff had attempted to remove her soaps and lotions in order to keep R2 from getting into them, however since they returned them to R6. On 4/9/26 at 10:36 AM V12 Registered Nurse stated R1 is constantly wandering into other resident's rooms. On 4/9/26 at 11:25 AM V13 Registered Nurse stated R2 wanders often and will pick things up as she goes in and out of other resident's rooms. V13 stated R6 has a lot of personal items and has gotten very upset when R2 is in her room. V6 must keep her door closed and a stop sign on her door to help detour R2 from entering into V6's room uninvited. On 4/9/26 at 1:00 PM V1 Administrator confirmed that it is hard for staff to provide adequate supervision for R2 who often wanders in and out of other resident's rooms. V1 confirmed the facility will have to figure out a better way to provide better supervision for R2 so that she does not impede the privacy of other residents or take other resident's things.

Based on interview and record review the facility failed to provide adequate supervision for a resident who wanders. This failure affected one of three residents (R2) reviewed for quality of care on the sample list of six. Findings Include: The facility's undated Nursing Services Policy documents it is the policy of the facility that each resident shall receive nursing care and supervision to obtain and maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessments, plan of care, physician's orders and accepted standards of nursing practice. It is the facility's responsibility to ensure that each resident is provided nursing care and supervision based on their needs. Staff are to provide care in a manner in which the resident is treated with respect, dignity and afforded privacy. R2's Medical Diagnoses List dated April 2026 documents R2 Diagnosed with Major Depressive Disorder, Generalized Anxiety Disorder, and Insomnia. R2's Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired and is independent with transfers and requires supervision with walking. R2 often wanders and has had physical behavioral symptoms directed towards other residents such as hitting, pushing, and grabbing. R2's Care Plan documents R2 is at risk for elopement related to exit seeking behavior, a history of elopement and wandering. R2 wanders into other resident's rooms where she is not welcome. R2 is at risk for abuse related to invading other's space and rummaging through other resident's belongings. R2 is physically vulnerable and has dementia, confusion, poor judgment, and wanders frequently in and out of other's spaces. R2's Nurses Notes dated 2/22/26 documents R2 wandered into another resident's room several times. The other resident (unknown) threatened to throw R2 out of their room if she comes in there again. On 4/8/26 at 12:15 PM V3 (R1's Wife) stated R2 is constantly wandering the halls and comes into R1's room. R2 will sit on his bed or in his recliner and wander in and out. V3 stated R2 wanders in and out of other people's rooms as well and staff are not doing enough to protect the residents from R2's intrusions. V3 stated she does not feel like staff are providing enough supervision for R2. On 4/8/26 at 12:40 PM V5 Activity Aide stated R2 often goes into other residents' rooms and wanders back and forth in the halls. On 4/8/26 at 12:45 PM V6 Certified Nurse's Assistant stated R2 goes into other resident's rooms and upsets them. R2 gets yelled at sometimes by the other residents and will occasionally lay in other people's beds. On 4/8/26 at 12:50 AM V8 Certified Nurse's Assistant stated R2 wanders up and down the halls and in and out of resident's rooms. On 4/9/26 at 10:36 PM V12 Registered Nurse (RN) stated R2 is always wandering into R1's room. V12 RN stated V3 told her she doesn't want to come to the facility to see R1 anymore because she is tired of R2 always coming into R1's room. V12 Registered Nurse stated R1 is constantly wandering into other residents' rooms. R2 will sit on other residents' bed, chairs, or stand and look out the windows in their rooms. On 4/9/26 at 11:20 M R6 stated she is tired of R2 coming into her room and she had to place a Stop sign on her door and keep her door closed to protect her things and have privacy. On 4/9/26 at 11:25 AM V13 Registered Nurse stated R2 wanders often and will pick things up as she goes in and out of other resident's rooms. V13 stated R6 has a lot of personal items and has gotten very upset when R2 is in her room. V6 must keep her door closed and a stop sign on her door to help detour R2 from entering into V6's room uninvited. On 4/9/26 at 1:00 PM V1 Administrator confirmed that it is hard for staff to care for other residents while trying to provide adequate supervision for R2 who often wanders in and out of other resident's rooms. V1 confirmed the facility will have to figure out a better way to provide better supervision for R2.

Based on observation, interview, and record review, the facility failed to document wound assessments for two (R2, R3) of three residents reviewed on a sample list of five residents.1. R2's Care Plan, Undated, documents on 8/2/24 high risk for pressure ulcers was added, and on 10/9/24, actual pressure ulcers of sacrum, right ischium, left heel, right lateral ankle, right heel, left dorsum foot, left gluteal fold and left gluteus was added. R2's Care Plan also documents Pressure Ulcers to be assessed weekly by licensed nurse, monitor for signs of infection daily, increased warmth, redness, swelling, pain, drainage, and odor. Notify physician if not healing.R2's Treatment Administration Record (TAR) dated November and December 2025 documents order for daily foot checks related to a history of ulcers. Document color, temperature, edema, and pedal pulses. On 11/2/25 and 11/25/25, there is missing documentation. On 11/26/25-12/4/25 and 12/30/25-12/31/25 edema bilaterally was documented.R2's progress notes do not document edema, open area, treatment, or notification of physician.R2's TAR dated November and December 2025 document order of daily skin checks. Document C-clear, R-red, O-open, P-pressure, and S-skin tear. On 11/2/25 and 11/25/25, there is missing documentation. On 11/1/25, 11/3/25-11/13/25, 11/16/25-11/21/25, 11/24/25, 11/26/25-12/24/25, and 12/26/25-12/31/25, O for open is documented. On 12/11/25 and 12/19/25, O-open, R-red, P-pressure is documented.R2's Skin Observation Tool dated 10/25/25 documents R2 has skin issues to right hip, sacrum both unstageable, left gluteal fold and both heels pressure. No further documentation.R2's Skin Observation Tool dated 12/7/25 documents sacrum pressure unstageable, Right heel pressure stage 2, left heel pressure stage 2, right iliac crest pressure unstageable, redness to groin and under bilateral breasts, left gluteal fold pressure stage 3, and left foot second toe pressure stage 2. Document does not include measurements or descriptions of wounds.R2's Wound Clinic Visit Notes dated 11/7/25 document R2's wounds and measurements as follows:Coccyx Pressure Stage 4 - 2.7 centimeters (cm) x 4.5cm x 2.82cmRight Ischial Tuberosity Pressure Stage 3 - 1.7cm x 1.5cm x 1.13cmLeft Posterior Heel Diabetic Ulcer Grade 1 - 0 x 0 x 0Right lower lateral ankle Diabetic Ulcer Grade 1 - 0 x 0 x 0Left Ischial Tuberosity Pressure Stage 3 - 1.3cm x 2cm x 0.15cm.No exposed bone to Coccyx area.R2's Wound Clinic Visit Notes dated 12/5/25 document R2's wounds and measurements as follows:Coccyx Pressure Stage 4 - 2cm x 4.8cm x 2.13cmRight Ischial Tuberosity Pressure Stage 3 - 1.7cm x 1.1cm x 1.52cmLeft Posterior Heel Diabetic Ulcer Grade 1 - 0.3cm x 0.7cm x 0.1cmRight lower lateral ankle Diabetic Ulcer Grade 1 - 0.6cm x 0.3cm x 0.13cmLeft Ischial Tuberosity Pressure Stage 3 - 1.2cm x 2cm x 0.24cm.Fibrin present on wound beds, exposed bone to Coccyx area, tunneling present to right ischial tuberosity.R2's Wound Clinic Visit for 1/7/26 was missed due to refusal of transportation by R2.On 1/8/26 at 1:35PM, R2 stated the facility takes care of her wounds and she does go to an outside clinic for wound treatment but is trying to switch somewhere closer. R2's family does not want the in-house wound physician to treat R2, but it is unclear why. R2 denied pain during wound care but did state it can cause discomfort from time to time. Observation of R2's wound care was completed on 1/8/26 at 1:35PM. Measurements were taken at time and are as follows:Right hip 1.5cm x 1cm x2cmLeft gluteal fold 2.5cm x 1.5cm x 0.2cmRight gluteal fold 2.5cm x 2.5cm x 0.2mSacrum 3.5cm x 2.5cm x 3.5cmRight outer heel 1cm x 2.5cmLeft heel 0.5cm x 0.6cmRight upper thigh 1.5cm x 1cmPeri area red and excoriatedBilateral breast folds red and excoriatedNo odors noted, R2's bedding clean and free of debris, stains, and holes. Wounds appear clean, no signs of infection observed.2. R3's undated Care Plan documents impaired skin integrity, and at risk for injury related to dementia.R3's Physician Order Sheet (POS) dated 1/8/26 documents order for wound care to left lateral ankle, daily foot exams, weekly skin checks, and preventative measures for coccyx skin breakdown.R3's Physician Wound Visit dated 10/26/25 documents left lateral ankle wound measuring 0.8 centimeters (cm) x 0.9cm with moderate exudate and erythema surrounding wound edges.R3's electronic medical record does not document any skin assessments completed by nursing staff.On 1/8/26 at 10:00 AM, R3 wound dressing change was observed. R3's wound was closed at that time. R3 denied pain or issues with wound site. On 1/7/26 at 10:00AM, V7 LPN stated that R1 is given all treatments with two staff members present due to R1's frequent accusations toward staff.On 1/7/26 at 11:00AM, V2 DON stated they do not write individualized documentation of wounds, they just upload notes from wound clinic visits. V2 stated nurses are not documenting on wounds as they should.Facility Pressure/Skin Breakdown-Clinical Protocol Policy dated January 2017 documents the nurse shall assess and document/report a full assessment of skin condition including but not limited to location, stage or partial/full thickness, length, width and depth, presence of exudates or necrotic tissue, signs/symptoms of infection, and impact of comorbid conditions on wound healing.

Based on interview and record review the facility failed to ensure sufficient lighting in a resident's bedroom and failed to provide adequate supervision for a restless resident with dementia. These failures resulted in a fall for one (R6) of three residents reviewed for accidents, causing a brain bleed and skin tears to the right shoulder, right hand, and right forearm on the total sample list of 17.Findings include:The facility's Falls and Fall Risk Management Policy, dated March 2018, documents that based on previous evaluations and current data, staff will identify interventions related to a resident's specific risks and causes to prevent falls and to minimize complications from falls. The policy defines a fall as unintentionally coming to rest on the ground, floor, or other lower level, not as a result of an overwhelming external force.Fall risk factors identified in the policy include:Environmental factors: wet floors, poor lighting, incorrect bed height or width, obstacles in the footpath, improperly fitted or maintained wheelchairs, and unsafe or absent footwear;Resident conditions: fever, infection, delirium and other cognitive impairments, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypotension, functional impairments, visual deficits, and incontinence; andMedical factors: arthritis, heart failure, anemia, neurological disorders, and balance and gait disorders.The policy documents that staff are to use resident-centered approaches to managing falls and fall risk. These approaches include:Staff, with input from the attending physician, will implement a resident-centered fall prevention plan to reduce specific fall risk factors for each resident at risk or with a history of falls;A systematic evaluation of a resident's fall risk may identify several possible interventions, and staff may prioritize interventions (e.g., trying one or a few interventions at a time rather than many at once);Examples of initial approaches include exercise and balance training, rearranging room furniture, improving footwear, and adjusting lighting; andIn conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding for osteoporosis, as applicable) to minimize serious consequences of falling.The policy further documents that staff should monitor subsequent falls and fall risk by documenting each resident's response to interventions intended to reduce falls or fall risk. If interventions are successful in preventing falls, staff are to continue those interventions.R6's Minimum Data Set (MDS) dated [DATE] documents diagnoses of non-Alzheimer's dementia with behavioral disturbances and severe cognitive impairment. The MDS also documents that R6 had post-traumatic stress disorder (PTSD).R6's Care Plan, initiated on 7/27/25, documents a history of falls related to decreased safety awareness and includes an intervention dated 7/29/25 for staff to walk with R6 when he exhibited signs of restlessness.R6's Care Plan, initiated on 6/11/25, documents a history of falls related to medications (psychotropic, diuretic, cardiovascular, and pain medications) and unspecified medical factors. This Care Plan included an intervention to provide adequate lighting.R6's Fall Risk Evaluation dated 9/7/25 documents that R6 was at high risk for falls.R6's Electronic Medical Record (EMR) contains a nursing note dated 11/13/25 documenting that R6 was periodically attempting to stand and walk independently throughout the night. The note documents that staff successfully implemented the Care Plan intervention by walking alongside R6 using a walker and gait belt until R6 became tired and requested to go to bed.R6's Incident Investigation Report documents that R6 was found on the floor in his bedroom on 11/16/25 at 4:17 AM. The report documents that R6 sustained a fall with physical harm, including a hematoma to the right side of his head above the eye, two skin tears to the right shoulder, a skin tear to the right hand, and a skin tear to the left forearm.On 12/16/25 at 12:33 PM, V20, Certified Nursing Assistant (CNA), stated that R6 had been up all night on 11/16/25 at the nurses' station due to agitation, restlessness, and attempts to hit staff and other residents. V20 stated R6 appeared busy that night and, in her professional opinion, R6 should not have been put to bed at that time because he repeatedly stood up and sat down. V20 stated she was an agency CNA and that suggesting R6 remain up would not have been well received by facility staff. V20 further stated that at approximately 4:30 AM, while sitting at the nurses' station, she heard a thud and went to R6's room, where she found the lights off and R6 lying on the floor at the end of his bed with blood coming from his head. V20 stated the television was hanging off the wall, with cords wrapped around R6's leg.On 12/16/25 at 2:36 PM, V19, CNA, stated that R6 was restless and repeatedly attempting to get up and down from his wheelchair the night of the fall. V19 stated she put R6 to bed and that the bedroom lights were off. V19 stated that V20 called for help at approximately 4:00 AM, reporting that R6 had fallen. V19 stated she entered the room and found R6 lying on his back on the floor with blood on his head and on the floor, and that R6's left foot was tangled in the television cords.On 12/16/25 at 10:04 AM, V14, Licensed Practical Nurse (LPN), stated she was the nurse caring for R6 on the night of the unwitnessed fall on 11/16/25. V14 stated that R6 was at high risk for falls, had fallen several times the prior week, and had been moved to the secured dementia unit for closer monitoring. V14 stated R6 was sitting with staff at the nurses' station around 2:30 AM due to restlessness, fidgeting, and attempts to get out of his wheelchair. V14 stated that V19 and V20, CNAs, toileted R6 and put him to bed. V14 stated that at approximately 4:30 AM, V19 notified her that R6 had been found on the floor in his room and was bleeding from his head and arms.On 12/17/25 at 9:29 AM, V2, Regional Nurse Consultant (RNC), stated that if it had been her decision, she would not have discontinued the ten-minute safety checks when R6 was transferred to the dementia unit one week prior. V2 further stated that staff on the dementia unit may lack the necessary knowledge to properly care for residents with dementia.On 12/17/25 at 12:36 PM, V26, [NAME] County Coroner, confirmed that R6's cause of death was determined to be complications from an unwitnessed fall, resulting in bleeding in the space around the brain (subdural hematoma).

Based on interview and record review, the facility failed to promptly honor a resident's request to be transferred to the emergency room for one resident (R4) of one resident reviewed for Resident's Rights in the sample list of 17. Findings include:R4's undated diagnoses sheet documents a diagnosis of constipation.R4's Nursing Progress Notes dated 11/25/25 at 4:16 PM, documented by V9, Licensed Practical Nurse (LPN), state: I'm constipated and I want to go to the hospital! (per R4). The nurse (V9) explained that a physician's order would be required to send R4 to the hospital and that obtaining the order could take time.On 12/16/25 at 11:45 AM, R4 stated that on 11/25/25 he complained of stomach pain and told V8, Certified Nursing Assistant (CNA), multiple times to notify the nurse early in the morning (around 6:00 AM). R4 stated that V9, LPN, did not enter his room until approximately 8:15 AM. R4 further stated that he requested to go to the emergency room and was not sent until approximately 4:00 PM that day.On 12/16/25 at 1:42 PM, V10, Medical Director, stated that if a resident requests to go to the emergency room, the resident should be sent, and the physician should be notified afterward.The facility's undated Attachment J, Statement of Resident Rights, documents that no resident shall be deprived of any rights and that residents have the right to exercise their rights as residents of the facility.

Based on interview and record review, the facility failed to ensure consistent monitoring and documentation of bowel movements for residents requiring bowel management, resulting in constipation for one resident (R4) of three residents reviewed for bowel management in the sample list of 17. Findings include:R4's undated diagnosis list documents diagnoses of constipation; hemiplegia and hemiparesis following cerebral infarction affecting the left nondominant side; unspecified disorder of muscle; and difficulty walking.R4's Physician Orders, active as of 12/16/25, document an order for ferrous sulfate 325 mg (milligrams) oral tablet, one tablet by mouth daily.R4's Bowel Movement (BM) Task Sheet dated 11/17/25 through 11/24/25 documents the following: 11/17/25 - none 11/19/25 - none 11/20/25 - not applicable 11/21/25 - none 11/24/25 - none at 11:51 AM and not applicable at 12:42 AMNo bowel movements were documented on 11/18/25, 11/22/25, or 11/23/25.There are no Nursing Progress Notes in R4's medical record dated 11/25/25 documenting that V9, Licensed Practical Nurse (LPN), completed any type of bowel assessment for R4 on that date.On 12/16/25 at 11:45 AM, R4 stated that on 11/25/25 he complained of stomach pain to V8, Certified Nursing Assistant (CNA), multiple times and asked V8 to notify V9, LPN, early in the morning at approximately 6:00 AM. R4 stated that V9, LPN, did not enter his room until approximately 8:15 AM.On 12/16/25 at 1:42 PM, V10, Medical Director, stated that if a resident has constipation, symptoms of constipation, or no bowel movement for two to five days (depending on the resident's normal pattern), staff should notify the medical doctor (MD) for further instructions. V10 stated that the nurse should have assessed the resident after R4 complained of abdominal pain.On 12/17/25 at 11:45 AM, V2, Regional Nurse Consultant, stated that staff should report when a resident has not had a bowel movement for three days and that the floor nurse or clinical manager should review daily clinical alerts for residents without a bowel movement for three days.The facility's Bowel Management Program dated 12/17/25 documents that CNAs are to promptly document bowel movements in the medical record; the floor nurse or clinical manager is to review daily clinical alerts to monitor residents who have not had a bowel movement in three days; and the floor nurse or clinical manager is to notify the MD as needed for further orders related to no bowel movement for three days.

Based on observation, interview and record review, the facility failed to develop and implement interventions and provide supervision to prevent a wandering resident from entering other resident's rooms invading resident privacy, disturbing the environment, taking assistive devices, and making inappropriate comments for five (R1, R5, R6, R7, R8) of five residents reviewed for accidents on a sample list of eight. This failure resulted in R1 falling on two separate occasions when R2 took R1's walker and sustaining a laceration to the knee requiring six sutures, a laceration to the left hand and a hematoma to the scalp. Findings include: R2's undated Care Plan documents diagnoses including Unspecified Dementia, Unspecified Severity with Other Behavioral Disturbance and Post Traumatic Stress Disorder (PTSD). The Care Plan documents R2 has behaviors related to diagnosis of Dementia, and history of PTSD. The Care Plan documents R2 has episodes of being physically aggressive towards others and that R2 is resistant to care with new interventions dated 7/25/25 to increase supervision and that R2 will be placed on 10-minute checks.R2's document titled 15 Minute Checks documents as follows: 11/4/25 blank from 6:15 AM to 5:45 PM, 11/7/25 blank from 6:15 PM to 11:45 PM, 11/10/25 no documentation, and 11/11/25 blank from 12:00 AM to 3:45 AM and 8:45 AM to 11:45 PM.R2's Progress Note dated 10/20/25 documents R2 raised a fist and swung at another resident because the other resident was in R2's way.R2's Progress Note dated 10/30/25 documents R2 wandering into other resident rooms without permission. R2 redirected. Behavior continues.R2's Physician Visit Note dated 11/10/25 documents R2 has Dementia, requires redirection and cuing for safety, and that R2 is impulsive and has poor safety awareness. The Note documents R2 was recently in the hospital for acute psychiatric services and R2 is now on therapy services. The Note documents R2 is inconsistent and difficult to redirect at times and R2 has frequent behaviors.R1's Care Plan, undated, documents R1 is [AGE] years old with an admission date of 7/28/25. The Care Plan documents R1 is independent with bed mobility, transfers, and toileting. The Care Plan documents R1 has diagnoses that include heart disease, atrial fibrillation, osteoporosis, low back pain, bilateral lower limb swelling, lump/mass, and that R1 is taking blood thinners. R1's Progress Notes dated 11/1/25, document R1 was found on the floor with her head resting on the table that her refrigerator sits on. A laceration was noted to the left hand. Resident was alert and oriented times four and denied any pain other than her hand. The Progress Notes document R1 stated that she hit her head during the fall. The Progress Notes document Emergency Medical Services were notified.R1's progress notes do not document a fall on 11/4/25.R1's Hospital Records dated 11/1/25 and 11/4/25 document R1 was sent to the emergency department for falls in the early morning hours on 11/1/25 and 11/4/25. On 11/1/25 hospital records document R1 was discharged at 4:02AM with a laceration of the finger of the left hand, hematoma of the scalp and fall. On 11/4/25 hospital records document R1 was discharged at 4:50AM with a laceration of left knee and a head injury. The facility investigation file dated 11/4/25 documents on 11/4/25 at approximately 0200 AM, R1 had an unwitnessed fall in R1's room related to walker not in reach of resident. The investigation documents R1 was attempting to toilet self when legs gave out. R1 alert and oriented times four. R1 hit R1's head on the bedside table next to the recliner where R1 was found by staff post fall. The investigation documents R1 did not have proper footwear on at the time of the incident and was not utilizing an assistive device. The investigation documents R1 was sent to the Emergency Department for complaints of knee pain and pain to left side of face. R1 returned to the facility with sutures to the left knee. The investigation file documents a new fall intervention of -- placed sign in room to remind R1 to use walker when ambulating. On 11/10/25 at 10:58 AM, R1 was observed walking from the bathroom to the recliner using a rolling walker and wearing non-skids socks. R1 had a large purple area across R1's forehead and a purple area across the bridge of R1's nose. R1's cheek was swollen and pink. R1's left palm was purple throughout with a laceration to R1's 5th finger.At 11:00 AM on 11/10/25, R1 stated that when she went to the bathroom, the first time she fell on [DATE], R2 entered her room and moved her walker out of reach over by her bed and was sitting on her bed trying to tear apart her call light. R1 stated that R2 proceeded to tell her when he was done with the call light, he was going to put her in bed and have sex with her. R1 stated she screamed for help, but no one came to her aide. R1 stated the second time she fell on [DATE], R2 was in her room again and moved her walker out of reach while she was in the bathroom. R1 stated this fall caused her to hit her head and receive six stitches to her knee. R1 stated she is fearful of R2 and that he was in her room last night on 11/9/25 as well. R1 stated R2 is always coming in her room and threatening her, and she is very scared. R1 stated that no one believes her and that now even her own son believes she is making these things up.On 11/12/25 at 9:35AM, R5 stated that R2 would enter his room about four to five times a night, at times he was using the restroom, or changing, other times he would be sleeping and awake to R2 grabbing his toes or going through his belongings. At one point, R2 had taken his wallet and R2's spouse returned it to him. R5 stated he is the [NAME] President of Resident Council and that many of the residents, especially female residents, have approached him complaining of R2 entering their rooms and frightening them stating they don't feel safe in the facility anymore. R5 stated that the facility doesn't seem to be doing anything about it.On 11/12/25 at 9:39AM, R6 stated I'm just afraid sometimes. R6 stated that when R2 resided on her hall he would come in her room and grab her toes and sometimes she would wake up and R2 would be standing over her staring. R6 stated she would tell R2 to get out of her room and R2 would leave but sometimes R2 wouldn't and R6 had to call staff for help.On 11/12/25 at 10:00AM R7 stated that R2 would come in his room multiple times throughout the night. R7 stated he does not get much rest and therefore is sleeping most of the day. R7 stated he is not able to function as he normally would on regular sleep.On 11/13/25 at 9:41 AM, R8 stated R2 has attempted to hit R8 several times but never made contact and that R2 rammed his wheelchair into another resident on purpose. R8 stated R2 does not respect other people's space, especially women, going into their rooms constantly especially R1's room directly across the hall from R8. On 11/10/25 at 12:55 PM, V8 Licensed Practical Nurse (LPN), stated that R2 is one on one with her during her shifts. V8 stated that she keeps R2 with her while caring for all 27 of her other residents and that during those times R2 is pleasant. V8 stated that R2 has past trauma and dementia and that he often has increased behaviors in the evening time, but night shift does not watch him. V8 stated she has reported to facility management multiple times about R2's increased behaviors. On 11/10/25 at 11:26 AM, V5 CNA stated R2 is very confused all the time and sometimes is angry (cusses, doesn't follow directives) and also goes into other resident rooms. On 11/12/25 at 9:15 AM, V13 Activity Director, stated that R1 is part of her morning rounds and that on 11/1/25, R1 reported to her that R2 had come into her room during the night and taken her walker while she was in the bathroom. R1 reported that when she opened the bathroom door, R2 was sitting on her bed in his underwear only and had her walker. V13 stated that while R1 was in the hospital she was distraught, crying, and scared and pleading with staff not to send her back to the facility. V13 stated that R2 has been a constant topic during Resident Council Meetings and is frequently brought up during Interdepartmental Team Meetings due to his behaviors and repeated offenses of entering resident rooms at night and scaring residents. V13 stated the staff are supposed to be doing 10-minute safety checks on R2, however she has seen him in activity room for hours at a time without any staff members checking on him.On 11/10/25 at 10:58 AM, V7 LPN (Agency) stated that it was reported to her this morning that R2 was awake until 2:00 AM and was going into other resident rooms during the night.On 11/10/25 at 11:00 AM V11, Certified Nursing Aide (CNA), when asked about R2, stated, I don't know how to answer that. V11 stated R2 is complete one on one at times.On 11/12/25 at 9:00 AM, R2 was observed self-transferring from a stationary chair to a wheelchair without assistance. R2 was able to take several steps without assistance. On 11/12/25 at 11:06 AM, V14 Licensed Practical Nurse (LPN)/Care Plan Coordinator/MDS stated 10-minute checks were put in place for R2 in July because R2 required increased supervision. V14 stated that on 10/24/25 the facility implemented a doorway sensor for R2 as an audible alert to staff that they needed to assess R2's whereabouts immediately when that alarm sounds. V14 verified that the door sensor was not implemented on care plan.On 11/13/25 at 8:45 AM, V16, Physical Therapist (PT), stated that R1 is independent with ambulation with the walker. V16 stated prior to July of 2025, R1 was independent without the walker but due to decline especially with leg issues, R1 requires use of the walker for ambulation.On 11/13/25 at 9:57 AM, V10, Medical Doctor, stated that due to R1's age, medical diagnosis and increased weakness, R1 is at high risk for falls and without use of the walker R1 would most likely suffer fall with injury.

Based observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two of four residents (R2 R3) reviewed for abuse in the sample list of eight. The facility's undated Abuse Prevention Policy documents that the facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of resident.This will be done by establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment; identifying concerns of residents; implementing systems to promptly and aggressively investigate all reports and mistreatment and making the necessary changes to prevent future occurrences.This policy defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents even those in a coma, cause physical harm or pain or mental anguish. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse is the infliction of injury on resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The facility investigation file dated 11/10/25 documents on 11/09/25 at approximately 10:18 AM, R3 was sitting on her walker, waiting in line to go out and smoke when R2 came up from behind and grabbed R3's shoulder. V15 (Occupational Therapist (OT)) overheard R3 yelling and when V15 OT approached R3, R3 reported that R2 had hit her in the shoulder. V15 OT reported this to V6 (Registered Nurse (RN)). This report also documents that R8 was a witness to the incident and R8 reported that while waiting to go out and smoke R2 wheeled up behind R3 and grabbed her right shoulder and R3 started yelling at R2 to stop touching her. V6 RN separated R2 and R3 and both residents were assessed by V6 RN. This report documents that the facility moved R2 to a secured unit, updated R2's Care Plan, and educated staff on behavior management.R3's Minimum Data Set (MDS) documents that R3 has normal cognitive function.R3's Electronic Medical Record (EMR) documents the following diagnoses: Legal Blindness, Major Depressive Disorder, History of Traumatic Fracture, Type 2 Diabetes mellitus with Hyperglycemia and Diabetic Neuropathy, Asthma, Chronic Obstructive Pulmonary Disease, Hallucinations, Cord Compression, Spinal Stenosis, History of Transient Ischemic Attack, Cerebral Infarction, Hypertension, and History of Alcohol Abuse.R2's undated Care Plan documents diagnoses including Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance, and Post Traumatic Stress Disorder. The Care Plan documents R2 has behaviors related to diagnosis of dementia, and history of Post Traumatic Stress Disorder. The Care Plan documents R2 has episodes of being physically aggressive toward others, and that R2 is resistant to care with new intervention dated 7/25/25 to increase supervision and resident will be placed on 10-minute checks.On 11/10/25 at 11:12 AM, R3 stated she was sitting on her four wheeled walker yesterday and waiting in line to go out to smoke and put on her brakes to her walker before standing up. R3 stated that when she stood up and turned around R2 was in her face and punched her in the right shoulder. R3 stated she was scared, and her first reaction was to hit him back, but she didn't and instead told him Don't touch me, don't you ever touch me again. R3 stated R2 said I told you I was coming! R3 stated it doesn't matter what he thinks he told me; he should never touch me.On 11/13/25 at 9:41 AM, R8 confirmed that he witnessed the incident on 11/09/25 between R2 and R3. R8 stated R3 was sitting on her walker next to him and they were waiting to get their cigarettes before they went outside to smoke. R8 stated R2 came up behind R3 and firmly, with an open hand grabbed R3's right shoulder. R8 stated R3 was mad as can be and shocked that R2 touched her. R8 stated R3 snapped at R2 to stop touching her and R2 backed off. R8 stated this wasn't the first time the facility has had this kind of trouble with R2. R8 stated R2 has attempted to hit R8 several times but never made contact and that R2 rammed his wheelchair into another resident on purpose. R8 stated R2 does not respect other people's space, especially women, going into their rooms constantly especially the room across the hall from R8. R2's progress notes dated 10/20/25 document R2 raised a fist and swung at another resident because the other resident was in his way.R2's Physician Visit Note dated 11/10/25 documents R2 has dementia, requires redirection and cuing for safety, is impulsive, and has poor safety awareness. The Note documents R2 was recently in the hospital for acute psychiatric services and is now on therapy services. The Note documents R2 is inconsistent and difficult to re-direct at times and that R2 has behaviors frequently.On 11/10/25 at 12:55 PM, V8 (Licensed Practical Nurse (LPN)), stated that R2 is one on one with her during her shifts. V8 LPN stated that she keeps R2 with her while caring for all 27 of her other residents and that during those times R2 is pleasant. V8 stated that R2 has past trauma and dementia and that he often has increased behaviors in the evening time. V8 stated she has reported to facility management multiple time about R2's increased behaviors.On 11/10/25 at 11:26 AM, V5 (Certified Nursing Aide (CNA)) stated R2 is very confused all the time and sometimes is angry (cusses, doesn't follow directives) and goes into other resident rooms. On 11/10/25 at 11:00 AM V11, CNA when asked about R2 stated, I don't know how to answer that. V11 CNA stated R2 is complete one on one at times.On 11/10/25 at 1:04 PM, V6 RN stated R2 has dementia, and he wanders quite a bit. V6 RN stated that after the altercation on 11/09/25 involving R2 and R3, V4, (Director of Nursing (DON)) told V6 to separate R2 and R3 and since there were three CNAs one was to stay with R2 and try to engage him in an activity.On 11/12/25 at 9:00 AM, R2 was observed self-transferring from a stationary chair to a wheelchair without assistance. R2 was able to take several steps without assistance.On 11/12/25 at 11:06 AM, V14 (Licensed Practical Nurse (LPN)/Care Plan Coordinator/MDS) stated 10-minute checks were put in place for R2 in July because R2 required increased supervision. V14 stated that on 10/24/25 the facility implemented a doorway sensor for R2 as an audible alert to staff that they needed to assess R2's whereabouts immediately when that alarm sounds. V14 verifies that door sensor was not implemented on care plan.On 11/13/25 at 9:03 AM, V4 DON stated she was aware of the incident between R2 and R3 and the allegation that R2 hit R3. V4 DON stated after the incident occurred, she instructed V6 RN to do a head-to-toe assessment of R2 and R3 and to keep a close eye on R2. V4 DON stated that R2 was not able to recall the incident, stating R2 is typically Alert and Oriented time one-two, sometimes he makes sense and sometimes he doesn't. V4 DON stated the facility had interventions in place including 10-minute checks to keep a close eye on R2 and that after the above-mentioned incident they moved R2 to the back (secured unit) and V4 DON stated R2 has only hit a CNA once since being back there. V4 DON stated R2 recently swung his fist at her because V4 DON asked R2 if he had a list of things he was going to do that day. V4 DON stated she has been advocating to move R2 to the facility's dementia unit for a long time but that the Intradisciplinary Team had concerns about the noise level in that unit and how it would affect R2. V4 stated I can't predict if R2 will hit someone again, staff will still need to keep a close eye on him. R2 is who he is.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision for a resident with Lewy Body Dementia to prevent a fall for one (R1) of three residents reviewed for falls on a sample list of three. This failure resulted in R1 falling to the ground and sustaining an acute fracture of the left hip. Findings include:The facility's Falls Guideline policy dated 08/2024 documents the following:Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to achieve each resident's maximum potential of physical functioning, to prevent or reduce injuries related to falls, to enhance residents' dignity and self-worth, to rehabilitate residents to their fullest potential of function. This policy also documents that the intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: identification of hazards and risks, evaluation, implementation, monitoring, and analysis.On 10/28/2025 at 10:12 AM, R1 was lying flat on his back with his head propped on a pillow and his left arm was in a sling. R1 stated, I have pain in my (groin area) on the left side. R1 did not remember that he had a fall and broke his left hip.R1's electronic medical record documents R1 has a diagnosis of Neurocognitive Disorder with Lewy Bodies and R1's Care Plan dated 9/19/2022 documents R1 has impaired cognitive function or impaired thought processes related to neurocognitive disorder with Lewy Bodies.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of five indicating R1 has severe cognitive impairment.R1's Fall Risk assessment dated [DATE] documents R1 is at high risk for falls.R1's Care Plan dated 5/18/2023 documents that R1 has the potential risk of elopement related to cognitive deficit, history of wandering, and walking about aimlessly without purpose. R1's Care Plan dated 8/23/2025 with a revision on 9/02/2025 documents that R1 is at risk for falls related to impaired cognition, poor safety awareness, dementia, shuffling gait, and weakness and at risk for falls with injury related to medications, history of falling, poor balance, unsteady gait, and weakness.R1's Progress Notes dated 8/30/2025 document that R1 had an unwitnessed fall that resulted in R1 sustaining a fracture to his left shoulder, a laceration on the side of his left eye, and a skin tear to R1's left elbow. The facility Fall Investigation for R1's 10/18/25 fall #1830 (10/24/2025) documents a witness statement dated 10/18/2025 from V7 (Certified Nurse Assistant (CNA)) which states, I was filling out paperwork at the desk and then I got up to go to the bathroom and (saw) that (R1) was walking out of his bathroom and begin to lose balance and went down to the floor.R1's Hospital Discharge summary dated [DATE] documents R1 was admitted to the hospital following a mechanical fall at the facility (on 10/18/25) where R1 resides and R1 sustained a left hip fracture. An x-ray report dated 10/18/2025 confirmed that R1 had an acute intertrochanteric fracture of the left femur with soft tissue swelling. In a phone interview on 10/27/2025 at 12:26 PM, V7 CNA stated (on 10/18/25) she was standing at the nurses' station and looked up and noticed R1 coming out of R1's neighbor's room, V7 CNA stated R1 lost his balance and fell. V7 CNA stated, I don't know what time the fall happened or the last time I saw (R1), and I don't have anything else to tell you.On 10/272025 at 1:13 PM, V4 (Registered Nurse (RN)) stated she was taking care of R1 the day of R1's fall (on 10/18/25). V4 stated R1 has dementia, was alert and oriented to person only and frequently would get up on his own. V4 RN stated the CNAs should have been checking R1 every two hours if not more frequently.R1's EMR (Electronic Medical Record) documents R1 was last repositioned at 8:22 AM on 10/18/25. R1's Progress Notes document R1 fell on [DATE] at 3:50 PM. On 10/27/2025 at 2:24 PM, V9 (Licensed Practical Nurse (LPN)/MDS Coordinator) stated, 15-minute checks (increased visuals) are implemented for those residents that have been determined to wander or who are at risk for elopement. On 10/27/2025 at 11:39 AM, V6 (Certified Nurse Assistant (CNA)) stated that R1 frequently gets up on his own without calling for help.On 10/28/2025 at 10:05 AM, V8 CNA stated that R1 is oriented to person only and gets up on his own frequently to get coffee and that is how he fell the first time (8/30/25). On 10/28/2025 at 10:21 AM, V3 (LPN/Assistant Director of Nursing (ADON)) stated that CNAs are responsible for checking residents that are at increased risk for falls every two hours and that it is a task in the EMR where they document those checks. V3 LPN stated residents that are a high risk for falls or high elopement risk should be checked on every 15 minutes. V3 stated the CNAs should have been checking on R1 at minimum every two hours and that it should be documented. V3 LPN could not provide documentation showing R1 had been checked on appropriately on 10/18/25. On 10/27/2025 at 2:16 PM, V2 (Director of Nursing (DON)) stated staff are responsible for doing rounds every two hours unless a resident is a high fall risk and then they should be checked more frequently (every 15 minutes), and this should be on the Care Plan. On 10/27/2025 at 3:00 PM, V2 DON confirmed that staff were not checking on R1 every 15-minutes even though he was a high fall risk.

Based on interview, and record review the facility failed to schedule a prompt appointment for physician ordered diagnostic Magnetic Resonance Imagining (MRI) of R2's right hip post-fall, and failed to obtain the results of the MRI in a timely manner. These failures resulted in R2's sustaining continued severe pain, and delay in surgical repair of a hip fracture. R2 is one of three residents reviewed for falls on the sample list of three. Findings include:R2's Current Diagnoses Sheet documents the following: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety; Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side; Acute Neurologic Condition; Low Back Pain, Unspecified; and Dorsalgia, Unspecified.R2's Current Physician Order Sheet (POS) documents the following: Tylenol (analgesic) oral tablet, 325 mg - Give two tablets by mouth one time a day, related to Disorder of Muscle, Unspecified. Order Date: 05/20/2025. Tramadol HCL (narcotic analgesic) oral tablet, 50 mg - Give one tablet by mouth every 12 hours as needed for pain rated 7-10 (on pain scale with 10 being severe pain). Order Date: 04/16/2025. Aspirin oral chewable tablet, 81 mg - Give one tablet by mouth one time a day for prophylaxis. Order Date: 04/16/2025. Xarelto oral tablet, 20 mg - Give one tablet by mouth one time a day as a blood thinner. Order Date: 04/16/2025.R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status score as 0 out of a possible 15, which indicates severe cognitive impairment.R2's Late Entry Nurse's Note dated 9/16/25 at 9:08 p.m. documents the following: This nurse (V20, Registered Nurse) was called to the North Hall shower room per CNA (V13, Certified Nursing Assistant), who stated that the resident (R2) had a witnessed fall during an assisted shower. CNA (V13) stated she was attempting to roll the resident out of the shower area in a wheelchair (w/c); the w/c got caught on a floor tile, and the resident (R2) fell out of the chair. Upon entry to the shower room, the resident was found lying on her right side with her head against the baseboard. Resident denied pain or discomfort. Head-to-toe assessment completed. Vital signs obtained. Resident assisted back to w/c. Resident agreeable to go to the ED (Emergency Department) for further workup due to hitting her head and being on a blood thinner. EMS (Emergency Medical Services) notified and en route. Resident at nurses' station with nurse until EMS arrived. Attempted to notify POA (V21, Power of Attorney); voicemail left. ADON (V3, LPN Nurse Supervisor), facility on-call manager (unidentified), and MD (unidentified physician) notified of incident.R2's Hospital emergency room Note dated 09/16/25 documents the following: Chief Complaint: Fall. Patient (R2) arrived via EMS from [Facility Name] Health Facility with complaint of a fall from standing. Healthcare facility states patient was in the shower, fell, and hit her head. EMS personnel state patient has a bump on the left side of her head that is chronic and a small bump on the right side from the fall. Patient did not lose consciousness. Patient is on blood thinners per [Facility Name] Health Facility. Facility staff state the patient is acting within her normal limits and at baseline (as noted on the above MDS, severe cognitive impairment), but they wanted her checked because she is on blood thinners. Patient denies neck and back pain and refused to have a C-collar placed by EMS. Patient has no other complaints at this time.R2's same Hospital emergency room Note documents that R2 underwent a Computed Tomography (CT) scan of the head and spine, which revealed no acute changes. (No diagnostic test or imaging was performed on R2's right hip.) R2 was returned to the facility. The hospital discharge summary instructed the facility to return R2 to the emergency room if new symptoms, regions of pain, or red-flag (serious or potentially life-threatening) symptoms developed.R2's Nurse's Note dated 9/17/2025 at 11:51 a.m. documents: Resident complained of right-sided hip and shoulder pain since the fall. Medical records from ER visit (9/16/25 post-fall) reviewed-no X-rays were obtained. Resident refusing to get out of bed due to pain. Spoke with resident's family member/POA (V21). Administrator (V1) approved transfer for evaluation. Received order from Nurse Practitioner (V22) to send to ER for complaints of increased pain in right shoulder and hip.R2's Second Transfer (Post-Fall) emergency room Note dated 09/17/25 documents:R2 was seen for Chief Complaint: Hip and Shoulder Pain. X-rays of the right shoulder and right hip were completed, showing no acute fracture or dislocation. The report also notes that the right hip X-ray did not have a true AP projection, indicating incorrect anteroposterior positioning, which can cause image distortion. The same note states: Consequently, if hip pain symptoms persist, consider non-contrasted CT scan of the right hip. No further diagnostics were performed until a family request on 09/29/25 (see below).R2's Narcotic Count Sheet documents that R2 received 26 Tramadol 50 mg tablets dispensed on 4/25/25. Only four doses were administered between 4/25/25 and 9/16/25 (the day of the fall). Since the fall, 18 doses were administered, indicating continued severe pain after the 9/17/25 X-ray (noted above as no true AP projection). There is no documentation that a non-contrasted CT scan of the right hip was pursued, as previously recommended.R2's Facility Facsimile to providers dated 9/29/25 (13 days post-fall) titled [Facility Name] Health and Rehab Center Physician Notification documents: Nursing Comments and Concerns: Resident continues to complain of pain in right arm and hip since fall on 9/16/25. Family is concerned that she isn't using her right leg since the fall and would like an MRI performed. Specific Request: Order for MRI? Stronger pain medication?Physician Comments & Signature: Okay to order right hip MRI and schedule patient to be seen by me (V22, Nurse Practitioner) or (V26, Physician/Medical Director) this week.R2's Provider Progress Note written by V22, Nurse Practitioner, dated 10/01/25, documents that R2 was examined bedside: Recently, patient had a fall on 9/16/25 and was taken to the ER. She had CT head and C-spine (9/16/25) and hip and shoulder X-rays (9/17/25), which were unremarkable, and was sent back to the SNF. Patient is complaining of ongoing right arm and hip pain. MRI of right hip has been ordered as patient is not utilizing her right leg well.R2's Nursing Note dated 10/01/2025 at 3:36 p.m. states: NP (V22) here and saw the patient for increased right hip pain. MRI scheduled for 10/10/25 (eleven days after order). No new orders-will wait for MRI results.R2's MRI of the Right Hip was completed on 10/10/25 at 11:18 a.m. (eleven days after the 9/29/25 order). The MRI documented the following Final Results: Acute, impacted subcapital hip fracture with lateral displacement and extensive soft tissue edema.These results were confirmed by a radiologist on 10/11/2025 at 11:19 p.m. (36 hours and one minute after completion).R2's Nursing Note dated 10/12/2025 at 4:22 p.m. (17 hours after the MRI results were finalized) documents: NP (V22) contacted management, who notified this nurse that patient (R2) needed to be sent to the hospital due to abnormal MRI results (subcapital hip fracture with lateral displacement and extensive soft tissue edema). This nurse notified POA (V21) and called EMS for patient transport to the hospital. This nurse then called [Local Hospital] ER and gave report to [nurse name]. EMS arrived and transported the patient to [Local Hospital] for evaluation.R2's Hospital Operative Note dated 10/13/2025 documents: Preoperative indication: Patient is a [age]-year-old female who sustained a femoral neck fracture. We discussed the treatment plan and associated complications with the patient and family. They chose surgical treatment-cemented bipolar hemiarthroplasty (minimally invasive hip replacement) of the right hip.Administrator (V1) statement, 10/15/25 at 10:00 a.m.: I am finishing up with R2's investigation. It was not an injury of unknown origin. We determined it was directly related to her fall on 9/16/25. There is too much evidence that she continued to have pain in her right hip since the fall. It's no wonder-her hip was fractured.Power of Attorney (V21) statement, 10/15/25 at 2:30 p.m.: The facility called me when Mom fell. They said she fell forward out of the shower and hit her face, shoulder, and hip. She had a large bruise on her buttock and hip for a couple of weeks-it was gone by the time she went for the MRI. Mom had been reporting pain to the nurses since her fall. She can answer questions but not always accurately. If she's sitting in a chair, she'll say no pain, but when she crosses her legs, she'll yell that she's in extreme pain. The staff nurse knew this and would give her pain medicine. Finally, they did the MRI and saw the fracture in the hip. I don't know why the MRI was scheduled so late-we waited nearly two weeks after the order. The fracture has been fixed now with surgery; they had to replace the ball of her hip joint.I'm happy with the care she gets in the facility-they said they were investigating the fall. My concern was how long she remained in pain. I saw her several times a week, and it reached the point where she couldn't move her leg at all. I know she'll get good care when she returns; she loves it there. Therapy is very good too.Medical Director (V26) statement, 10/16/25 at 12:55 p.m.: I was told the family requested an MRI on 9/29/25 for continued pain, and the NP (V22) ordered it. The MRI should have been completed sooner than 10/10/25-waiting that long was too delayed. NP (V22) is very good with residents and would have addressed the delay if she had known. I would have expected the MRI within a few days. I was not aware the MRI results (10/10/25) were not received until 10/12/25, since it showed a fracture. The hospital usually calls. I can see the MRI was read by a tele-med physician, which can cause delays. Facility nurses should have followed up that same day for results-waiting until 10/12/25 added two extra days of pain before surgery.

Failures at this level required more than one deficient practice statement: A. Based on observation, interview, and record review, the facility failed to provide a safe environment by leaving a normally secured bathroom door ajar, effectively failing to supervise R1, a resident with a diagnosis of dementia, to prevent a traumatic fall. This failure resulted in R1 falling and striking their head, sustaining a hematoma, a rib fracture with a partially collapsed lung, and two brain bleeds requiring emergency hospitalization and treatment at two separate hospitals. R1 was one of three residents reviewed for falls in a sample of three. B. Based on observation, interview and record review the facility failed to maintain a shower chair, in safe operable condition, which resulted in R2's fall with a hip fracture that required surgical repair. R2 is one of three residents reviewed for falls on the sample list of three. Findings include:A. R1's Resident Assessment (6/26/2025) documents R1 has moderately impaired cognition. The same record documents R1 uses a wheelchair for mobility, has wandering behavior, is dependent on staff for transfers and toileting, and requires substantial/maximal staff assistance to walk. R1's diagnosis list (10/14/2025) documents diagnoses including Dementia and Osteoarthritis (degenerative joint disease). R1's Fall Risk Assessment (6/14/2025) documents R1 is at high risk for falls. R1's Elopement Evaluation (9/5/2025) documents R1 is at high risk for elopement. R1's care plan (10/14/2025) documents R1 is at risk for falls and injuries due to medical factors, including Dementia, non-compliance, pain, poor safety awareness, and Osteoarthritis, with the intervention that staff should not leave R1 alone in R1's room when R1 is in a wheelchair. The same record documents R1 wanders in the facility. The facility Incident Investigation Summary (9/26/2025) documents R1 sustained a fall on 9/20/2025 in the facility dementia unit central bathroom, resulting in a head injury and was sent to the hospital emergency department. The facility Fall Investigation #1808 (9/20/2025) documents V4 (Licensed Practical Nurse) was walking down a facility hallway and noticed R1 trying to crawl out of a bathroom. The same record documents V4 observed a large hematoma (localized blood collection outside of blood vessels) on the right side of R1's forehead above the eyebrow, and R1 was sent to the hospital emergency department by ambulance. The hospital emergency department report (9/20/2025) documents R1 experienced an unwitnessed fall in a facility bathroom and was found by facility staff crawling on the ground with an abrasion/swelling to the right eyebrow and complaints of pain in the right rib cage. The same report documents R1 reported having a headache and was experiencing pain with respiration and with movement. The hospital radiology report (9/20/2025) documents R1 sustained a large traumatic subdural hematoma (collection of blood between the brain and skull), subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it), fracture of right rib, pneumothorax (partially collapsed lung), and a hematoma adjacent to R1's right eyebrow. The same report documents R1 needed trauma surgery and was sent to a regional trauma center for a higher level of care. The Trauma Evaluation History and Physical (9/24/2025) documents R1 was admitted to the trauma center intensive care unit on 9/20/2025 and received an intravenous catheter, pain medication, and required surgical placement of a chest tube on 9/21/2025 to treat R1's worsening pneumothorax. The same record documents R1 remained hospitalized until 9/24/2025 before transferring back to the facility. On 10/15/2025 at 10:32 AM, V4 (Licensed Practical Nurse) reported working on the facility dementia unit on 9/20/2025 and noticing the door to the unit central bathroom was partially opened, and R1 was attempting to crawl out of the bathroom. V4 reported no other staff were present at the time, and V4 last observed R1 seated in R1's wheelchair in the dining room across the hall from the central bathroom waiting for supper. V4 denied staff continuously monitor the central bathroom and denied staff had provided R1 access to the bathroom to use independently. V4 reported R1 can make R1's needs known to staff and will tell staff when R1 needs to use the bathroom. V4 reported R1 has a history of frequently wandering in the dementia unit, room to room, looking for R1's brother or other people. On 10/15/2025 at 12:25 PM, the above central bathroom door on the dementia unit was fully closed and had a keypad lock mechanism present on the door handle, requiring staff to enter a code to open the door. V23 (Certified Nurse Aide) was nearby and attempted to open the door without success. The door slab appeared to be sticking, and V23 thrust V23's shoulder and feet forcefully against the door repeatedly, along with re-entering the unlock code several times before finally succeeding in opening the door after numerous attempts. On 10/15/2025 at 12:30 PM, V11 (Registered Nurse) reported the dementia unit central bathroom door required two staff to get open on 10/14/2025. V11 reported some residents will use the bathroom independently. On 10/15/2025 at 2:25 PM, the above door was slightly ajar with the latching mechanism not engaged. No facility staff were located in the vicinity of the central bathroom. On 10/15/2025 at 2:19 PM, V23 (Certified Nurse Aide) reported the central bathroom door began sticking shut and became difficult to open sometime over the summertime. V23 reported not being sure if any staff had submitted a maintenance work order to repair the malfunctioning door. V23 stated, I might need to put another (maintenance work order request) ticket in. V23 reported staff can submit maintenance requests through a software system accessible at the nurse's station adjacent to the dementia unit central bathroom, and V23 denied any issues with the facility maintenance department responding to requests in a timely manner. On 10/15/2025 at 2:28 PM, V24 (Certified Nurse Aide) reported not being certain facility staff had submitted a maintenance work order to repair the malfunctioning door. V24 stated, I've been meaning to (submit a maintenance work request for the door). V24 reported facility staff working on the dementia unit leave the door slightly ajar, unlatched, and unlocked to facilitate use of the central bathroom since the door sticks shut and is difficult to open. V24 denied the facility maintenance department has any delays in responding to work order requests submitted by nursing staff. On 10/16/2025 at 11:47 AM, the dementia unit central bathroom door was ajar, unlatched, and unlocked. On 10/16/2025 at 2:30 PM, V5 (Certified Nurse Aide) reported being on a break away from the dementia unit when R1 experienced an unwitnessed fall in the central bathroom on 9/20/2025. V5 reported R1 had been seated in R1's wheelchair in the dining room prior to V5 leaving the unit for a break, and V4 and V28 remained on the unit to take care of residents. V5 reported V28 (Certified Nurse Aide) was leaving the dementia unit for a break as V5 was returning to the unit, and V5 believed V28 was unaware R1 had accessed the unlocked bathroom independently and had experienced a traumatic fall to the floor and remained on the bathroom floor at the time V5 returned from a break. V5 reported V4 found R1 injured and attempting to crawl out of the bathroom after V5 had returned to the unit, and when V5 went to help with R1, R1's forehead was really bulged from R1's fall in the bathroom. V5 reported the dementia unit central bathroom door has always been hard to open, so the nursing staff leave the door cracked open, or else they have to type the unlock code into the keypad over and over again and punch the door to get it to open. V5 denied R1 had any history of attempting to unlock any doors with a keypad but would shake handles to doors sometimes. When the surveyor asked V5 if the bathroom door had remained shut and locked, could that have prevented R1 from accessing the bathroom independently and experiencing a fall, V5 replied, Yes. On 10/14/2025 at 3:20 PM, R1 was sleeping in bed with a large, hand-sized bruise remaining around R1's right eye, eyebrow, and forehead from R1's fall 24 days ago on 9/20/2025. The facility fall policy (9/2024) documents the intent of the policy is to ensure the facility provides an environment free from hazards over which the facility has control and provides appropriate supervision to each resident. B. R2's current Diagnoses Sheet documents the following: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Acute Neurologic, Low Back Pain, and Unspecified Dorsalgia, Unspecified. R2's current Physician Order Sheet (POS) documents the following: Tylenol (analgesic) Oral Tablet, 325 mg, give 2 tablets by mouth, one time a day, related to Disorder of Muscle Unspecified – Order Date 05/20/2025; Tramadol HCL (narcotic analgesic) Oral Tablet, 50 milligrams (mg), give 1 tablet by mouth every 12 hours as needed for pain 7–10 (on pain scale with 10 being severe pain) – Order Date 04/16/2025; Aspirin, Oral Tablet Chewable, 81 mg, give 1 tablet by mouth one time a day for prophylaxis – Order Date 04/16/2025; and Xarelto Oral Tablet 20 mg, give 1 tablet by mouth one time a day for blood thinner – Order Date 04/16/2025. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status score as zero out of a possible 15, indicating severe cognitive impairment. The same MDS documents R2 uses a manual wheelchair and a walker for mobility. The same MDS documents R2 requires staff assistance with showering and that R2 has had no falls or pain during the look-back period of this assessment. R2's Late Entry Nurses Note dated 9/16/2025 at 9:08 PM documents the following: Note Text: This nurse (V20, Registered Nurse) was called to North Hall shower room per CNA (V13, Certified Nursing Assistant); states resident (R2) had a witnessed fall during assisted shower; CNA (V13) states (V13) was attempting to roll resident out of shower area in w/c (wheelchair); w/c got caught on floor tile, and resident (R2) fell out of chair; upon entry to shower room, resident was found lying on right side w/head against baseboard of floor; denies pain or discomfort; head-to-toe assessment complete; VS (vital sign measurements) obtained; resident assisted to w/c; resident agreeable to go to ED (hospital emergency department) for further work-up d/t (due to) hitting head and being on a blood thinner; EMS (Emergency Medical Services) notified and en route; resident @ (at) nurses' station w/nurse until EMS arrived; attempted to notify POA (V21, Power of Attorney), received voicemail; ADON (V3, LPN Nurse Supervisor), facility on-call manager (unidentified), and MD (unidentified physician) notified of incident. R2's Hospital emergency room note dated 9/16/2025 documents the following: Chief Complaint: Fall. Pt (Patient/R2) arrived via EMS from [NAME] Health Facility with c/o a fall from standing. Healthcare facility states pt was in the shower, fell, and hit her head. EMS personnel state pt has a bump on the left side of head that is there all the time, and there is a small bump on the right side of her head from where she hit it when she fell. Pt did not lose consciousness. Pt is on blood thinners per (Proper Name) Health Facility. (Proper Name) Health Facility states that pt is acting within her normal limits and is at baseline (as noted on above MDS, severe cognitive impairment), but they wanted to have her checked out because she is on blood thinners. Pt denies neck and back pain and refused to have a C-collar placed by EMS. Pt has no other complaints at this time. R2's same Hospital emergency room note documents R2 underwent a Computed Tomography (CT) scan of R2's head and spine, which revealed no acute changes were identified. (There was no diagnostic test or result performed on R2's right hip.) R2 was sent back to the facility. R2's discharge summary directs the facility that R2 is to return to the emergency room with new symptoms or regions of pain, red flag (serious—potentially life-threatening) symptoms. R2's Nurses Note dated 9/17/2025 at 11:51 AM documents the following: Note Text: Resident c/o right-side pain in hip and shoulder since fall. Med (medical) records from ER (emergency room) visit (9/16/2025 post fall) were reviewed, no x-rays were obtained. Resident is refusing to get out of bed with c/o pain. Spoke with resident's (V21, Family Member/POA). (V1, Administrator) ok to send out to be evaled (evaluated). Received order from (V22, Nurse Practitioner) to send to ER for c/o of increased pain in right shoulder and hip. R2's second trip from the facility to the hospital emergency room note dated 9/17/2025 documents the following: R2 was seen for the Chief Complaint: Hip and Shoulder Pain, and X-rays of R2's right shoulder and right hip were completed, and there was no acute fracture or dislocation identified. The same report further elaborates that R2's right hip X-ray does not have a True AP projection, which means the resident's anteroposterior positioning was incorrect during the X-ray diagnostic test, which can lead to image distortion. The same emergency room note documents: Consequentially, if hip pain symptoms persist, consider non-contrasted CT scan of the right hip. No further diagnostics were completed until family request on 9/29/2025 as noted below. R2's Narcotic Count Sheet documents R2 had 26-count Tramadol (narcotic analgesic) 50 mg tablets dispensed from the pharmacy on 4/25/2025. R2 had only been administered four doses of the Tramadol supply between 4/25/2025 and 9/16/2025 (the day of R2's fall), which is indicated on the above physician order to be administered for a pain level of 7–10 (severe pain). The same Narcotic Count Sheet documents 18 doses of Tramadol were administered to R2 since her fall occurred 9/16/2025, which indicates R2 continued in severe pain after her X-ray. That X-ray, documented above as no true AP projection, and there was nothing documented that the non-contrasted CT scan of the right hip was considered, as noted in that X-ray report 9/17/2025. R2's facility facsimile to the providers dated 9/29/2025 (13 days after the fall), (Facility name) Health and Rehab Center Physician Notification, documents the following: Nursing Comments and Concerns: Resident (R2) continues to c/o (complain of) pain in R (right arm) and hip since (a) fall 9/16/2025. Family (unidentified) is concerned that she isn't using her right leg since the fall and would like to have an MRI (Magnetic Resonance Imaging) done. Specific Request: Order for MRI? (sic) Stronger pain med (medication)? (sic) Physician Comments & Signature: okay to order right hip MRI and schedule patient to be seen by me (V22, Nurse Practitioner) or (V26, Physician/Medical Director) this week. R2's Provider Progress Note, written by V22, Nurse Practitioner (NP), dated 10/01/2025, documents R2 was examined bedside. V22, NP, further documents: Recently patient had an episode of fall on 9/16/2025 and was taken to ER. She had a CT head and C-spine (9/16/2025) and hip and shoulder X-ray (9/17/2025), which was unremarkable and was sent back to SNF (Skilled Nursing Facility). Patient is complaining of ongoing right arm and right hip pain. MRI of right hip has been ordered as patient is complaining of ongoing pain and is not utilizing her right leg well. R2's Nursing Note dated 10/1/2025 at 3:36 PM documents the following: Note Text: NP (V22, Nurse Practitioner) here and seen (sic) the patient for increased pain in right hip. Patient has MRI scheduled 10/10/2025 (eleven days after the 9/29/2025 order). No new orders; we will wait for MRI results. R2's MRI of the right hip was completed on 10/10/2025 at 11:18 AM. The MRI of R2's right hip documents the Final results as an Acute, Impacted (broken pieces of the bone are wedged together tightly) Subcapital Hip Fracture With Lateral Displacement, and Extensive Soft Tissue Edema (swelling). These results were not confirmed by a radiologist until 10/11/2025 at 11:19 PM (36 hours and one minute after the MRI was completed). R2's Nursing Note dated 10/12/2025 at 4:22 PM (seventeen hours and three minutes after the late results were identified as documented above) documents the following: Note Text: (V22, Nurse Practitioner) reached out to management (unidentified), in which they reached out to this nurse (unidentified) and stated that patient (R2) needed sent to hospital due to abnormal MRI results (as noted on the MRI above). This nurse notified POA (V21, R2's Power of Attorney) and called EMS for patient transport to hospital. This nurse then called (Local Hospital) ER and gave report to (proper first-named nurse). EMS arrived and transported the patient to [NAME] Hospital for eval (evaluation). R2's Hospital Operative Note dated 10/13/2025 documents the following: Preoperative indication:Patient is (specified age) delightful female who sustained injury resulting in fracture of femoral neck. We discussed in detail with patient and family regarding the treatment plan and complications associated with all the options. They chose to proceed with the surgical treatment plan. Treatment plan was to proceed with bipolar MI (minimally invasive) arthroplasty (hip replacement) of the right hip.Procedure performed: 1. Cemented bipolar hemiarthroplasty (surgical repair of the femoral head and neck bone) of the right hip. R2's Illinois Department of Public Health (IDPH) final report documents: Detailed Incident Summary documents the following: Final: Resident CM with PMHx of dementia, osteopenia with degeneration, cerebral infarction, COPD, heart disease, adjustment disorder with anxiety and depression, fibromyalgia, hypertension, atrial fibrillation, and anemia was sent to the emergency department on 10/12/2025 after facility received the report of resident's MRI showing an acute impacted subcapital hip fracture. This same IDPH report documents: Upon investigation, resident CM had a witnessed fall in the shower room on 9/16/2025. During shower, wheel of chair got caught on shower drain and the chair tipped forward resulting in resident fall. Resident (initials of R2) was sent to emergency department for evaluation and treatment. Resident (initials of R2) returned same day with no new orders. It was noted that the hospital completed CT of head and C-spine but no X-rays. On 9/17/2025, resident (initials R2) was continuing to have c/o pain and was sent back to emergency department for X-rays. The hospital completed 2-view X-rays of shoulder and hip w/pelvis. The results were negative for findings. Resident (initials of R2) was assessed by nurse practitioner on 9/18/2025, 9/25/2025, and 9/29/2025. On 9/29/2025, resident (R2) was given order to obtain MRI r/t resident (initials of R2) continuing to have c/o pain. Facility scheduled MRI per order for 10/1/2025 (not scheduled until 10/10/2025, ten days later). Resident (initials of R2) was assessed by nurse practitioner on 10/1/2025 and 10/9/2025. On 10/12/2025, facility received notifications r/t MRI obtained on 10/10/2025. MRI revealed an acute impacted subcapital fracture of right hip. Facility obtained orders from nurse practitioner to send resident to emergency department for evaluation and treatment of fracture. From initial fall on 9/16/2025 to facility receiving abnormal MRI results, resident (initials of R2) had no further incidents or accidents. Resident (initials of R2) was on therapy caseload and facility clinical staff as well as nurse practitioners were following resident r/t fall on 9/16/2025. Pain was being managed with both scheduled and as-needed pain medications. It is facility's determination that the root cause of the fracture is from the fall on 9/16/2025. Care plan was reviewed and intervention put into place addressing root cause of fall. Resident (initials of R2) will be assessed upon return from hospital, after being sent out on 10/12/2025. Care plan will be revised to reflect care required r/t fracture after resident assessment and review of physician's orders. This serves as final report. The facility Work Order dated as created 9/17/2025 at 9:46 AM documents:Small white shower chair wheels – North shower room.Assigned to (V18, Maintenance Director). Wheels need checked out.The same Work Order documents Updated Status dated 9/22/2025 at 9:50 AM (five days post R2's fall) by V19, Maintenance Assistant, documents: Set to Completed. On 10/15/2025 at 10:00 AM, V1, Administrator, stated, I am finishing up with (R2's) investigation. It was not an injury of unknown origin. We determined it was directly related to her fall 9/16/2025. There is too much evidence that she continued with pain in her right hip ever since the fall. It is no wonder she was having the pain. It was fractured. On 10/15/2025 at 11:40 AM, V13, Certified Nursing Assistant (CNA), stated V13 was giving R2 a shower in the North Hall shower room when the shower chair wheel got stuck on the drain. V13, CNA, stated he used the small, white shower chair that had wheels that never worked right. Everybody knew it. V13 said the shower chair is old, and the wheels were really worn and did not straighten out. They would turn sideways. V13 stated he was standing in front of the shower chair at the front of the stall after shutting off the water. V13, CNA, said, I tried to pull the shower chair forward out of the shower stall. The wheels turned sideways, and the back one got stuck in the drain. First, the shower chair was leaning forward. I tried to catch (R2), but then the whole chair shifted sideways and fell to the ground. (R2) hit her head and landed on her right side. (R2) immediately complained of her head, shoulder, and hip pain. The nurse came and did a complete skin assessment and sent (R2) to the hospital. (R2) came back (to the facility) the same day. I worked the next day (9/17/2025). (R2) stayed in bed, which (R2) never normally did. Her daughter (unidentified) was at her bedside. (R2) was having extreme pain. We could not shift her weight at all to move her in bed. The nurse (unidentified) gave her meds and tried to keep her comfortable (R2 was also sent to ER as noted above). The next time I worked, she was up in her wheelchair like normal. She (R2) went to the dining room per her usual. She still complained of pain at times, and the nurse would give her meds to keep her comfortable. I worked over on [NAME] (Dementia Unit) maybe twice since her fall, then was off for several days. I did hear she had a hip fracture and was in the hospital while I was off. On 10/15/2025 at 11:50 AM, V14, Certified Nursing Assistant (CNA), walked down to the North Hall shower room and confirmed there is only one small white shower chair and two white bariatric shower chairs in the North Hall shower room. V14, CNA, stated, These (two bariatric and one small) are the shower chairs that are always in the North shower room. I (V14) often will go to South (Hall) shower room and get the newer black shower chair when I give showers if it is not in use. V14 also stated, Today, I just gave a shower in this (plastic-like p-framed, small, white, wheeled) shower chair because the good one was not available. They have finally changed the wheels on this (small white shower chair). The wheels were worn and moved every which way, but not straight like they should have. The wheels don't match now, but it is better than it was with these (three matching grey and one black wheel). See the tread coming off this wheel (unmatched back black wheel)? The front ones were the worst. It is good that at least three wheels got replaced. It is much better than it was. All our shower chairs need replaced, if you ask me. The previous DON (unidentified) knew it but never had them replaced. The black one (shower chair) in South (hall shower room) is the best we have. If they (shower chairs) all functioned right, it would be nice and much safer for the residents. On 10/15/2025 at 12:20 PM, V18, Maintenance Director, walked down to the shower room on North Hall. V18 looked at the shower chair and stated three of the wheels were replaced after (R2) fell from the shower chair. We use (specific company, computer program) to get work orders from staff. We only had three wheels this (to use on the shower chair) height, so we only replaced the three. V18 then confirmed the fourth wheel's rubber tread was tattered and had one-inch tread peeled away from the tire and flapping loosely on both sides of the fourth wheel as it was rolled front and back during observation. V18 stated, This is a very old shower chair. We decided to replace what we could and picked the one (back left) in the best condition to leave on. It was It was the right height (for the shower chair). We were not told which wheel caused the resident (R2) to fall from this (shower) chair. It could have been this back one. It obviously needs replaced too. V18 then stated he has the work order, in his office computer and will provide. On 10/15/25 at 12:30 pm V18 walked down to the Maintenance room office to obtain the work order to fix the shower chair that resulted in R2's fall on 9/16/25. V19, Maintenance Assistant was present. While V18 searched the maintenance work orders on the computer, V19 agreed to an interview. V19 stated he could not remember how many of the wheels he replaced on the shower chair that caused R2's fall on 9/16/25. V19 stated When I lifted the chair (shower) I think all the wheels fell off. V18, Maintenance Director stated to V19, that the facility only had three wheels the right height, so we replaced three of the wheels. V19 stated That sounds right. On 10/15/25 at 2:30 pm V21, (R2's Power of Attorney) stated The facility called me when mom fell. They said she fell forward out of the shower and hit her face, shoulder and hip. She had a very large bruise on her butt and hip for a couple of weeks. It was gone by the time mom (R2) went for the MRI. Mom had been reporting to the facility nurses since her (R2's) fall (9/16/25) that she was in extreme pain. She can answer questions when asked, but not necessarily accurate. If you ask her if she is in pain and she is setting in a chair, she will say no. As soon as she would cross her legs, she would yell out to me that she was is extreme pain. The staff nurse knew this and would give her pain medicine. Finally, they did the MRI and saw the fracture in the ball of her hip. I have no idea why the MRI was scheduled so late. I think we waited for the MRI appointment two weeks (9/29/25 until 10/12/15 MRI results) after the nurses got the order for her to have that. The fracture has been fixed in surgery, now. They had to replace the whole ball in her hip joint. V21, also stated I am very happy with the care she gets in the facility. They said they were investigating how she fell. I am not sure of the details of that investigation. My concern was that she continued in so much pain. I was in to see her several times a week. It reached the point where she couldn't move her leg on her own, at all. I know she will get good care when she returns there (to the facility). Mom loves it there and I am glad of that. Therapy is very good too. On 10/15/25 at 3:00 pm V1, Administrator stated The shower chair should have been taken out of service when Maintenance was notified there were problems with the shower chair wheels, and they needed fixed. Maintenance should have said something if they couldn't do a complete wheel change. V25, Regional Nurse Consultant stated A new shower chair has been ordered since only three of the four wheels were replaced (on the small white shower chair that resulted in R2's fall). On 10/16/25 at 1:30 pm V26, Medical Director/Physician stated The resident equipment is meant to be, always maintained in a safe manner. The wheels on the shower chair are an easy fix. (R2's) fall should have never happened. It could have been easily prevented with some routine monitoring of that equipment. The facility Falls Guideline policy dated 08/2024 documents the following: Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to: To achieve each resident's maximum potential of physical functioning. To prevent or reduce injuries related to falls. To enhance residents' dignity and self-worth. To rehabilitate residents to their fullest potential of function. The same policy documents: The intent of this guideline is the ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: I. Identification of hazards and risks II. Evaluation III Implementation IV. Monitoring V. Analysis

Based on interview and record review, the facility failed repeatedly to maintain complete and accurate medical records for one of three (R2) residents reviewed for falls/ medical records on the sample list of three.Findings include:R2's Magnetic Resonance Imagining (MRI) report of the Right Hip was completed at a local hospital on [DATE] at 11:18 am. The MRI of R2's Right Hip documents the Final results as an Acute, Impacted (broken pieces of the bone are wedged together tightly) Subcapital Hip Fracture With Lateral Displacement, and Extensive Soft Tissue Edema (swelling). There is no documentation in R2's medical records that R2 left the faciity on [DATE] to have the MRI at the local hospital.The last documentation in R2's record was a Nurse Practitioner Note dated 10/9/2025 at 11:46 am.The next documentation was on 10/12/2025 at 4:01 pm which documents: Change of Condition /Transfer Note Text: (R2) was transferred on a gurney via ambulance to acute care hospital Sent To: (name of Local) Community Hospital Date: 10/12/2025 16:10 Sent From: (Name of the facility) Healthcare Center Unit: North Wing. Reason(s) for Transfer: Other - Abnormal MRI results MD (unidentified) notified of transfer. See Transfer Form for other details.R2's current Physician Order Sheet (POS) documents the following: Tramadol HCL (narcotic analgesic) Oral Tablet, 50 Milligrams (mg), Give 1 tablet by mouth every 12 hours as needed for pain 7-10.R2's same POS documents: Pain Assessment - every shift using 1-10 Scale (scale of ten, being the worst pain level).R2's Narcotic Count Sheet documents R2's had 26 count of tablets; Tramadol (narcotic analgesic) 50 mg tablets dispensed from the pharmacy on 4/25/25. R2's had been administered four doses of the Tramadol supply between 4/25/25 and 9/16/25 (the day of R2's fall). The same Narcotic count sheet documents 18 doses of Tramadol were administered to R2, since her fall occurred 9/16/25. All doses signed out on the narcotic count sheet, correlate with the Medication Administration Record (MAR) records documented below except, the following doses were removed from R2's supply on 9/19/25 at 7:00 am, 9/28/25 at 8:00 am or 8:00 pm, 9/29/25 at 8:00 pm and 10/9/25 at 8:00 pm.R2's corresponding Medication Administration Record (MAR) dated 9/16/25 through 9/30/25 and R2's MAR dated 10/01/25 through 10/12/25 do not document R2 received Tramadol HCL (narcotic analgesic) Oral Tablet, 50 mg on 9/19/25 at 7:00 am, 9/28/25 at 8:00 am or 8:00 pm, 9/29/25 at 8:00 pm and 10/9/25 at 8:00 pm.R2's same MAR documented above fail to document R2's pain level scores as ordered: Pain Assessment - every shift using 1-10 Scale (scale of ten, being the worst pain level).On 10/16/25 at 11:55 am V2, Director of Nursing (DON) reviewed R2's Tramadol (narcotic analgesic) 50 Milligram (mg) tablet, Controlled Drug Administration, narcotic count sheet. V2 confirmed, according to R2's narcotic count sheet that R2's Tramadol 50 mg tablets, were removed the supply, from the locked compartment on the medication cart, on 9/19/25 at 7:00 am, 9/28/25 at 7:00 am and 8:00 pm, 9/29/25 at 8:00 pm, and 10/9/25 at 8:00 pm. V2, DON then reviewed R2's Medication Administration Records (MAR). V2, DON acknowledged R2's MAR does not document R2 was administered the Tramadol 50 mg tablets on the documented dates noted. V2, DON stated I am confident the Tramadol was given for (R2's) pain. I reviewed (R2's) records yesterday (10/15/25) and realized the nurses failed to document on the MAR's, that (R2's) Tramadol was given (9/19/25 at 7:00 am, 9/28/25 at 8:00 pm, 9/29/25 at 8:00 pm, and 10/9/25 at 8:00 pm). I confirmed with those nurses (unidentified) that it (Tramadol) was given. They just forgot to document on the MAR. V2, DON further reviewed R2's Medication Administration Records and confirmed that nurses had been signing off that they completed the pain assessments each shift but failed to complete the documentation by not identifying the level of pain on the scale of 1-10, 10 being the most severe. V2 DON also confirmed R2's went out to the hospital via ambulance for an MRI on 10/10/25, and the nurses failed to documents her leaving and returning the facility. V2, DON stated I am new to the facility and new to the Director of Nursing position. This will be addressed. It is Nursing 101 to document accurately and completely in the resident's medical record.

Based on observation, interview, and record review, the facility failed to post an accurate notice for the location of the survey results book and failed to identify the survey book. This failure has the potential to affect all 81 residents residing in the facility.Findings include: On 9/16/25 at 1:00 PM during a resident group interview, R27, R52, R59 all stated they had no knowledge of where the survey results book was located. Each of these residents stated no facility staff had informed them where the survey results book was. On 9/16/25 at 2:05 PM, the was an eight and one half inch by eleven inch sign posted in the front hallway documenting the survey inspection results book could be found in a plastic holder outside the front office. There was not a plastic holder outside of the administrative office, the reception office, nor the conference room, which were visible from the location of this posted sign. There was a plastic holder outside of the human resources office which was empty of any contents. On 9/16/25 at 2:07 PM, V1, Administrator, located a 4-inch-thick black notebook inside the glass doors of a small cabinet in the resident and family lounge room. This notebook was not labeled to identify it as the survey results book. V1 stated the plastic holder referred to the plastic file holder outside of the human resources office, but the book was too thick to fit into that holder. V1 concluded by stating she would need to change the posted sign and also to review the location of the survey book in the resident council. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 9/18/25 documents 81 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to observe and implement controlled temperature safeguards for potentially hazardous foods served to residents to prevent food borne illness (R30), failed to prevent the potential for physical cross-contamination of stored food, and failed to maintain sanitary dietary service floor areas. These failures have the potential to affect all 81 residents residing in the facility.Findings include: 1. On 9/16/25 at 11:48 AM, R13 was lying in bed with his breakfast tray in front of him on the over bed tray table. R13 was actively eating and drinking from this tray which contained scrambled eggs, oatmeal, and milk-based nutritional supplements. All of these items are included as high protein potentially hazardous foods with high water activity in the Food and Drug Administration Code 2017. On 9/16/25 at 12:00 PM, V4, Dietary Aide, stated the trays delivered to residents in their rooms are served prior to the residents in the dining room. V4 further stated the North Hall trays (where R13 resides) went out of the kitchen around 7:15 AM or so. V4, concluded by stating after four hours of food sitting around she would not want to be messing with that. On 9/16/25 at 12:03 PM, V3, Dietary Manager, stated it is the Certified Nursing Assistants working on the residential halls who serve the food trays and are supposed to be collecting them after the meal. On 9/16/25 at 12:15 PM, an insulated tray cart left the kitchen and was delivered to the residential North Hall. On 9/16/25 at 2:20 PM, V3 stated she would not let food sit out at room temperature for more than two hours and definitely not four hours as things start growing that can make people sick. V3 continued to state she would not even attempt to reheat food after two hours but would prepare something totally new. On 9/16/25 at 2:34 PM, R13 was lying in bed with his lunch tray on the over bed tray table actively eating and drinking from his tray which contained a hot dog, baked beans, and a milk-based nutritional supplement. These food items are also identified as high protein and high water activity potentially hazardous foods. At this time, R13 stated no one had ever talked to him about how long food can sit out at room temperature before it starts to go bad, and he had no knowledge about how long food can sit out before it goes bad. On 9/16/25 at 2:40 PM, V5 and V6, both Certified Nursing Assistants working on the North Hall, stated R13 takes a long time to eat and that R13 knows we will bring him something new or a snack, but he doesn't want to give up his tray. R13's Minimum Data Set, dated [DATE] documents R13 received a score of 9 out of a possible 15 for a Brief Interview for Mental Status, indicating moderate cognitive impairment. On 9/18/25 at 10:15 AM, R13 was lying in bed with his breakfast tray in front of him on the overbed tray table. R13 was actively eating from the tray which included crumbled pork sausage and gravy, and milk-based nutritional supplement, included as high protein and high water activity potentially hazardous foods. R13's tray was not removed from in front of him until 10:50 AM. On 9/18/25 at 3:29 PM, R13's lunch tray was removed form his over bed tray table and contained roast beef and gravy, potentially hazardous foods. 2. On 9/16/2025 at 10:40AM, a disposable foam cup was being used as a food scoop and was located inside of a bulk dry food storage bin containing sugar. The cup was resting on its side in contact with the stored sugar. On 9/18/2025 at 12:30PM, V3 (Dietary Manager) observed the above cup and reported dietary staff should not use a foam cup as a food scoop. 3. On 9/16/2025 at 10:50AM, the flooring surfaces of the kitchen, pantry, and dishwashing room were soiled throughout with dark accumulations of food deposits located at the baseboard and floor junctions and along flooring threshold areas. Plastic and paper debris was scattered across the dish room floor area including beneath storage racks of clean dishes. Multiple dishwashing scrub pads were also located on the floor surface. On 9/18/2025 at 12:30PM, the above floor surfaces remained soiled. On 9/18/2025 at 2:54 PM, V3 reported food made in the kitchen is available for all residents in the facility to eat. The Long-Term Care Facility Application for Medicare And Medicaid (9/18/2025) documents 81 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to maintain residents' rights to dignity by failing to keep urinary catheter collection bags inside of a privacy cover. This failure affects two residents (R1, R12) of five reviewed for dignity in the sample list of 30. Findings include:1. R1's diagnosis list (9/18/2025) documents diagnoses including Hemiplegia (paralysis of one side of the body), Hemiparesis (weakness on one side of the body), Epilepsy (brain disorder causing seizures), History of Traumatic Brain Injury, Parkinsonism (brain condition causing slow movements, stiffness, and tremors), and Vascular Dementia with Agitation. R1's Resident Assessment (8/20/2025) documents R1 has severe cognitive impairment. The same record documents R1 uses a wheelchair for mobility, is dependent on staff to complete activities of daily living, uses an indwelling urinary catheter, and has impaired upper and lower extremity range of motion.R1's Orders sheet (9/18/2025) documents a medical order for an indwelling urinary catheter and urine collection bag. The same record documents an order to ensure R1's urine collection bag always has a cover in place.On 9/17/2025 at 12:30PM, R1's bedroom door was open and R1 was sitting in a wheelchair in R1's room and was visible from the hallway. A urine collection bag was present and attached to R1's wheelchair but the bag was not covered with a privacy cover. Yellow urine was clearly visible partially filling the transparent collection bag. V15 (R1's family) was present and reported coming to the facility daily to visit R1 and reported R1's urine collection bag is never contained in a privacy cover. On 9/18/2025 at 11:05AM, R1 was seated in a wheelchair in the hallway outside of R1's room. A urine collection bag was fastened to R1's wheelchair and remained uncovered as above and was partially full of yellow-colored urine. On 9/19/2025 at 11:50AM, R1 was seated in a wheelchair in R1's room with the door open to the hallway. R1's urine collection bag was visible from the hallway, partially filled with yellow-colored urine, and was not contained in a privacy cover. On 9/19/2025 at 12:22PM, R1 was seated in a wheelchair outdoors on the front porch of the facility with other residents waiting for transportation to an offsite activity. R1's urine collection bag remained as above partially filled with urine and uncovered. 2. R12's diagnosis list (9/19/2025) documents diagnoses including Hemiplegia (paralysis of one side of the body), Hemiparesis (weakness on one side of the body), Dementia, and Seizures. R12's Resident Assessment (7/3/2025) documents R12 has severe cognitive impairment. The same record documents R12 uses a wheelchair for mobility, is dependent on staff to complete activities of daily living, and uses an indwelling urinary catheter.R12's Orders sheet (9/18/2025) documents a medical order for an indwelling urinary catheter and urine collection bag. The same record documents an order to ensure R12's urine collection bag always has a cover in place.On 9/17/2025 at 10:57AM, R12's bedroom door was open and R12 was sitting in a wheelchair in R12's room and was visible from the hallway. A urine collection bag was present and attached to R12's wheelchair but the bag was not covered with a privacy cover. Yellow urine was clearly visible partially filling the transparent collection bag. On 9/18/2025 at 11:31PM, R12 was seated in a wheelchair in R12's room with the door open to the hallway. R12's urine collection bag was visible from the hallway, partially filled with yellow-colored urine, and was not contained in a privacy cover. On 9/18/2025 at 3:00PM, R12 was seated in a wheelchair in R12's room with the door open to the hallway. R12's urine collection bag was visible from the hallway, partially filled with yellow-colored urine, and was not contained in a privacy cover. On 9/19/2025 at 11:50AM, R12 was seated in a wheelchair in the hallway outside of R12's room. R12's urine collection bag was visible, partially filled with yellow-colored urine, and was not contained in a privacy cover. The facility's Dignity policy (October 2009) documents facility staff shall promote dignity and assist residents as needed by helping residents keep urinary catheter bags covered.

Based on observation, interview and record review the facility repeatedly failed to maintain nebulizer respiratory equipment in a clean sanitary manner, change oxygen nasal canula and tubing in a timely manner, provide an oxygen humidification water bottle, failed to obtain an oxygen administration order, and failed to care plan respiratory status, interventions for the monitoring of oxygen administration, and for safe and sanitary practices for R43. The facility also failed to provide an oxygen humidification water bottle for (R64). These failures affected two of three residents (R43 and R64) reviewed for respiratory care and medication administration on the sample list of 30.Findings include: 1.R43's Physician Order Sheet (POS) dated 9/18/25, (time stamp at 10:27 am when copied, prior to an updated version), documents: Elevate head of bed to avoid shortness of breath when lying flat R/T (related to) COPD (Chronic Obstructive Pulmonary Disease), every shift. Start date 8/7/25.The same POS documents: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (milligrams/ milliliters) one vial inhale (per nebulizer) , three times daily. The same POS does not document a Physician Order for the administration of oxygen direction for use or monitoring. R43's Care Plan dated 8/25/25 does not document R43 has a compromised respiratory status, that require respiratory interventions for monitoring of oxygen administration, , positioning to prevent shortness of breath, and measurements of blood oxygen level per standards of practice or maintaining respiratory equipment for safe and sanitary practices. On 9/18/25 at 9:10 am R43's undated, clear plastic nebulizer mask was soiled with a build-up of opaque white splatter on the inside of the mask, and something beige and sticky on the outside of the mask. The nebulizer mask was lying in top draw of R43's bedside dresser with the undated tubing dangling to one approximately one inch of the floor.R43's bedside oxygen concentrator had an empty, disposable humidifier bottle attached to the nipple of the actively running oxygen concentrator, The empty humidifier bottle was dated 8/31/25. R43's oxygen was infusing at three liters per nasal canula. The nasal canula/tubing was undated. During the same observation at 9:10 am, V11, Registered Nurse (RN) removed R43's soiled nebulizer mask from R43's dresser drawer. V11 RN filled R43's medication apparatus cup with one vial of Ipratropium-Albuterol Inhalation Solution and placed the respiratory medication inhalation therapy mask on residents' face. R43 told V11 he has done his nebulizers treatments at home and does not have a problem with turning off the machine when the administration is complete in approximately 15 minutes. On 9/18/25 at 9:30 am V11 RN turned off R43's nebulizer inhalation therapy treatment. V11 confirmed the nebulizer mask was soiled and should not have been used to administer the medication. V11 also confirmed nebulizer mask and tubing were undated as required to ensure they are changed weekly. V11 also verified the oxygen tubing and nasal canula was undated and R43's humidifier botte was empty and outdated 8/31/25. V11 stated All this equipment is supposed to be changed every week, dated and the humidifier bottle should be changed before it runs dry. On 9/18/25 at 11:20 am V8, Acting Director of Nursing/RN, V2, Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) and V9 LPN were in their shared office. V8, V2 and V9 all reviewed R43's electronic medical records and confirmed R43 has no physician order for oxygen administration order, no respiratory care planned interventions to maintain respiratory status and care of the equipment as required. V2, ADON/LPN stated R43 just returned from the hospital. The orders were missed on readmission. V8 confirmed the respiratory equipment is to be changed weekly and as needed for all residents on oxygen. 2. On 9/17/25 at 1:34 PM, R64 was lying in bed receiving oxygen therapy through a room air concentrator at four liters per minute through a nasal tubing (cannula). R64's oxygen humidifier bottle was totally dry and was dated 9/8/25. R64's oxygen nasal tubing was undated to indicate when the last time the tubing was changed. At this same time, R64 stated the bottle runs dry all the time. On 9/18/25 at 3:55 PM, R64's oxygen humidifier bottle was still dry and still dated 9/8/25. R64's current Physician Order Sheet dated 9/17/25 documents for the oxygen tubing and humidifier bottle to be changed every week on Sunday nights. The facility's policy Oxygen Administration dated as revised 3/17/22 documents humidifier bottles, oxygen masks, and oxygen tubing are needed equipment for oxygen administration. This same policy documents oxygen will be administered in accordance with physician orders. This policy documents the mask, tank, and other equipment to ensure proper working order. This policy documents humidifier bottles will be changed as needed. This policy documents a cautionary statement that constant flow of oxygen can cause drying and thickening of normal secretions resulting in laryngeal ulcerations (open sores in the throat). This policy documents an oxygen mask or tubing not in use will be placed inside a plastic bag.

Based on observation, interview, and record review the facility failed to follow pharmacy instruction for the administration of physician ordered medication, for two of seven resident (R3 and R43) reviewed during medication observation. The facility had three medication errors, out of 32 opportunities, resulting in an 9.38 percent medication error rate.Findings include:1. R3's current Physician Order Sheet (POS) documents: Ferrous Sulfate Oral Tablet, Delayed Release 324 (65 FE (65 milligrams iron) MG (milligrams). Give 1 (one) tablet by mouth two times a day for Supplement.R3's same POS documents: Cefdinir Oral Capsule 300 MG (antibiotic). Give 1 capsule by mouth two times a day for leukocytosis, bacteremia for 10 Days. Give with or without meals. No iron/antacids within 2 hours.On 9/19/25 at 8:00 am V13, Licensed Practical Nurse administered R3's Iron, and Cefdinir at the same time, in direct contrast to the physician order and pharmacy directions on the prescription label. V13, Licensed Practical Nurse confirmed she had given Cefdinir antibiotic with Ferrous Sulfate and did not wait two hours, as the physician order and the pharmacy label directs.2. R3's current POS also documents: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 MCG/ ACT (Fluticasone-Umeclidinium-Vilanterol) (micrograms per actuation), one puff, inhale orally, one time a day for respiratory (airway exchange). Rinse mouth thoroughly after each use. Discard after six weeks once foil is opened.On 9/19/25 during the 8:00 am medication administration pass, after R3 had taken oral medications, V13,Licensed Practical Nurse (LPN) administered R3's Trelegy Ellipta Inhaler. V13 LPN did not provide water for R3 to rinse R3's mouth after the Trelegy Ellipta inhalation medication administration. R3 stated They have never told me to rinse after taking this inhaler. Should I rinse? V13, Licensed Practical Nurse acknowledged to R3 that R3 should rinse R3's mouth thoroughly, after the administration of Trelegy Ellipta inhaler administration. V13,LPN then stated, I should have caught that (directions on physician order and pharmacy label to rinse thoroughly after administration). 3. R43's Current Physician Order documents the following: R43 Florastor (yeast based probiotic) Capsule 250 MG (Saccharomyces boulardii). Give 1 tablet by mouth two times a day for PROPHYLACTIC.On 9/18/25 at 9:21 am V11, Registered Nurse (RN) had prepared R43's oral medications for administration. V11 stated there was no supply of R43's Florastor Capsule 250 MG available for administration. V11 RN administered R43's other oral medications. V11 RN then searched the medication room on the north hall unit, and the facility-wide medication stock room. V11, RN confirmed there was no Floraster 250 mg in stock, to administer R43 Floraster.The facility policy Medication Administration Policy/Procedure dated as revised 9/27/22 documents the following:PURPOSETo ensure proper administration of oral medications.POLICYMedications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required.RESPONSIBILITYIt is the responsibility of all licensed nursing staff to safely administer medications to residents. 2. Remove the individual's medication(s) from the medication storage area. 8. Follow the specific instructions listed for each type of medication to be given. Offer adequate fluids with medications.

Based on record review and interview the facility repeatedly failed to report changes in condition to a provider, for a resident with hypotension. These repeated failures resulted in a delay in treatment and hospitalization to stabilize residents blood pressure. This failure affected one of three residents (R1) reviewed for a change in condition on the sample list of three. Findings include:R1's Current Diagnoses List includes the following: Type II Diabetes with Other Specified Complications, Type II Diabetes With Other Diabetic Neurological Complications, Chronic Ischemic Heart Disease, Unspecified, Hypertensive Heart Disease With Heart Failure Presence Of Automatic Implantable Cardiac Defibrillator, Peripheral Vascular Disease Unspecified, Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris, Non-rheumatic Tricuspid Insufficiency, Acute Kidney Disease, Essential Hypertension, Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Unspecified Severity Without Behavioral Disturbance, Mood Disturbance and Anxiety, Encounter for Orthopedic Aftercare Following Surgical Amputation, Gangrene, Not Elsewhere Classified, Acquired Absence Of Left Great Toe, and Chronic Osteomyelitis Left Ankle and Foot.R1's Minimum Data Set, dated [DATE] documents R1's Brief Interview of Mental Status score of five out of a possible 15 indicating severe cognitive impairment.R1's Current Physician Order Sheet (POS) documents the following: Cipro (antibiotic) Oral Tablet 500 MG (milligrams) (Ciprofloxacin HCI), Give 1 tablet by mouth, two times a day related to GANGRENE, NOT ELSEWHERE CLASSIFIED, (administer) until 08/02/2025 . Start date 06/02/25.R1's same POS documents: Entresto (combination heart failure medication that relaxes blood vessels, and prevents blood vessels from constricting which helps lower blood pressure), Oral Tablet 24-26 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day for Congestive Heart Failure. Start dated 05/16/25.R1's Nurses Note dated 6/5/2025 at 11:51 am, documents the following: Note Text: Resident was seen today by (the) wound clinic. It was noted that resident had (an) allergy to Cipro. (V8, Wound Physician ) requested clarification from (V9, Medical Director's) office to hold Entresto while on Cipro. (V9) did not want to hold Entresto. Per (V8, Wound Physician) since resident is tolerating medication well, monitor blood pressure every shift. Will continue to monitor (the) resident.R1's same POS above, documents: Monitor blood pressure every shift for antibiotic while on antibiotic therapy. Start date 6/05/25, End date 6/27/25.R1's Electronic Vital Sign medical record includes blood pressure measurements. The same Electronic medical record indicates an alert to the nursing staff, when the measurement is outside the normal range. R1 ‘s Electronic Vital Sign record documents the following, out of normal range, blood pressure measurements:On 6/5/2025 at 10:09 pm R1's blood pressure measured 107 (systolic)/ 59 (diastolic) mm/ Hg (millimeters of mercury), Sitting (position the resident was in when the blood pressure was measured), Rt (Right) arm (location on the residents body where the reading was obtained). Alert was triggered as follows Diastolic Low of 60 exceeded.On 6/6//2025 at 10:44 am R1's blood pressure measured 118/59 mm/ Hg. Sitting, lt (left) arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/6//2025 at 9:35 pm R1's blood pressure measured 105/49 mm/ Hg. Sitting, rt (right) arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/7//2025 at 8:28 am R1's blood pressure measured 112/54 mm/ Hg . Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/7//2025 at 5:19 pm R1's blood pressure, again, measured 112/54 mm/ Hg. Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/10/2025 at 11:26 am R1's blood pressure measured 112/52 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/11/2025 at 12:23 pm R1's blood pressure measured 126/54 mm/ Hg . Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/12/2025 at 12:33 pm R1's blood pressure measured 116/54 mm/ Hg . Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/12/2025 at 8:04 pm R1's blood pressure measured 96/43 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/14/2025 at 8:23 pm R1's blood pressure measured 101/45 mm/ Hg. Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/15/2025 at 7:48 pm R1's blood pressure measured 108/56 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/21/2025 at 9:03 pm R1's blood pressure measured 82/66 mm/ Hg. Sitting, rt arm. A new alert was triggered for R1's systolic measurement as follows: Systolic Low of 90 exceeded.On 6/22/2025 at 9:43 am R1's blood pressure measured 86/42 mm/ Hg . Sitting, lt arm. A double alert triggered which included both systolic and diastolic blood pressure measurement as follows: Systolic Low of 90 exceeded. and Diastolic Low of 60 exceeded.On 6/22/2025 at 1:15 pm R1's blood pressure again measured 86/42 mm/ Hg . (does not indicate what position R1 was in, or what location on R1's body R1's blood pressure was measured). A double alert again, was triggered which included both systolic and diastolic blood pressure measurement as follows: Systolic Low of 90 exceeded. and Diastolic Low of 60 exceeded.R1's Occurrence Note dated 6/22/2025 at 9:30 pm documents the following: Note Text: Incident Note: called to residents' room by CNA (Certified Nursing Assistant, unidentified) upon entering room resident (R1) was sitting on floor on his coccyx, left arm resting on his recliner. When asked what happened (R1) stated I fell trying to get back in my chair. Asked if he hit his head he said no. Asked if he was hurting he said my left elbow a little. Thorough assessment of resident completed no injures noted but small abrasion to left elbow cleaned and band aid applied. Neuros (neurological assessment) initiated . VS (Vital signs) T97.2 (Temperature) P75 (Pulse) B/P 92/56 (Blood /Pressure) R 20 (Respirations) sat 97% (blood oxygen measurement of saturation) on RA (room air). (Full-body, mechanical lift transfer) with assist of two (staff) off floor and back into his chair. Currently sitting at nurses station. Notified the Nurse supervisor (V2, Director of Nursing) for the facility of the fall, notified his (R1's,Family Member/ Power of Attorney) and physician (unidentified) . No c/o (complaints/of) any voiced at this time.As documented above, in this occurrence note 6/22/25 at 9:30 pm, R1's blood pressure measured 92/56 mm/hg indicating R1's diastolic measurement was low due to a measurement below 60.As noted above on the Vitals Log above, R1 sustained a low blood pressure measurement for 24 hours and 27 minutes prior to the fall documented on the above occurrences report.Post R1's fall 6/22/25 at 9:30 pm documented in the occurrence note, R1 continued with abnormal blood pressure measurements after the fall as follows:On 6/22/25 at 9:45 pm R1's blood pressure measured 97/56 mm/ Hg . Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/22/25 at 9:53 pm eight minutes after the previous measurement R1's blood pressure was measured again at 96/56 mm/ Hg. Sitting, lt arm. Alert was again triggered as follows: Diastolic Low of 60 exceeded.On 6/22/25 at 11:22 pm one hour and 29 minutes after the previous measurement R1's blood pressure was measured again at 95/56 mm/ Hg . Sitting, lt arm. Alert was again triggered as follows: Diastolic Low of 60 exceeded.On 6/23/25 at 9:42 am R1's blood pressure measured 99/58 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/23/25 at 7:44 pm R1's blood pressure measured 100/56 mm/ Hg . Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.There was no documentation in R1's medical record that a nurse practitioner or physician was notified of the 19 abnormal blood pressure measurements documented above. The fall occurrence note documents an unknown physician was notified of the fall 6/22/25. ( V9, Medical Director clarified in the interview documented below that he was notified of the fall but was not notified of the blood pressure drop.R1's Nurses Note date 6/25/25 at 1:36 pm documents the following: Note Text: Resident OOF (out f facility) via (by way of) the facility van to go to the wound center for routine visit. Paperwork sent with the transporter and family will meet at the clinic. Resident (R1) was reported to have been up all night when shift change done this AM and obtained a new skin tear to an upper extremity that the previous nurse covered with a dressing.R1's Nurses Note dated 6/25/25 at 2:45 pm documents the following: Note Text: Transporter returned from the wound clinic with progress report from (V8, Wound Physician) and reported to this nurse that resident is currently in the emergency department per family wishes due to not acting like self. Noted in the report that per the RN (unidentified); resident left the appointment (wound clinic) in no pain via W/C (wheelchair) with transport assist and will RTC (Return to see the wound clinic) in 1 week for F/U (follow-up). Plan to follow up with ED (Hospital, emergency department) on resident's status prior to leaving the facility today.R1's Nurse's Note dated 6/25/25 at 8:50 pm documents the following: Note Text: Placed a call the ED and was informed that resident was noted to be hypotensive (low blood pressure) and hypothermic (low body temperature, sometimes exacerbated by hypotension) upon arrival in ER. Awaiting the hospitalist (unidentified, hospital physician) decision as to which hospital (R1) will be the admitting facility for inpatient stay for treatment and family in hopes that resident will remain in (name of local hospital) for their visitation convenience. Requested that the local hospital please call back to let the current nurse on duty know what was decided. Notified the on- call nursing supervisor (V2, Director of Nursing) of the above and resident current status.R1's Hospital Discharge Summary report dated 6/30/25 at 12:12 pm, signed by V9, Facility Physician/ Medical Director documents the following: Discharge Diagnoses: -Systemic Inflammatory Response Syndrome (serious inflammatory response, over reaction to stressors such infection, trauma, surgery) - Primary. Hospital CourseSpecified (age) year-old male with a medical history significant for coronary artery disease status post CABG (Coronary Artery Bypass Grafting surgery), cardiomyopathy status post PM/ICD (Pacemaker Implantable Cardioverter Defibrillator) placement with associated heart failure, peripheral artery disease, peripheral neuropathy, non-insulin-dependent diabetes mellitus, COPD, questionable dementia, and recent bout of left foot osteomyelitis (May 2025) (prior to facility admission), presented to the emergency room with chief complaint of altered mental status for several days. Patient's clinical picture was highly suspicious for septic shock. Patient was hypotensive (low blood pressure) and pressor (type of medication to increase blood pressure) dependent. He was started on broad-spectrum antibiotics. Patient has some baseline dementia. No clear source of infection but has history of chronic osteomyelitis of the left foot. Patient responded well to pressers, fluids and broad-spectrum antibiotics although no definitive source of infection was found. Patient has autonomic dysfunction which probably lead to hypothermia and hypotension. His cultures have so far remained negative. He was discharged (from the hospital 5/16/25) last admission to nursing home on IV (intravenous) antibiotics but he kept pulling his lines (IV catheters) out so podiatry (wound clinic) changed him to oral antibiotics for chronic (osteomyelitis). I again rechecked with lab and his blood cultured have panned out to be negative. At this point he is ready for discharge back to nursing home. He can continue oral antibiotics at the nursing home as he was previously taking. R1's General Note dated 6/30/25 at 5:01 pm documents R1 return to the facility from the hospital after a five day hospitalization. Note Text: documents a new physician ordered medication for Midodrine (that works by constricting blood vessels, thereby raising the blood pressure). The same General note documents R1 returned to the facility with vital signs within normal limits as follows: Vitals (measurements): (B/P) 120/70, (R)18, (02 saturation) 98%, (P) 80, (T) 97.7 (all vital signs measurement are within normal limits).On 7/16/25 at 2:20 pm V9, Medical Director (MD) reviewed R1's electronic medical records. V9, MD confirmed R1's Blood pressure readings were out of normal range and should have been reported. V9, MD stated The diastolic below 60 were not as concerning, until the measurement dropped below 50. Systolic readings below 90 should have been reported. The repeated low readings are the concern. Not necessarily a one- time event. Either way I should have been notified. V9, MD stated Myself or a Nurse Practitioner would have evaluated (R1) on day shift, had we been notified. (R1's) medications would have been reviewed and adjusted accordingly. On evening or night shift, the on-call provider should have been notified. They would have sent (R1) to the hospital for an evaluation and treatment. V9, MD stated (R1's) low blood pressure could have resulted in that fall. It is hard to know at this point. The potential for harm would be a fall with a fracture. That did not happen. The potential for great harm due to the fall is a [NAME]. Though this was a possibility. V9 also stated I was notified of the fall. I was not told of (R1's) blood pressure drop. I was told this was a no injury fall. V9, MD also stated I had previously been (R1's) physician. I know his family well. I explained in detail to the family (R1) was not in septic shock. It was necessary to rule this out. (R1) was hospitalized to identify the origin of (R1s) hypotension. Initially Septic Shock was considered. After all diagnostics were completed, (R1's) diagnosis is Orthostatic Hypotension. He has a history heart failure and multiple other co-morbidities. I adjusted his medication. He is now taking Midodrine for hypotension. Had the adjustment been made in the nursing home, a hospital admission may have been avoided. Of course, that is the best-case scenario. The facility policy Change of Condition date 1/23/23 documents the following: PURPOSE:To provide facility guidance when a change of condition occurs with a resident.POLICY: This facility shall identify and treat residents with acute change of conditions.POLICY INTERPRETATION AND IMPLEMENTATION:1, The interdisciplinary team, with the assistance of the physician, will help identify individuals with a significant risk for having acute changes of condition during their stay.2. Direct care staff, including nursing assistants, will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the Nurse.The same policy documents:5. The physician will help identify medications and medication combinations that are associated with adverse consequences that could cause significant changes in condition.6. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician, for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to the attending or on-call physician should be made by an adequately prepared nurse who has collected and organized pertinent information including the resident/patient's current symptoms and status, history, current medications etc.7. The nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physician and request a prompt response.8. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status.a. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.9. The nurse and physician will discuss and evaluate the situation.a. The physician should request information to clarify the situation10. The staff and the physician will discuss possible causes of the change in condition based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results.a, If necessary, the physician will order diagnostic tests and evaluate the patient directly.11. As needed, the physician will discuss with the staff and resident/patient and/or family the pros and cons of diagnosing and managing the situation in the facility or the need for hospitalization.a. Many acute changes of condition can be managed effectively in nursing facilities with outcomes that are comparable to those of hospitalization.b. This discussion should consider the patient's overall condition, prognosis, and wishes (either direct or as conveyed by a substitute decision-maker).

Based on interview and record review the facility failed to notify a resident's physician of signs of a potential wound infection subsequently delaying treatment resulting in Cellulitis of the wound. This failure affected one of three residents (R1) reviewed for Wound Treatments on the sample list of three. Findings Include: The Acute Change of Condition policy dated 1/23/23 documents the facility will identify and treat residents with an acute change of condition. The nursing staff will collect pertinent details to report to the physician. The nursing staff will contact the physician based on the urgency of the situation. The physician will help identify and authorize appropriate treatments. R1's Medical Diagnosis List dated April 2025 documents R1 is diagnosed with Atherosclerotic Heart Disease, Diabetes Mellitus Type II, Dementia, and Local Infections of the Skin and Subcutaneous Tissue. R1's Physician Order Sheet (POS) dated April 2025 documents an order placed on 2/20/25 for staff to complete a daily foot check related to a history of skin impairment/ulcer, current skin impairments/ulcers, color, temperature, edema, and pedal pulses and notify the physician with any changes. R1's POS dated 3/20/25 documents V6 Vascular Wound Physician ordered Bactrim (Antibiotic) 800/160 milligrams twice per day for seven days for Cellulitis. R1's current Care Plan dated April 2025 documents R1 has current vascular wounds and staff should monitor, document, and report any signs or symptoms of infection and consult the wound physician as needed. R1's Nurses Progress Note dated 3/16/25 documents V5 Licensed Practical Nurse (LPN) noted a change in R1's right second toe wound. The toe was noted to be edematous (swollen) and red. R1 winced when her toe was touched to clean the area. V5 documented she notified the facility wound nurse (V3) about the change. On 4/24/25 at 3:35 PM V3 Wound Nurse confirmed she was notified on 3/16/25 by V5 LPN about changes concerning R1's right second toe wound. However, a physician was not notified. V3 stated she had planned to notify someone the following day. However, forgot that R1's wounds were being treated by V6 Vascular Wound Physician. V3 confirmed V6 should have been notified concerning the wound changes on 3/16/25. V3 confirmed no treatment for potential infection was put into place until R1's previously scheduled appointment with V6 on 3/20/25. On 3/20/25 R1 returned to the facility with an order for an antibiotic for cellulitis of R1's right second toe. V3 confirmed physician notification should have been done right away to see if any treatment could have been started prior to R1's wound clinic visit on 3/20/25. V3 also confirmed R1's right second toe was diagnosed with Cellulitis and treated for the infection with antibiotics. On 4/25/25 at 1:30 PM V9 Medical Physician confirmed the facility staff should have contacted a provider on 3/26/25 to get treatment orders (antibiotics -if wound looked infected) until R1 could have been seen for the change in wound condition. V9 confirmed R1's wound did end up with an infection which was determined by V6 Vascular Wound Physician and antibiotics were eventually ordered by V6 on 3/20/25. V9 confirmed R1's wound could have gotten much worse or caused further issues due to R1's co-morbidities and the four-day delay in treatment. V9 confirmed this delay put R1 at risk for complications.

Based on observation, interview, and record review, the facility failed to store a Schedule II Controlled medication (Morphine Sulfate) in a locked location by leaving the medication on top of the medication cart in plain view, unsupervised, and readily accessible to wandering residents on a dementia care unit. This failure resulted in facility staff observing R1 at the medication cart with the bottle of Morphine placed to R1's lips, when staff removed the bottle, no medication remained in the bottle and then staff later observed R1 unresponsive with a decreased respiration rate followed by staff administering Narcan (an emergency medication that rapidly reverses life-threatening opioid overdoses) and sending R1 to the hospital emergency room for evaluation and treatment. This failure affects one resident (R1) of four reviewed for medication storage in the sample list of ten The Immediate Jeopardy began on 1/28/2025 when a bottle of liquid Morphine was left unattended on top of a medication cart and staff found R1 with the bottle up to R1's lips. V1 (Administrator) was notified of the Immediate Jeopardy on 2/19/2025 at 10:57AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 1/28/2025 and the deficient practice corrected on 1/29/2025 prior to the start of the survey and was therefore Past Noncompliance. Findings include: R1's Medical Diagnosis list (printed 2/14/2025) documents R1 diagnoses include: Dementia with Psychotic Disturbance, Major Depressive Disorder, and Other Conduct Disorders (a mental health condition characterized by persistent and severe antisocial and aggressive behaviors that violate social norms and rules). R1's Clinical Census sheet (printed 2/20/2025) documents R1 has resided on the facility's Dementia care unit since admission to the facility. R1's comprehensive assessment (1/8/2025) documents R1 does not require staff assistance for eating or drinking, does not use any mobility devices (such as a cane, walker, or wheelchair), and has daily wandering behavior in the facility. On 2/11/2025 at 1:55PM, the nurses' station at the facility Dementia care unit consisted of chest-height countertops and cabinetry arranged in an oval shape in the center of the care unit. Standard swinging doors the same height as the countertops were located at each end (East and West) of the station for staff to enter the work area. Standard lever style door handles were located at the top of each door. Numerous residents (unidentified) were congregating around the station and a medication cart was also stored inside of the station in plain view. R1's nursing care plan in effect on 1/28/2025 (printed 2/20/2025) documents R1 walks independently and also wanders in the facility. The same record documents the focus area Potential Risk of Elopement Cognitive deficit, History of wandering, Walks about aimlessly w/o (without) purpose with the goal (R1) will remain safely in facility through review date with a target date of 5/6/2025. The plan lists the following facility interventions/tasks to achieve the goal: Monitor whereabouts regularly, recognize any unsafe conditions or escalating patterns, and provide re-direction and diversion as needed. On 2/11/2025 at 1:55PM, V3 (Licensed Practical Nurse) reported R1 has a history of wandering and will wander into the nurses' station if the doors at each end are open. V3 reported R1 had previously drank from staff beverages located inside of the nurses' station. V3 reported R1 also recently drank fingernail polish remover during an activity on 1/19/2025 and coughed all over getting the solution on R1's shirt and staff had to call the Poison Control telephone hotline for emergency medical instructions to care for R1. V3 reported R6 is another resident who wanders and will attempt to manipulate the door handles located at each door leading into the nurses' station and other residents also will sometimes reach over the top of the doors to attempt to unlock the handles. On 2/13/2025 at 11:11AM, V4 (Licensed Practical Nurse) reported R1 does wander in the Dementia care unit and reported R1 has a history of getting inside of the nurses' station on the unit. V4 reported the unit has several residents who like to wander and residents will pull on and shake the doors at the nurses' station. V4 stated Residents will shake the doors, we need more secure doors because of the wandering residents and the (door) handle on the East side doesn't lock and it doesn't have a sliding lock anymore. V4 reported if staff leave a soft drink beverage at the nurses' station, R1 will absolutely drink it. V4 reported R1 does not normally spill any drinks on R1's self when R1 is drinking a beverage. On 2/11/2025 at 2:15PM, V5 (Certified Nurse Aide) reported R1 does not normally spill any liquids when drinking and is not normally messy when drinking. On 2/11/2025 between 1:50-2:05PM, a medication cart remained stored inside of the Dementia care unit nurses' station. R1 was present and ambulating independently outside of the station in a random pattern before sitting down on a nearby chair. Facility staff then handed R1 an insulated water bottle with a flip top and R1 began drinking independently from the water bottle. R1 did not dribble or spill any of the water when R1 was taking sips from the bottle. When the surveyor attempted to speak to R1, R1 began screaming and was unable to coherently answer any questions. The facility incident investigation (undated) documents on 1/28/2025, V4 (Licensed Practical Nurse) accidentally left a bottle of liquid morphine (an opiate medication used to treat moderate to severe pain) out in the open and V7 (Certified Nurse Aide) and V10 (Certified Nurse Aide) observed R1 with the bottle in R1's hand and then up to R1's mouth. The same record documents V7 retrieved the bottle of liquid Morphine from R1 and observed the bottle was empty. On 2/23/2025 at 11:11AM, V4 (Licensed Practical Nurse) reported accidentally leaving a bottle of liquid morphine out on top of the medication cart on the facility Dementia care unit on the late afternoon of 1/28/2025. V4 reported opening a new bottle of liquid Morphine Sulfate (30 milliliters total volume at a concentration of 10 milligrams/5 milliliters) at around 3:05-3:06PM and administering 0.25 milliliters to R3 and then replacing the bottle and remaining Morphine (29.75 milliliters of remaining liquid equating to 59.5 milligrams of medication) back inside of the locked medication cart. V4 reported later retrieving the bottle of Morphine and placing the bottle into a small biohazard bag because the bottle was not contained in a cardboard box as is usual when the medication was received from the facility pharmacy provider. V4 reported then placing the bag containing the Morphine bottle on top of the medication cart at about 5:00PM, with the cart located in the Dementia care unit nurses' station, followed by V4 leaving the Dementia care unit. R3's Physician Orders (printed 2/11/2025) document an order for Morphine Sulfate, 0.25 ml by mouth every 4 hours as needed for severe pain with a start date of 1/25/2025 and end date of 2/3/2025. R3's Medication Administration Record (1/28/2025) documents V4 administered 0.25 milliliters of Morphine Sulfate to R3 at 3:07PM. R3's Controlled Drug Administration Record (January 2025) documents the facility received a 30 milliliter bottle of Morphine Sulfate (10 milligram/5 milliliter solution) and V4 administered 0.25 milliliters to R3 on 1/28/2025 at 3:07PM leaving 29.75 milliliters of solution remaining in the bottle. The facility incident investigation (undated) documents on 1/28/2025 V5 (Certified Nurse Aide) was walking to the dining room on the Dementia unit to help serve resident supper meals and observed R1 with a bottle of something in R1's hand. The investigation documents V7 and V10 were serving resident meals in the dining room at the time and V7 observed R1 in a common area with a bottle up to R1's mouth. The record documents V7 then grabbed the bottle away from R1 and observed the bottle was empty and then asked V5 what was in the bottle and V5 reported the bottle contained Morphine and contacted V4 (Licensed Practical Nurse) who was located outside of the Dementia care unit on a break to report the concern (R1 having potentially drank Morphine Sulfate from an unsecured medication bottle). The record documents V4 then immediately returned to the unit and staff called emergency medical services to transport R1 to the hospital emergency room for evaluation and treatment. The investigation documents the incident was a Medication Incident and documents Medication (Morphine Sulfate) as Administered Dose 59.5mg (milligrams) and Medication as Administered Name (R1). On 2/11/2025 at 2:15PM, V5 (Certified Nurse Aide) reported standing at the entrance of the Dementia unit dining room adjacent to the nurse's station on the evening of 1/28/2025 and observing R1 standing beside the medication cart which was located inside of the nurse's station. V5 reported observing R1 with something in R1's hand that V5 initially thought was a candy bar and then realizing R1 had a bottle in R1's hand and then asked nearby staff (V7 Certified Nurse Aide) what R1 had in R1's hand. V5 reported staff then realized R1 had a bottle of Morphine in R1's hand and the bottle was empty and R1 just had the bottle up to R1's mouth. V5 reported V7 then called V4 (Licensed Practical Nurse) back to the Dementia care unit. V5 reported staff did not see any spilled liquid Morphine on R1 anywhere and did not see any spilled Morphine on the medication cart and also looked at nearby surfaces including the interior of a nearby trash can to see if R1 poured or spilled the Morphine out and they did not find any evidence of the Morphine in the environment and concluded R1 drank the entire bottle of Morphine. On 2/13/2025 at 11:11AM, V4 (Licensed Practical Nurse) reported receiving a call from V5 on 1/28/2025 informing V5 that staff found R1 with a bottle of Morphine Sulfate up to R1's mouth on the Dementia unit. V4 reported V5 stated please tell me this (Morphine) bottle was empty (prior to staff observing R1 placing the bottle to R1's lips). V4 reported returning to the Dementia care unit after receiving the call and helping staff look around to see if R1 had spilled instead of drank the liquid Morphine. V4 stated We looked around and went to trash can and didn't find any moisture anywhere (to indicate R1 spilled part or all of the Morphine instead of ingesting the contents of the bottle). The facility Physician Notifications form (a facsimile sent to R1's attending medical provider, V12, after the incident on 1/28/2025) documents R1 was sent to the hospital emergency room after accidentally ingesting another residents liquid morphine. R1's Progress Notes (1/28/2025 at 5:15PM) document: Incident Note: Medication error occurred. Resident refused V/S. Only able to obtain respiratory rate. Facility protocol followed. The facility Medication Incident report (undated) documents the facility sent R1 to the hospital emergency roiagnom on [DATE] at 5:50PM. The emergency medical services (EMS) Patient Care Report (0263) documents facility staff called EMS on 1/28/2025 to transport R1 to the hospital emergency room due to R1 possibly ingesting 29.75 milliliters of liquid Morphine. The report documents the dispatch reason as Overdose/Poisoning/Ingestion and documents R1 was not cooperative and would not walk to the EMS cot to be transported by ambulance to the hospital so EMS staff carried R1 by R1's extremities to the cot. The report documents R1 had constricted pupils at the time of transportation to the hospital. The report documents R1 was taken to the hospital emergency room at 5:37PM. The hospital emergency department report (1/28/2025) documents R1 arrived at the hospital awake and irritated and V27 (Registered nurse) at the emergency room contacted the facility to get information about R1. The report documents V31 (former Director of Nursing) reported to V27 that R1 got 29.75ml (milliliters) of morphine at 1715 and the bottle was completely empty when the nurse found it and she called 911. The same report documents the bottle of Morphine had a concentration of 2 milligrams per milliliter and was sitting on top of the medication cart unattended (at the nursing home). The report documents R1 arrived at the hospital emergency room via ambulance with a chief complaint of accidental overdose, was evaluated, and then sent back to the nursing home with the medication Narcan (an emergency medication that rapidly reverses life-threatening opioid overdoses) and printed patient care instructions titled Opioid Overdose: Care Instructions. The report does not document the hospital emergency room attempted to obtain any laboratory specimens from R1 at the time of R1's visit to the emergency room to directly screen for Morphine (opiate) ingestion. The report documents V28 (emergency room physician) signed R1's discharge instructions at 6:32PM. Progress notes (1/28/2025) document R1 returned to the facility from the hospital at 7:09PM via emergency medical services. On 2/7/2025 at 2:43PM, V6 (Registered Nurse) reported starting a work shift at 6PM on 1/28/205 on the Dementia care unit where R1 resided. V6 reported R1 had already been sent to the emergency room at the hospital and V4 (Licensed Practical Nurse) had reported to V6 during shift change report that R1 had gotten ahold of some Morphine that facility staff left unsupervised and staff were not sure if R1 drank or spilled the Morphine but staff could not find evidence the Morphine was spilled. V6 reported the hospital called emergency room called V6 around 6:30-6:45PM about sending R1 back to the facility. V6 reported emergency medical services brought R1 back to the facility and R1 was at R1's baseline but a bit more lethargic. V6 reported around 10:00PM, R1's oxygen saturation fell off to around 88% and R1's respiration rate started becoming lower and lower and R1 was less responsive. V6 reported when R1 is normally in R1's room, staff can not go into R1's room without R1 screaming and V6 stated you certainly can't check her vitals (without R1 screaming). V6 reported when V6 was in R1's room taking R1's blood pressure, R1 looked at V6 but was silent. V6 reported a Certified Nurse Aide (unidentified) was doing a fifteen minute check on R1 later and reported to V6 that R1's respiration rate was at 13 and so V6 went to R1's room immediately. V6 reported observing R1's respiration rate decrease to 10 and that R1 does not have any history of having a low respiration rate. V6 reported then calling 911 to get emergency medical services to transport R1 to the hospital emergency room a second time and then administering 4mg (milligrams) of Narcan to R1 as R1 seemed less and less responsive. Progress Notes (1/28/2025) document R1 was sent back to the emergency room at 10:41PM due to decreased respirations. The emergency medical services (EMS) Patient Care Report (0265) documents facility staff called EMS on 1/28/2025 to transport R1 to the hospital emergency room due to a report of a resident who is unresponsive, but breathing and Respirations down to 11. 1 dose of Narcan has been administered and Staff reports that during their assessment they found pt's (patient's) respirations to be between 11-13 breaths per minute. After noting this change in pt (patient) condition staff administered 4mg (milligrams) of nasal Narcan. EMS assessed pt respirations and found them to be at 18 breaths per minute. The report documents the dispatch reason as Breathing Problem. The report documents R1 was taken to the hospital emergency room at 10:48PM. The hospital emergency department report (1/28-1/29/2025) documents R1 presented to the hospital emergency department due to the chief complaint of possible overdose and R1 was uncooperative and yelling at hospital staff in the emergency department. The record documents nursing home staff reported completing fifteen minute checks on R1 when R1 was found unresponsive with a respiration rate of 11 and an oxygen saturation of 88% followed by nursing home staff administering Narcan to R1. The emergency department report documents R1 received an intravenous catheterization in R1's arm at 11:30PM on 1/28/2025 which R1 pulled out of R1's arm at 11:47PM followed by the notes bleeding controlled at this time and ER MD notified. The same report documents hospital staff inserted a second intravenous catheter into R1's arm at 12:10AM on 1/29/2025. The report also documents hospital emergency room staff performed a urinary catheterization on R1 at 11:27PM on 1/28/2025 to obtain a urine specimen for a urinary drug screen and at 11:47PM, the screen resulted positive for the presence of Morphine (an opiate) in R1's urine. The emergency department notes document on 1/28/2025 at 11:50PM, V28 (Emergency department physician) stated R1's urine drug screen was positive for opiates but R1 did not currently have any opiates on R1's medication list and that V29 (Hospitalist) was concerned R1's positive urine drug screen may be an actual (Morphine) ingestion and the hospital will observe R1 in the Emergency Department overnight. On 2/13/2025 at 11:45AM, V9 (facility Quality Assurance Pharmacist) looked at R1's medication records and reported R1 was opiate naive prior to the incident (had not been taking any opiates recently) and if R1 had ingested the bottle of liquid Morphine containing 59.5 milligrams, V9 would expect to see traditional signs of opioid overuse, especially respiration rate depression and mental status changes. V9 reported additional signs would include lethargy and trouble concentrating. V9 reported expecting the onset of liquid Morphine to be within 30-60 minutes but possibly longer. V9 reported it would be reasonable for R1 to not show signs of opiate overdose for some time after ingestion depending on food in R1's stomach and other factors. V9 reported death is possible with opioid overdose and other possible outcomes include temporary or permanent harm. On 2/14/2025 at 11:26AM, V9 reported typical dosing for Morphine Sulfate at a concentration of 2 milligrams/milliliter is as low as a few milligrams for an opiate naive patient and reported standard dosing for a patient without previous use would be 5 milligrams or lower per dose. R1's Medication Administration record (January, 2025) does not document R1 was taking any opiate medications at the time of the incident on 1/28/2025. On 2/14/2025 at 12:21PM, V12 (R1's attending medical provider at the facility) reported if R1 was positive for opiates on a urinary drug screen, then R1 must have ingested some of the liquid Morphine. V12 reported facility staff leaving the Morphine out on the medication cart unsupervised was a high risk for residents. V12's (R1's attending medical provider in the facility) Progress Note (1/30/2025) documents V12 discussed in great detail with nursing home staff that they should not leave any medication unattended to prevent future incidents with any resident. The note documents V12 recommended to provide all staff necessary education and discussed this with V1 (Administrator) and V31 (former Director of Nursing) and they agreed. The Immediate Jeopardy that began on 1/28/2025 was removed on 1/28/2025 when the facility removed the bottle of Morphine Sulfate from R1's possession and sent R1 to the hospital emergency room for evaluation. The deficient practice was corrected on 1/29/2025 after the facility took the following actions: 1. R1 was evaluated and sent to the Local emergency room for evaluation on 1/28/25 at 5:50p.m. When EMS personnel arrived, they attempted to administer Narcan to R1 prior to transferring R1 to the local emergency room . 2. V4, Licensed Practical Nurse, was suspended on 1/28/2025 pending a comprehensive investigation of the incident. 3. Upon Return to the facility on [DATE], R1 was placed on 15-minute checks and increased assessment and monitoring with hourly vital signs/Level of Consciousness for eight hours and then every shift times two days. 4. Upon Return to facility, R1 had a change in condition. V6, Registered Nurse, administered Narcan to R1, called 911, and sent R1 back to the Local emergency room for Evaluation at 10:41p.m. 5. R1 returned from the hospital on 1/29/25 at 7:35a.m. Upon return to the facility, R1 was placed on 15-minute checks and increased assessment and monitoring with every 4 hour vital signs for 2 days. 6. All licensed nursing staff were educated on Storage of Controlled Substances, Medication Administration, Accidents and Incidents, and Change of Condition Policies prior to their next scheduled shift either in person or via phone by V31 (former Director of Nursing), V2 (former Nurse and current Director of Nursing), (former Registered Nurse and current Director of Nursing), and V36 (Licensed Practical Nurse) completed 1/29/25. 7. V2 (former Registered Nurse and current Director of Nursing) contacted V37 (R1's Power of Attorney) for notification on 1/28/25 at 6:01p.m. 8. V2 (former Registered Nurse and current Director of Nursing) contacted V12 (R1's Physician) for notification on 1/28/25 at 7:15p.m., V31 (former Director of Nursing), and the facility pharmacy provider on 1/29/25 for assistance with Medication Audits. 9. V30 (Maintenance Director) completed a sweep of the Dementia Unit to ensure that all items that are liquid and hazardous products were locked up or put away out of reach on 1/28/25. 10. The Facility Corporate team (V32 Chief Nursing Officer, V33 Regional Clinical Consultant, V34 Chief Executive Officer, V35 Regional Director of Operations) reviewed and revised policies and procedures related to Medication Administration, Medication Storage, Accidents and Incidents, and Change of Condition. (Completed 1/29/25) 11. The Director of Nursing or designee will complete audits three times weekly for a period of 8 weeks in the following categories: (Initiated 1/29/25) Medication Administration Policy, Storage of controlled substances, Accidents and Incidents, and Change of Condition. Results of the above reviews will be discussed at a weekly quality assurance meeting for a period of 4 weeks and will provide additional education as needed and implement interventions for improvement until resolution.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review the facility failed to protect a resident's right to be free from restricted access from areas of the facility without clinical justification. These failures affect one (R9) out of three residents reviewed for seclusion in a sample list of 16 residents. These failures resulted in R9 expressing fear of being yelled at by staff and threats of room move to a locked down Dementia unit if R9 walked the length of her own hallway. Findings include: The facility policy titled Abuse Policy revised 1/9/24 documents the Administrator and/or designee is the Abuse Coordinator for this facility. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment. It is the responsibility of all facility staff to ensure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Unreasonable confinement or Involuntary Seclusion means the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will, or the will of the resident's legal representative. Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs. R9's undated Face Sheet documents medical diagnoses as Cerebral Infarction, Peripheral Vascular Disease, History of Right Artificial Hip Joint, Seizures, Intellectual Disabilities, Alzheimer's Disease, Psychosis, Pulmonary Hypertension, Intervertebral Disc Degeneration, and Congestive Heart Failure. R9's Minimum Data Set (MDS) dated [DATE] documents R9 as cognitively intact and uses a walker for ambulation. On 12/13/14 at 1:20 PM, R9 walked the entire length of North Hall in the facility, rounded the corner to walk the length of the back hall and then turned around when she reached the end of the South Hall where R14 resides. R9 then retraced her steps down the back hall and back down the North Hall. R9 stated I can't go down there, or I will get into trouble with that mean lady Administrator (V1). I don't want to get yelled at anymore. On 12/12/24 at 1:00 PM, V1, Administrator, stated V1 told R9 to not walk down the back half of R9's hallway due to a complaint that R9 was standing in the hallway staring in (R14's) room. V1 stated I absolutely told (R9) to not walk down her hallway. (R9) could go to the nurse's station but no further. What am I supposed to do when there is a family member complaining about (R9) staring in (R14's) doorway? (V55) (R14's) Power of Attorney (POA) is just going to keep complaining so I made it clear to (R9) she can't go down there anymore. On 12/12/24 at 9:35 AM, V16, Certified Nursing Assistant (CNA) stated (R9) can only walk to the nurse's station and not any farther per (V1). I am not sure why but (R9) never walks down the rest of the hall. (R9) walks all around the halls but not down the other half of her own hall. On 12/12/24 at 10:35 AM, V2, Director of Nurses (DON), stated a family member of another resident (R14) complained that R9 would walk by R14's room and stare in. V2 stated V2 was not aware if R9 ever entered R14's room but would stop and stare in. V2 stated the staff are busy down R9's hall and do not have time to monitor R9 to make sure she is not staring into someone else's room so V1 told R9 that she cannot walk down that half of the hall. V2 stated R9 and R14 live on opposite ends of the same hallway. V2 stated V1 stated R9 was allowed to walk to the nurse's station on her hall but not any further. On 12/12/24 at 10:45 AM, V4, Social Service Director (SSD), stated on 12/6/24 at lunch time V1 asked V2 and V4 to witness a conversation with R9. V4 stated V23 Director of Business Development was already sitting in the conference room working for the day. V4 stated V1 yelled at R9 until she cried. V4 stated V4 could see R9 become visibly upset when V1 was yelling at her. V1 asked R9 if she wanted to live in the Dementia unit again and R9 replied No! I hated it back there! V1 Administrator then told R9 You better get your act together or you will be moving back to the Dementia unit. V4 stated after this incident was over R9 walked back to her room with V4. V4 stated once R9 got to her room, she began sobbing saying Why does (V1) talk so mean to me? (V1) yelled at me about walking down my own hallway. I won't ever walk down that part of the hall again! On 12/12/24 at 1:10 PM, R9 stated V1 had come to R9 and told R9 that she was not supposed to walk past the nurse's station on her own hallway due to R14's wife complained that R9 was staring into R14's room. R9 stated R9 didn't think anything of that so she continued to walk all around the facility including past R14's room. R9 stated R9 might have stopped in front of R14's room but did not recall staring in at anyone, just admiring the room. R9 stated R14's room has a private bathroom and more space than her room and would like to move into R14's room. R9 stated (V1) called me into that room by (V1's) office (conference room) to yell at me. (V1) threatened to move me back to the Dementia unit. I lived there once before, and it was awful. You are locked up back there. (V1) told me if I don't behave, she was sending me back there. I remember crying in that room and I was very upset. I went back to my room and had a good cry. I am never going down that hall again! I don't ever want to be treated like that again! On 12/13/24 at 12:45 PM, V23 Registered Nurse (RN), stated R9 walks from the nurse's station on South Hall where R9 resides, past her room, past the front offices, down North Hall and the back hall and then turns around when R9 reaches the other end of South Hall. V23 stated R9 will not walk by R14's room. V23 stated R9 has followed that same path every time for the last few weeks. On 12/18/24 at 1:45 PM, V43, Medical Director, stated V43 is very familiar with R9. V43 stated R9 walks up and speaks to V43 every time he visits the facility. V43 stated R9 has a fragile demeanor due to her Intellectual Disability and Mental Health history. V43 stated R9 should be walking around the entire perimeter of the facility in order to maintain her current mobility. V43 stated R9 had a Right total hip replacement in May 2024, and it is imperative to her recovery. V43 stated there is no reason why R9 cannot walk down the length of her own hallway and every hallway in the facility. V43 stated I am not sure why the facility thought restricting (R9's) access to open areas would help resolve the issue. The last I checked, this is a free country. (R9) has every right to all of the resident designated areas in that facility. If you restrict that access, you are basically secluding the resident. We should never do that unless it's in case of an emergency. B. Based on observation, interview and record review the facility failed to ensure one (R6) resident was assisted to smoke breaks out of three residents reviewed for smoking in a sample list of 16 residents. Findings include: The facility policy titled Resident Rights revised 7/11/22 documents employees shall treat all residents with kindness, dignity and respect. R6's undated Face Sheet documents medical diagnoses as Dementia with Agitation, Chronic Obstructive Pulmonary Disease (COPD), Macular Degeneration, Systolic Heart Failure, Non ST Elevation R6's Minimum Data Set (MDS) dated [DATE] documents R6 as severely cognitively impaired. R6's Smoking assessment dated [DATE] documents R6 requires supervision while smoking. R6's Careplan initiated 7/22/24 does not document a focus area, goal nor intervention for R6 smoking. On 12/12/24 at 9:52 AM, a sign was posted on the wall at the nurses station that reads smoking times are at 9:00 AM, 1:00 PM, 4:00 PM and 7:00 PM. This same sign stated that Certified Nurse Aides (CNA) and Activity staff are not responsible for assisting residents to designated smoking area and that residents had to get to the designated smoking on their own or they would not be allowed to smoke. On 12/13/24 at 2:23 PM R6 was laying in his bed in his room. R6 stated he would like to have a cigarette but no one has asked him to go outside today. R6 stated I wouldn't stay long because it is cold but I could go out for a few minutes. On 12/12/24 at 10:13 AM, R6 stated he smokes outside with staff. R6 stated the facility allows him to smoke four times per day having two cigarettes each time. R6 stated the staff ask him twice per day and not the four times like they should. R6 stated sometimes it is too cold out but the staff still only ask him if he wants to smoke twice per day and not four times per day. R6 stated I would rather have one cigarette four separate times than have two cigarettes two times. Then I have to wait all night to have another one. That is a very long wait! On 12/12/24 at 2:42 PM, R6 stated he has not been asked to go outside to smoke today. R6 stated I would like a cigarette. I haven't had one since yesterday afternoon. On 12/13/24 at 1:40 PM, V27 Activity Director, stated the residents are allowed to smoke two cigarettes with staff supervision at 9:00 AM, 1:00 PM, 4:00 PM and 7:00 PM. V27 stated there are two residents (R6, R7) who reside on the Dementia unit who smoke. V27 stated the Dementia unit staff are responsible for making sure (R6, R7) get their smoke breaks. On 12/13/24 at 1:50 PM, V25, Dementia Unit Coordinator, stated R7 is always escorted up front to smoke with the other group from the main part of the facility. V25 stated R6 has had behavioral problems with some of those other smokers so R6 smokes with supervision but not in a group of residents. V25 stated R6 should be offered smoking times as scheduled like everyone else but sometimes there is a problem getting staff from the main building to help out when they can. V25 stated if the Dementia unit staff are busy providing cares to other residents and no one else steps in to supervise R6 while he smokes, then R6 doesn't get to smoke. V25 stated that is not fair to R6. On 12/13/24 at 8:30 AM, R6 stated I sure would like a cigarette. I haven't had one in two days. On 12/17/24 at 9:45 AM, R6 was sitting up in his wheelchair next to the nurses station. R6 stated I would like to go smoke. It's cold out so I will only stay outside for one cigarette. I haven't had a cigarette in five or six days. No one will take me out. On 12/17/24 at 1:55 PM, V2, Director of Nurses (DON), stated the facility is a smoking facility and every resident who wants to smoke should be allowed to at the designated times. V2 DON stated sometimes the staff might not be able to get to take R6 out to smoke at the exact moment R6 wants to go but there should be staff available within a short amount of time to supervise R6 smoking. V2 stated R6 should be offered alternate times to smoke. V2 stated anyone [AGE] years of age or older can supervise a resident smoking. V2 DON stated allowing R6 to smoke could help alleviate behaviors and was an intervention to a prior incident.

Based on interview and record review the facility failed to protect one (R9) resident's right to be free from mental abuse by a staff member (V1) out of three residents reviewed for mental abuse in a sample list of 16 residents. This failure resulted in R9 being yelled at and threatened by staff, crying, expressing humiliation, and fear of participating in activities. Findings include: The facility policy titled Abuse Policy revised 1/9/24 documents the Administrator and/or designee is the Abuse Coordinator for this facility. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment. It is the responsibility of all facility staff to ensure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff's responsibility to report any allegation or witnessed abuse immediately to the Administrator (Abuse Coordinator). The facility will report all allegations of abuse timely to the proper authorities to include State Agency, Ombudsman, Power of Attorney (POA) and Physician. R9's undated Face Sheet documents medical diagnoses as Cerebral Infarction, Peripheral Vascular Disease, History of Right Artificial Hip Joint, Seizures, Intellectual Disabilities, Alzheimer's Disease, Psychosis, Pulmonary Hypertension, Intervertebral Disc Degeneration, and Congestive Heart Failure. R9's Minimum Data Set (MDS) dated [DATE] documents R9 as cognitively intact and uses a walker for ambulation. On 12/12/24 at 10:35 AM, V2, Director of Nurses (DON), stated V1, Administrator, asked V2 to be present for a conversation with R9. V2 stated V4, Social Service Director (SSD), was also present. V2 stated V1 did raise her voice at R9. V2 stated V1 was not cursing or screaming at R9. V2 stated R9 looked upset while V1 was raising her voice at R9. V2 stated a family member of another resident (R14) complained that R9 would walk by R14's room and stare in. V2 stated Sometimes you have to be stern with these residents. You have to set firm boundaries. (V1) said to (R9) I don't want to have to put you back on the Dementia unit. Do you like your freedom? V2 stated (R9) replied yes and was upset. V2 stated (R9) cries all the time when she gets in trouble, so I don't know if she was crying that day. (R9) could have been crying. I don't really remember because (R9) is so sensitive she cries a lot anyway. On 12/12/24 at 10:45 AM, V4, Social Service Director (SSD), stated on 12/6/24 at lunch time, V1 asked V2 and V4 to witness a conversation with R9. V4 stated V23, Director of Business Development, was already sitting in the conference room working for the day. V4 stated V1 yelled at R9 until she cried. V4 stated V4 could see R9 become visibly upset when V1 was yelling at her. V1 asked R9 if she wanted to live in the Dementia unit again and R9 replied No! I hated it back there! V1 then told R9 You better get your act together or you will be moving back to the Dementia unit. V4 stated after this incident was over R9 walked back to her room with V4. V4 stated once R9 got to her room, she began sobbing saying Why does (V1) talk so mean to me? (V1) yelled at me about walking down my own hallway. I won't ever walk down that part of the hall again! On 12/12/24 at 10:50 AM, V45, Anonymous, stated V1 yells at residents. V45 stated V1 has a loud voice naturally but the yelling is not meant for residents due to hearing impairment, V1 just yells at everyone. V45 stated V1 will slam her fist down on a table, yell from her office out into the hallway or just yell down the hall at staff in front of residents. V45 stated I heard (V1) yelling at (R9) the day (12/6/24) (V1) brought (R9) into the conference room. I heard (R9) crying outside the conference room door when it was done. (V1) was yelling so loud you could hear her in the dining room down the hall. The residents in the dining room were looking around like who is yelling like that? On 12/12/24 at 1:10 PM, R9 stated V1 had come to R9 and told R9 that she was not supposed to walk past the nurse's station on her own hallway due to R14's wife complained that R9 was staring into R14's room. R9 stated R9 didn't think anything of that so she continued to walk all around the facility including past R14's room. R9 stated R9 might have stopped in front of R14's room but did not recall staring in at anyone, just admiring the room. R9 stated R14's room has a private bathroom and more space than her room and would like to move into R14's room. R9 stated (V1) called me into that room by (V1's) office (conference room) to yell at me. (V1) yelled so loud everyone could hear it. (V1) did not use any curse language. (V1) was yelling at me because I walked down my own hallway. (R14) lives on my hallway too. I don't mean to bother (R14), I just like his room. (V1) threatened to move me back to the Dementia unit. I lived there once before, and it was awful. You are locked up back there. (V1) told me if I don't behave, she was sending me back there. I don't know why (V1) had to yell at me in front of all those people. That was humiliating. I remember crying in that room and I was very upset. I went back to my room and had a good cry. (V4) was there with me. (V4) was very kind and helped me calm down. I am never going down that hall again! I don't ever want to be treated like that again! On 12/13/24 at 3:00 PM, V28, Registered Nurse (RN), stated R9 used to attend activities all of the time and has recently stopped going. V28 stated V28 has encouraged R9 to participate in activities but R9 declines stating she doesn't want to get into trouble. On 12/13/24 at 3:15 PM, V27 stated V27 was walking in the hallway adjacent to the conference room '30 feet' away. V27 stated V27 heard V1 yelling inside the conference room. V27 stated V27 did not know until later that a resident (R9) was in the conference room with V1, V2 , V4 and V23. On 12/18/24 at 1:52 PM, V43, Medical Director, stated staff should never raise their voices when talking to residents. V43 stated Verbal and Mental abuse is a very serious issue. (V1) should have addressed the issue of where (R9) can walk or not in a better way. (V1) should never have raised her voice at (R9). There is no need to use a firm tone with (R9) or any other resident. (R9) will not respond to that. (R9's) temperament can be fragile and the facility staff should be trained on how to address issues without abusing residents.

Based on observation, interview and record review the facility failed to protect a resident's right to be free from restricted access from areas of the facility without clinical justification. These failures affect one (R9) out of three residents reviewed for seclusion in a sample list of 16 residents. These failures resulted in R9 expressing fear of being yelled at by staff and threats of room move to a locked down Dementia unit if R9 walked the length of her own hallway. Findings include: The facility policy titled Abuse Policy revised 1/9/24 documents the Administrator and/or designee is the Abuse Coordinator for this facility. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment. It is the responsibility of all facility staff to ensure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Unreasonable confinement or Involuntary Seclusion means the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will, or the will of the resident's legal representative. Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs. R9's undated Face Sheet documents medical diagnoses as Cerebral Infarction, Peripheral Vascular Disease, History of Right Artificial Hip Joint, Seizures, Intellectual Disabilities, Alzheimer's Disease, Psychosis, Pulmonary Hypertension, Intervertebral Disc Degeneration, and Congestive Heart Failure. R9's Minimum Data Set (MDS) dated [DATE] documents R9 as cognitively intact and uses a walker for ambulation. On 12/13/14 at 1:20 PM, R9 walked the entire length of North Hall in the facility, rounded the corner to walk the length of the back hall and then turned around when she reached the end of the South Hall where R14 resides. R9 then retraced her steps down the back hall and back down the North Hall. R9 stated I can't go down there, or I will get into trouble with that mean lady Administrator (V1). I don't want to get yelled at anymore. On 12/12/24 at 1:00 PM, V1, Administrator, stated V1 told R9 to not walk down the back half of R9's hallway due to a complaint that R9 was standing in the hallway staring in (R14's) room. V1 stated I absolutely told (R9) to not walk down her hallway. (R9) could go to the nurse's station but no further. What am I supposed to do when there is a family member complaining about (R9) staring in (R14's) doorway? (V55) (R14's) Power of Attorney (POA) is just going to keep complaining so I made it clear to (R9) she can't go down there anymore. On 12/12/24 at 9:35 AM, V16, Certified Nursing Assistant (CNA) stated (R9) can only walk to the nurse's station and not any farther per (V1). I am not sure why but (R9) never walks down the rest of the hall. (R9) walks all around the halls but not down the other half of her own hall. On 12/12/24 at 10:35 AM, V2, Director of Nurses (DON), stated a family member of another resident (R14) complained that R9 would walk by R14's room and stare in. V2 stated V2 was not aware if R9 ever entered R14's room but would stop and stare in. V2 stated the staff are busy down R9's hall and do not have time to monitor R9 to make sure she is not staring into someone else's room so V1 told R9 that she cannot walk down that half of the hall. V2 stated R9 and R14 live on opposite ends of the same hallway. V2 stated V1 stated R9 was allowed to walk to the nurse's station on her hall but not any further. On 12/12/24 at 10:45 AM, V4, Social Service Director (SSD), stated on 12/6/24 at lunch time V1 asked V2 and V4 to witness a conversation with R9. V4 stated V23 Director of Business Development was already sitting in the conference room working for the day. V4 stated V1 yelled at R9 until she cried. V4 stated V4 could see R9 become visibly upset when V1 was yelling at her. V1 asked R9 if she wanted to live in the Dementia unit again and R9 replied No! I hated it back there! V1 Administrator then told R9 You better get your act together or you will be moving back to the Dementia unit. V4 stated after this incident was over R9 walked back to her room with V4. V4 stated once R9 got to her room, she began sobbing saying Why does (V1) talk so mean to me? (V1) yelled at me about walking down my own hallway. I won't ever walk down that part of the hall again! On 12/12/24 at 1:10 PM, R9 stated V1 had come to R9 and told R9 that she was not supposed to walk past the nurse's station on her own hallway due to R14's wife complained that R9 was staring into R14's room. R9 stated R9 didn't think anything of that so she continued to walk all around the facility including past R14's room. R9 stated R9 might have stopped in front of R14's room but did not recall staring in at anyone, just admiring the room. R9 stated R14's room has a private bathroom and more space than her room and would like to move into R14's room. R9 stated (V1) called me into that room by (V1's) office (conference room) to yell at me. (V1) threatened to move me back to the Dementia unit. I lived there once before, and it was awful. You are locked up back there. (V1) told me if I don't behave, she was sending me back there. I remember crying in that room and I was very upset. I went back to my room and had a good cry. I am never going down that hall again! I don't ever want to be treated like that again! On 12/13/24 at 12:45 PM, V23 Registered Nurse (RN), stated R9 walks from the nurse's station on South Hall where R9 resides, past her room, past the front offices, down North Hall and the back hall and then turns around when R9 reaches the other end of South Hall. V23 stated R9 will not walk by R14's room. V23 stated R9 has followed that same path every time for the last few weeks. On 12/18/24 at 1:45 PM, V43, Medical Director, stated V43 is very familiar with R9. V43 stated R9 walks up and speaks to V43 every time he visits the facility. V43 stated R9 has a fragile demeanor due to her Intellectual Disability and Mental Health history. V43 stated R9 should be walking around the entire perimeter of the facility in order to maintain her current mobility. V43 stated R9 had a Right total hip replacement in May 2024, and it is imperative to her recovery. V43 stated there is no reason why R9 cannot walk down the length of her own hallway and every hallway in the facility. V43 stated I am not sure why the facility thought restricting (R9's) access to open areas would help resolve the issue. The last I checked, this is a free country. (R9) has every right to all of the resident designated areas in that facility. If you restrict that access, you are basically secluding the resident. We should never do that unless it's in case of an emergency.

Based on observation, interview and record review the facility failed to monitor and prevent a wound from worsening, failed to prevent new wounds from developing, failed to implement pressure reducing interventions and failed to complete treatments as ordered for three of three residents (R1, R2, R3) reviewed for pressure ulcers in the sample list of three. This failure resulted in R1 requiring hospitaliztion. for a maggot infestation of R1's wound. Findings include: The facility's Pressure Ulcer Prevention, Identification and Treatment policy with a revised date of 8/31/23 documents, Purpose: To v guidelines that will assist nursing staff in prevention, identification, and appropriate treatment of pressure ulcers. The facility will initiate an aggressive treatment program for those resident who have pressure ulcers. Responsibility: It is the responsibility of the Charge Nurse/Designee to care for pressure areas, and provide treatments as ordered. It is the responsibility of the Charge Nurse/Designee to measure and document on the pressure areas weekly. It is the responsibility of the Charge Nurse/Designee to monitor for healing progress, and ensure appropriate treatment are in use. It is recommended that D.O.N. (Director of Nursing)/Designee make frequent pressure ulcer rounds with the charge nurse. It is the responsibility of the CNA (Certified Nursing Assistant) to report any skin conditions to the charge nurse immediately upon identification. Procedure: 1. All residents will have a Pressure Ulcer Risk Assessment (Braden Assessment) completed weekly for 4 weeks upon admission. Assessments shall continue at least quarterly thereafter and with any significant change of status. 2. Nurses are to complete skin assessments daily on resident deemed 'High Risk' for skin breakdown (Scoring 12 or lower on Braden Scale). Skin assessments shall be done at least weekly on all other residents. 3. Support services shall be utilized in the prevention of wound development, including, but not limited to: Redistributing pressure (repositioning, off-loading, etc. {etcetera}), minimizing exposure to moisture, providing appropriate pressure-redistributing, non-irritating support surfaces and evaluation/maintenance of proper nutrition and hydration. 4. When a pressure ulcer is identified, whether in-house or upon a resident's admission, the area will be assessed using the Skin & Wound assessment, a skin inspection assessment shall be completed, and initial treatment started per physician's orders. Daily skin checks shall be initiated initiated on residents with a pressure wound to provide increased monitoring from nursing staff. Resident may be referred to wound physician for evaluation and treatment (where applicable). The physician is to be notified when A) pressure ulcer develops, B) when there is a noted lack of improvement after a reasonable amount of time, C) and/or upon signs of deterioration. 1.) R1's Order Summary Report Osteomyelitis, Type 2 Diabetes Mellitus with Hyperglycemia, Pressure Ulcer of Right Heel Unstageable, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-dominant Side, Chronic Pain and Acquired Absence of Other Left Toes. This Order Summary documents R1 was readmitted to the facility on [DATE]. R1's electronic census documents R1 was originally admitted to the facility on [DATE]. R1's Care Plan with a revised date of 6/24/24 documents R1 has an actual pressure ulcer on the Right Heel with interventions dated 2/24/24 of daily skin checks, float heels, monitor for signs and symptoms of infection daily - increased warmth of surrounding tissue, redness, swelling, pain, purulent drainage, foul odor, notify physician if identified, assess pressure ulcer weekly by a licensed nurse and provide off loading of ulcer site. R1's Treatment Administration Record (TAR) dated 7/1/24 through 7/31/24 documents an order to cleanse wound on right heel with wound cleanser, apply collagen to wound bed and cover with an abdominal pad and rolled gauze every day and as needed every evening shift with an order start date of 4/16/24 and discontinue date of 7/17/24. The treatment order was not signed off as completed on 7/15/24. This TAR documents an order with a start date of 7/17/24, may change clear dressing to right heel as needed. Do not remove anything below clear dressing. Will be done by wound Nurse Practitioner weekly as needed for wound care. This order is not signed off as completed from 7/17/24 through 7/27/24. V3 Wound Nurse Practitioner's note dated 7/17/24 documents R1's wound on the right heel measured 4.1 cm (centimeters) x (by) 2.5 cm x 0.1 cm with a treatment of a skin graft, apply normal saline moistened gauze, oil emulsion dressing, super absorbent dressing covered with a bordered gauze dressing. Secure with a transparent medical dressing, monitor and change daily every one time a week and as needed. R1's Nurse's Note dated 7/23/24 at 11:52 AM, V11 Licensed Practical Nurse (LPN) documented V11 called and spoke with V3 Wound Nurse Practitioner in regards to R1's right heel not having the clear under dressing on the heel and gave a one time order to clean with normal saline/wound cleanser apply collagen to wound bed and cover with dry bordered gauze until follow up with V3 tomorrow 7-24-24. V3's wound note dated 7/24/24 documents R1's right heel wound measured 4 cm x 2.5 cm x 0.1 cm with the same treatment as 7/17/24. R1's Nurse's Notes dated 7/28/24 at 11:23 AM by V11 documents V11 could not find the clear film of R1's dressing and R1's wound dressing was slipping down, V11 reinforced the dressing with foam gauze dressings. There is no documentation that V3 Wound Nurse Practitioner was notified. R1's Nurse's Notes dated 7/30/24 at 10:08 AM by V11 documents the wound Nurse Practitioner (V3) will do the wound treatment tomorrow. R1's Nurse's Notes with an effective date of 7/31/24 at 11:00 AM and an entered date of 8/1/24 at 3:55 PM by V2 Director of Nursing documented an SBAR (Situation Background Assessment Recommendation) for a change in condition of a skin wound/ulcer. This note documents R1's wound on the right heel has had increased drainage and odor with recommendations to send to the emergency room . R1's Nurse's Notes dated 7/31/24 entered at 4:06 PM documents effective at 11:00 AM by V5 Licensed Nurse Practitioner V3 here to see R1 for wound on the right heel. V3 noted wound to have foul smell and had deteriorated. Wound culture was done and V5 requested R1 be sent to the emergency room to be evaluated for Osteomyelitis. POA (Power of Attorney) contacted and was agreeable with plan. V3's Wound assessment dated [DATE] documents a Right Heel Pressure Injury with declining status measuring 4.4 cm x 3.3 cm x 0.1 cm with a large amount of exudate and odor. This Wound Assessment also documents, Strong odor and new wound beneath dressing when removed. Increased measurements. Wound declined with unstable eschar noted within wound bed. Wound culture obtained. Wound nurse and DON (V2 Director of Nursing) present in room and aware of changes. Ordered to send R1 to emergency room for evaluation to rule out Osteomyelitis and Sepsis. V3 documents a Wound Assessment of the new wound on the right medial foot as pressure injury, measuring 4.4 cm x 2.4 cm and 100% eschar. V3 documents a strong odor and red streaking observed to periwound measuring 8.5 cm x 8 cm. R1's Nurse's Notes dated 7/31/24 at 4:07 PM, R1 admitted to the hospital, on IV (Intravenous) antibiotic, wound consult tomorrow. R1's hospital records dated 7/31/24 documents R1 has had on ongoing wound involving the right heel and was receiving wound care at the nursing facility and reportedly maggots were expressed from the wound along with malodorous material. Plain films do not show any obvious bony destruction. There is some surrounding erythema and a dark eschar overlying the wound along with some other traction types of abrasion around the Calcaneus. R1's MRI (Magnetic Resonance Imaging) results dated 8/1/24 documents recent debridement after maggots were present on plantar wound. Impression: soft tissue ulcer in the plantar subcutaneous tissues inferior to the posterior calcaneal bone associated with both cellulitis and Osteomyelitis. R1's hospital physical exam note dated 8/4/24 documents wound cultures from 8/2/24 demonstrate Proteus Mirabilis and R1 will require 6 weeks of Daptomycin and Ceftriaxone (antibiotics) and a PICC (Peripherally Inserted Central Catheter) line has been placed for IV antibiotic administration. R1's Nurse's Progress notes dated 8/4/24 at 6:30 PM documents R1 returned to the facility with a diagnoses of Osteomyelitis. On 8/5/24 at 9:45 AM, R1 stated that the Wound Nurse Practitioner was trying a skin graft on his wound on his foot. R1 stated that the dressing was supposed to stay on for 7 days. R1 stated that the wound was smelling but staff didn't do anything except agree that it smelled. R1 stated when they went to remove the dressing on 7/31/24 there were maggots on the wound. At this time R1 is laying in his bed with his heels laying on the bed. R1 has foam rings around both calves but they are not keep his heels off the bed. There are two different types of heel cushions on R1's wheelchair but are not being used. On 8/5/24 at 11:40 AM, R1's heels are laying directly on the bed. On 8/5/24 at 2:17 PM, R1's heels are laying directly on the bed. On 8/5/24 at 2:57 PM, V5 Licensed Practical Nurse (LPN) stated on 7/31/24 that V3 Wound Nurse Practitioner and V8 Business Office Manager went in to change R1's dressing and V3 came out and told her that the wound had maggots on it and V3 wanted R1 sent to the hospital for evaluation. V5 stated that she did notice an odor outside of R1's room earlier that morning when she was passing medications but did not address it. On 8/6/24 at 10:06 AM, V11 LPN stated R1's dressing was coming off and she could not find the transparent dressing so she just reinforced what was already on there. V11 stated that they were told not to touch the wound dressing. V11 stated that she informed V8 since she assists the Wound Nurse Practitioner. V11 stated that on 7/30/24 the shower aide (V9) told V11 that R1's odor was really bad and thought she was going to throw up from the smell. V11 stated she informed V8 regarding the strong odor but did not document anything about it or notify the Wound Nurse Practitioner. On 8/6/24 at 10:26 AM, V8 stated that V8 is a Licensed Nurse in another stated but not here so she cannot practice as a nurse but goes with the Wound Nurse Practitioner on her rounds to get things for her. V8 stated that on 7/31/24 she was rounding with V3. V8 stated that V3 pulled the top of R1's dressing back and said Oh my gosh and put the dressing back in place. V8 stated there was a very strong odor. V8 stated that they went to get more supplies to clean the wound. V8 stated that on 7/30/24 someone told her that there was an odor but V8 stated V3 Wound Nurse Practitioner told them there would be some odor since the graft was a living thing. V8 confirmed that she did not assess the odor or report the odor to V3. V8 confirmed there was a new pressure area under the dressing and confirmed there were maggots present along with the strong odor. On 8/6/24 at 10:58 AM, V2 Director of Nursing confirmed V2 was present in the room when R1's dressing was being changed on 7/31/24 and confirmed there was a new pressure area and confirmed there were maggots present and there was a strong odor. V2 stated that the nurses should have been going in and visually inspecting the dressing and V2 stated that if the nurses noticed an odor that strong they should have notified the Wound Nurse Practitioner. On 8/6/24 at 11:09 AM, V9 Certified Nursing Assistant/Shower Aide stated on 7/30/24 that R1's odor was awful and there was drainage soaking through the dressing. V9 stated that there was also drainage on R1's bed sheet. V9 stated that she reported the odor and drainage to V11 and V8. V9 stated that it was the worst smell she had every smelled. On 8/6/24 at 11:59 AM, V3 Wound Nurse Practitioner stated that R1's wound had previously been treated with collagen and it had stalled out so she discussed trying a skin graft with R1 and he was willing to try it. V3 stated that the skin graft needed to try to stay in place for 7 days at a time. V3 stated she placed the skin graft over the wound and used tape strips to hold it in place then covered with a dressing and then a secondary dressing that the nurses could change if needed. V3 stated that the nurses should have been monitoring the secondary dressing everyday. V3 stated on 7/31/24 there was a strong odor coming from R1's foot and confirmed there were maggots present on his wound when she removed the dressing. V3 stated that the dressing must have had a break in the seal and it would have only taken one fly to get inside the dressing. V3 stated that R1 was mobile in his chair throughout the facility and went outside frequently so it is no surprise that the maggots were present. V3 confirmed that she was not made aware of the strong pungent smell coming from R1's wound and should have been made aware. V3 stated R1 has a history of Osteomyelitis so she wanted him evaluated and had him transferred to the hospital right away on 7/31/24. On 8/6/24 at 1:12 PM, V12 LPN stated V12 worked night shift 6:00 PM to 6:00 AM on 7/29/24 and confirmed that there was an odor to R1's wound. V12 stated that the day shift nurse V11 was aware of the odor. On 8/6/24 at 1:17 PM, V13 Certified Nursing Assistant (CNA) confirmed taking care of R1 7/29/24 and 7/3024 and confirmed there was an awful odor coming from R1. V13 stated that she told the nurses and they thought it was coming from the skin graft. On 8/6/24 at 1:33 PM, V14 CNA stated that there was an odor outside of R1's room on either 7/30/24 or 7/31/24 and stated that she changed R1's bedding after they cleaned up his wound and confirmed there were a couple of maggots on the sheets after the dressing change. On 8/6/24 at 1:40 PM, V15 CNA stated that she could smell the odor outside of R1's room on 7/30/24 and V15 stated that she reported it to the nurse V11. On 8/6/24 at 3:27 PM, V16 CNA stated that she worked on 7/29/24 and 7/30/24 and remembers that on 7/29/24 she let the nurse know that the odor was bad and stated that R1 told her that the odor was coming from his foot. On 8/6/24 at 1:54 PM, V11 completed a dressing change on R1's right foot. There was a large wound on R1's heel that was pink and was clean and there were two other areas in the arch of the foot that were open and red with some scabbed areas on them. 2.) R2's Treatment Administration Record (TAR) dated 7/1/24 through 7/31/24 documents diagnoses including Type 2 Diabetes Mellitus, Severe Morbid Obesity and Extended Spectrum Beta Lactamase (ESBL) Resistance. This TAR documents an order dated 7/18/24 for the Coccyx wound to cleanse with wound cleanser or normal saline, pack with bleach solution soaked gauze, cover with a bordered foam dressing two times a day. This TAR documents this treatment was not signed off as completed on 7/18/24 at 8:00 AM, 7/20/24 at 8:00 PM and 7/24/24 at 8:00 PM. 3.) R3's Treatment Administration Record dated 7/1/24 through 7/31/24 documents diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Personal History of Traumatic Fracture, Crohn's Disease, Severe Protein Calorie Malnutrition, Pressure Ulcer of Sacral Region Stage 4, Adult Failure to Thrive and Extended Spectrum Beta Lactamase (ESBL) Resistance. This TAR documents a treatment order for the Coccyx with a start date of 7/19/24 to cleanse the area with normal saline, apply skin protectant to the periwound, apply collagen dressing to wound bed and cover with a bordered gauze daily. This treatment is not signed out as completed on 7/19/24, 7/21/24, 7/27/24 and 7/28/24. R3's TAR dated 8/1/24 through 8/31/24 documents an order dated 7/24/24 for the Right Heel to cleanse with normal saline, pat dry, apply Betadine to the wound bed and leave open to air daily and as needed. This treatment is not signed off as completed on 8/1/24, 8/2/24 and 8/3/24. This TAR documents an order dated 7/30/24 for the Sacrum to cleanse with normal saline, apply skin protectant to the periwound, apply a collagen dressing to the wound bed and cover with a bordered gauze daily. This treatment is not signed off as completed on 8/2/24 and 8/3/24. This TAR documents an order to float R1's heel every shift. On 8/5/23 at 11:43 AM R3 was laying in bed with his feet directly on the bed. R3 did not have any heel protectors on or any device to float his heels. On 8/6/24 at 9:23 AM, R3 is in bed laying on his right side and he did not have any heel protectors on and did not have any device in place to float his heels. R3's feet were laying directly on the bed. On 8/5/24 at 1:40 PM, V6 Registered Nurse stated that R3 should have heel protectors on his feet and did not know where they were. On 8/6/24 at 10:58 AM, V2 Director of Nursing stated that the nurses are supposed to sign off the treatments on the Treatment Administration Record when they are completed and confirmed there were days that were not signed off as completed for R1, R2 and R3.

Based on interview and record review the facility failed to prevent staff to resident mental abuse and failed to immediately suspend alleged perpetrators in order to prevent further staff to resident mental abuse. This failure affects three of four residents (R2, R3, R4) reviewed for abuse. This failure resulted in R2, R3, and R4 being subjected to mental abuse by two Certified Nurses Assistants (CNAs) (V9, V14) engaging in sexual behavior in residents' rooms. The Immediate Jeopardy began on 12/15/23 when V9 CNA and V14 CNA engaged in sexual groping in front of R4. V1 Administrator was notified of the Immediate Jeopardy on 1/09/24 at 2:20 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 1/10/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: 1. On 1/7/24 at 1:00 PM V11 Certified Nurse's Assistant (CNA) stated on 12/15/23 at approximately 9:20 AM V11 observed V14 CNA standing right behind V9 CNA, rubbing on V9's bottom when V9 was assisting R4 with a shower. V11 is unsure if R4 understood what was going on but V11 stated R4 could see both V9 and V14. V11 stated she did not report this to V1 Administrator. R4's Medical Diagnoses List dated January 2024 documents R4 is diagnosed with Intellectual Disabilities, Alzheimer's Disease, Psychosis, and Parkinson's Disease. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact however when interviewed R4 was not answering questions appropriately and appeared confused. R4's same MDS documents R4 requires maximum staff assistance for showering. R4's Care Plan dated 10/26/23 documents R4 is at risk for abuse/neglect do to vulnerable physical condition. 2. On 1/7/24 at 11:06 AM V4 Registered Nurse (RN) stated on 1/2/24, V5 CNA and V11 CNA called her to R3's room. R3 reported to V4 that two female CNAs had been kissing in his room and doing sexual things in front of him on three different occasions. V4 stated R3 appeared very upset and uncomfortable with the situation. V4 stated she immediately reported R3's allegations to V1 Administrator. V4 stated V1 told her the situation was being handled, she shouldn't believe rumors and asked V4 to talk to R3 and encourage him to not discuss it further with anyone. V4 stated she was never interviewed and never asked to make a statement regarding R3's allegations. On 1/9/24 at 11:30 AM R3 stated two girl Certified Nurses Assistants (CNAs) (V9, V14) came into his room to care for him. Three times last week, they kissed each other in front of him. Twice they went into the bathroom. Once with the door closed. R3 stated he could not see but could hear what he described as loud sexual noises. R3 stated they went into the bathroom a second time with the door open and R3 could see the one of them push the other one against the wall and get down to her knees with her head in the others pelvis. R3 stated there was a lot of sexual noises and moaning. (R3 started tearing up) R3 stated he hates to talk about it. It makes him so uncomfortable. He does not want to see other people engaging in sexual/intimate things in front of him. R3 stated nobody wants to see that kind of stuff. R3 stated those things should be done in private. R3 stated he told some other staff (CNAs) (V5, V11) and his nurse (V4 Registered Nurse) and his daughter (V17). R3's Medical Diagnoses List dated January 2024 documents R3 is diagnosed with Pubis Fracture, Heart Failure, Cancer History, and Skin Infection. R3's Minimum Data Set, dated dated dated [DATE] documents R3 is cognitively intact. R3 has a history of a Stroke and requires staff assistance for toileting, transferring, bed mobility, and personal hygiene. R3's Care Plan dated 12/18/23 documents R3 is at risk for abuse/neglect do to vulnerable physical condition. 3. On 1/7/24 at 12:14 PM V12 CNA stated on 1/4/24 she witnessed V9 CNA and V14 CNA making out in R2's personal bathroom while R2 sat on the edge of his bed. The bathroom door was open and R2 was approximately ten feet away. V12 stated she immediately reported this to V1 Administrator. V12 stated she made V1 Administrator aware that V9 and V14 were scheduled together again the following day (1/5/24). V12 stated she was never asked for a statement or interview regarding an investigation. V12 stated both V9 and V14 did work together again the next day - 1/5/24. R2's Medical Diagnoses List dated January 2024 documents R2 is diagnosed with Alzheimer's Disease, Mood Disorder, Post-Traumatic Stress Disorder, and Anxiety. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired. R2's same MDS documents R2 requires staff assistance for toileting, transferring, bed mobility, and personal hygiene. R2's Care Plan dated 12/8/23 documents R2 is at risk for abuse/neglect do to vulnerable physical and mental condition. On 1/7/24 at 2:40 PM V1 Administrator confirmed the 12/15/23 allegation was never reported to her. V1 Administrator confirmed both the 1/2/24 and 1/4/24 allegations were reported to her however she did not identify potential abuse and did not complete an abuse investigation regarding either incident. V1 confirmed both V9 CNA and V14 CNA were not suspended until the afternoon of 1/7/24 after the state survey agency investigation already began. V1 confirmed sexual interactions between staff members while at work was inappropriate and not acceptable. On 1/7/24 at 5:15 PM V2 Director of Nurses confirmed both alleged perpetrators (V9 and V14) were allowed to continue to work after allegations were reported and worked shifts on 1/2/24, 1/3/24, 1/4/24, 1/5/24, and 1/7/24. V9 CNA was working on 1/7/24 when this survey began. V2 Director of Nurses confirmed both V9 and V14 had access to all residents in the facility when they worked. On 1/10/24 at 2:39 PM V3 Regional Consultant confirmed sexual interactions between staff are not appropriate while in the facility and if done in front of a resident, the action could be considered mental abuse. V3 confirmed the expectation is for staff, including V1 Administrator, to follow the facility abuse policy by thoroughly investigating all allegations of potential abuse, suspending alleged perpetrators, and reporting alleged abuse to required entities in the correct timeframe. On 1/5/24 both V9 CNA and V14 CNA were given Written Corrective Action for the incident on 1/4/24. Corrective Action form documents this was their second warning of inappropriate behavior, sexual in nature, in the workplace. A verbal and written warning were given for prior inappropriate sexual behavior in the workplace for an incident that occurred on 12/18/23 where V9 and V14 were observed kissing in a residents (R1's) bathroom. R1 was not present at the time. These details were confirmed by V1 Administrator on 1/10/24 at 2:09 PM. The facility's Abuse Policy date 9/15/23 documents the purpose of the policy is to provide guidance and procedures to the facility and staff to assure residents remain free from abuse. The policy documents the facility is to designate an Abuse Coordinator and all staff are responsible to report any allegation or witnessed abuse immediately to the Abuse Coordinator (Administrator). The facility is to do everything within it's control to prevent occurrences of abuse. Part of this process is to establish an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse; implementing systems to promptly and aggressively investigate all reports and allegations of abuse and mistreatment and make necessary changes to prevent future occurrences; as well as filing accurate and timely investigative reports. The policy documents any staff member or person suspected of abuse will be escorted by staff out of the facility and will not be permitted back in the facility until the investigation has completed. The facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities, including the State Surveying Agency, Ombudsman, Resident's Power of Attorney, and Physician. The facility will immediately and thoroughly investigate all allegations of abuse to include but not limited to interviews with residents, staff, visitors, and vendors. The policy defines Abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is a willful act that causes physical harm, pain, or mental anguish. The term willful in the definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. The Immediate Jeopardy that began on 12/15/23 was removed on 1/10/24 when the facility took the following actions to remove the immediacy: 1. On 1/7/24 V1 Administrator initiated abuse investigation concerning V9 CNA and V14's CNA sexually inappropriate behavior and V9 and V14 were suspended from further work until investigation 2. On 1/7/24 all facility staff were in-serviced by V1 Administrator and V3 Regional Consultant regarding the facility Abuse Policy and immediately reporting suspected abuse. 3. On 1/8/24 R3 was discharged from the facility due to physical decline. 4. On 1/9/24 R2 and R4 were assessed by V13 Social Service Director and had no psychosocial needs noted. 5. On 1/9/24 V20 [NAME] President of Quality Assurance reviewed and updated the facility Abuse Policy to ensure that staff to resident mental abuse is clearly defined with guidance for staff to identify abuse and initiate investigations. 6. On 1/9/24 V3 Regional Consultant was in-serviced regarding the updated Abuse Policy by V20 [NAME] President of Quality Assurance. 7. On 1/9/24 V1 Administrator and V2 Director of Nurses were in-serviced regarding the updated Abuse Policy and how to report allegations and conduct investigations by V3 Regional Consultant. 8. On 1/10/24 V9 and V14 were terminated. 9. Moving forward, V1 Administrator will be monitoring 24/72-Hour Report during morning clinical meeting for any documentation that reflects possible abuse allegations. 10. V3 Regional Consultant will review all abuse allegations weekly for eight weeks to ensure thorough investigations are completed and include interviews with residents and staff. The facility presented an abatement plan to remove the immediacy on 1/9/24. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 1/10/24, and the survey team accepted the abatement plan on 1/10/24.

Based on observation, interview, and record review, the facility failed to prevent the potential for fire and burn hazards by installing portable space heaters in resident rooms throughout the facility and intentionally labeling working emergency exit doors with signs declaring the doors do not open, are out of order, and should not be used to discourage or prevent use by exit-seeking residents. These failures affect all 74 residents residing in the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/28/2023 when facility staff first placed portable space heaters in resident rooms throughout the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 12/29/2023 at 3:43PM. The surveyor confirmed by observation and interview that the Immediate Jeopardy was removed on 12/29/2023 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: 1. On 12/28/2023 portable electric space heaters were observed throughout the facility in the following resident rooms: -at 11:55AM, an operating space heater was located in R74's room and the front radiating surface of the heater was positioned approximately four inches away from R74's wooden dresser at the perimeter of R74's room. -at 11:56AM, an operating space heater was located in R73's room and the front radiating surface of the heater was positioned approximately three inches away from R73's adjacent privacy curtain at the perimeter of R73's room. -at 11:56AM, an operating space heater was located in R71 and R72's shared room. -at 11:56AM, an operating space heater was located in R69 and R70's shared room. -at 11:58AM, an operating space heater was located in R67 and R68's shared room. The front radiating surface of the heater was located approximately two inches away from R67's wooden dresser. -at 11:58AM, an operating space heater was located in R62's room. -at 11:45AM, an operating space heater was located in R15's room with the heating elements of the heater glowing orange in color. The front radiating surface of the heater measured 370 degrees Fahrenheit by the State Agency thermometer. -at 1:45PM, an operating space heater was located in R1's room. - at 1:52PM, an operating space heater was located in R4's room. R4 reported the heater had been in place for two months. -at 2:25PM, an operating space heater was located in R5's room. -at 2:26PM, an operating space heater was located in R8's room facing R8's bed and immediately in the pathway where R8's privacy curtain would be positioned when closed. The heating elements of the heater were glowing orange in coloration. Wheels were attached to the bottom of the heater which was easily movable when lightly touched. R8 was present in bed and reported facility staff keep pushing R8's privacy curtains back away from the heater (to prevent the potential for accidental fire.) R8 reported some staff automatically reposition the curtains when they are in R8's room, but R8 has to request other staff to reposition the curtains to avoid contact with the heater. A warning label was attached to the space heater stating: WARNING Risk of Fire - Keep Combustible material such as furniture, papers, clothes, and curtains as least 3 feet (0.9M) away from the front of the heater and away from the sides and rear. -at 3:44PM, the front radiating surface of R8's space heater measured 440 degrees Fahrenheit by the State Agency thermometer. -at 2:28PM, an operating space heater was located in R9's room and positioned approximately eight inches away from R9's bed. -at 2:32PM a space heater (turned off) was located in R10 and R11's shared room. -at 2:34PM, an operating space heater was located in R12's room. -at 2:40PM, an operating space heater was located in R62's room. -at 2:52PM, a space heater (turned off) was located in R63 and R64's shared room. -at 2:54PM, an operating space heater was located in R67 and R68's shared room. -at 2:54PM, an operating space heater was located in R69 and R70's shared room. -at 2:55PM, an operating space heater was located in R71 and R72's shared room. -at 2:55PM, an operating space heater was located in R73's room and the front radiating surface of the heater measured 227 degrees Fahrenheit by the State Agency thermometer. -at 2:55PM, an operating space heater was located in R74's room. -at 3:51PM, an operating space heater was located in R59 and R60's shared room towards the perimeter of their room. Both R59 and R60 were resting in bed. The heating elements of the heater were glowing orange in coloration and the front radiating surface of the heater measured 380 degrees Fahrenheit by the State Agency thermometer. A winter coat was resting on the ground approximately four inches away from the front radiating surface of the heater. An upholstered chair was located approximately six inches away from the front of the heater on the opposite side from the coat. A warning label was attached to the space heater stating WARNING - TO REDUCE THE RISK OF FIRE, KEEP COMBUSTIBLE MATERIAL SUCH AS FURNITURE, PAPERS, CLOTHES, AND CURTAINS AT LEAST 3 FEET (0.9M) FROM THE FRONT OF THE HEATER AND AWAY FROM THE SIDES AND REAR. On 12/28/2023 at 2:44PM, V9 (Licensed Practical Nurse) reported the facility's main heating system had failed and the facility has used alternate main heat sources ducted into hallways for over a month and residents have also received space heaters by request for additional resident room heat. V9 reported the space heaters the facility supplied to the residents are supposed to be positioned in the middle of their rooms and not towards the perimeter of their rooms or against any potentially combustible items. On 12/29/2023 at 11:09AM, V5 (Registered Nurse) reported the winter coat placed beside the space heater in R59 and R60's room on 12/28/2023 was definitely a fire hazard. On 12/29/2023 at 12:31PM, V6 (Maintenance Director) reported the facility's heating system was not functional at the beginning of [NAME] so the facility has used outdoor heat exchangers ducted into the hallways for a temporary heat supply while individual resident heaters are permanently installed in each resident room. V6 reported the facility placed space heaters in resident rooms at the same time the heat exchangers were installed, and both have been in place for about one and a half months. V6 reported all space heaters in the facility are facility supplied and not resident property and reported instructing staff to keep the space heaters away from combustible items in resident rooms. V6 was asked about the winter coat located immediately adjacent to R59 and R60's operating space heater on 12/28/2023 and V6 stated I believe it's (the resident coat near the glowing hot front surface of the space heater) an issue. V6 was asked if V6 thought the resident space heaters were a burn hazard and V6 replied I do. V6 was asked if V6 thought the space heaters in resident rooms were a fire hazard and V6 stated they (the heaters) are always a concern with anybody. 2. On 12/28/2024 at 11:44AM, an 8.5x11 horizontal sign stating, Door does not open!!! out of order!! was taped to the dementia unit East hallway emergency exit door. A second yellow-colored octagonal sign approximately six inches in size was attached to the door and stated, STOP TURN AROUND. A third octagonal sign was also present on the door stating STOP. On 12/28/2023 at 11:47AM, an 8.5x11 horizontal sign stating Door does not open!! Out Of Order!! was taped to the dementia unit [NAME] hallway emergency exit door. A second red-colored octagonal sign stating STOP TURN AROUND was also taped to the door. On 12/28/2023 at 11:49AM, V3 (Licensed Practical Nurse) reported the emergency exit doors on the dementia unit do work properly and are not out of order but the facility placed the signs to discourage exit seeking residents from exiting through the doorways. The above East and [NAME] hallway emergency exit doors are the only doorways providing emergency egress on the dementia unit. On 12/28/2023 at 11:58AM, a red-colored octagonal sign stating Stop was attached above the door handle on the North hallway emergency exit door at the East end of the hallway. This doorway is the only emergency exit located on the East end of the North hallway. On 1/5/2024 at 3:02AM, V8 (Regional Nurse Consultant) reported the facility began placing space heaters in resident rooms on November 28, 2023. On 1/5/2024 at 3:17PM, V14 (Business Development) reported the above dementia unit door signs have been in place for a couple weeks. The facility Midnight Census Report (12/29/2023) documents R1, R5, R11, R13, R15, R16, R17, R19, R21, R23, R25, R26, R27, R51, R53, R55, R58, R59, R60, R61, R63, R64, R65, R66, R67, R68, R69, R70, R72, R73, and R74 are cognitively impaired. The same record documents R11, R12, R14, R15, R16, R20, R23, R62, R63, R64, R65, R67, R68, and R74 are dependent on staff for mobility. The Immediate Jeopardy that began on November 28, 2023, was removed on 12/29/2023 when the facility took the following actions to remove the immediacy: 1. On 12/28/2023 all space heaters were removed from resident areas by the facility Interdisciplinary Team. 2. On 12/29/2023 V1 (Administrator), V8 (Regional Nurse Consultant), and V14 (Business Development) removed all Stop and Out of Order signage from the three designated fire exit doors. 3. On 12/29/2023 V6 (Maintenance Director), V1 (Administrator), and V8 (Regional Nurse Consultant) evaluated the alternate sources of heat and adjusted/moved the sources to ensure maximum heat coverage. 4. On 12/28/2023 hourly room temperature checks were initiated on North/South halls by nursing staff and the leadership team - Maintenance Director, Director of Business Development, Housekeeping supervisor, and Administrator. 5. The facility staff (Maintenance Director and Regional Maintenance team) are currently installing PTAC's (Type of Heater). 6. On 12/28/2023 V8 (Regional Nurse Consultant) in-serviced V6 (Maintenance Director) and V1 (Administrator) on not utilizing space heaters in resident areas. 7. On 12/28/2023 and 12/29/2023, V8 (Regional Nurse Consultant) in-serviced facility staff on not utilizing space heaters in resident rooms and not posting stop signage at fire exit doors. 8. Facility Maintenance Director/Administrator or designee will monitor facility for no space heater use in resident areas daily x 8 weeks or until permanent heat source is completed. 9. Department managers will monitor exit doors daily x 8 weeks to ensure no stop signage is posted on fire exit doors. 10. The results of #7 and #8 audits will be discussed in the monthly Quality Assurance Committee Meeting with any trends tracked and recommendations made as needed. The facility presented an abatement plan to remove the immediacy on 12/29/2024 at 4:44 PM. The survey team reviewed the abatement plan and were unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 1/2/2024 at 11:00AM. The facility presented a revised abatement plan on 1/2/2024 at 11:58AM, and the survey team accepted the revised abatement plan on 1/2/2024 at 1:28PM.

Based on observation, interview, and record review the facility failed to follow resident care plan fall interventions for three (R10, R48, R59) residents. The facility also failed to provide safe feeding assistance for one (R23) resident on swallowing precautions while eating and facility failed to securely store a pressurized Oxygen tank for one resident (R6). These failures affect five residents (R6, R10, R23, R48, R59) out of eight residents reviewed for Accidents. These failures resulted in R10 sustaining a Right front of scalp Hematoma and R59 sustaining Right sided 10th, 11th Rib Fractures and a Hematoma. Findings include: 1.) On 6/13/23 at 2:15 PM R59 observed sitting in a wheelchair next to the nurse's station. On 6/15/23 at 3:00 PM V22 observed Certified Nurse Aide (CNA) assist R59 in wheelchair from end of hallway to nurse's station. On 6/15/23 at 11:55 AM V26 Physical Therapy Assistant (PTA) stated I will remember that day forever. I felt so bad that I caused that fall. (R59) was in a therapy session with me in the therapy gym. The therapy gym was full of people that day. I was assisting (R59) with walking. (R59) was using his walker heading towards the end of the line to meet his goal. I forgot to put (R59's) wheelchair at the end of the line so when we (V26, R59) got down there, I had to reach around to pull his wheelchair so that it was positioned in front of him. When I was getting the wheelchair, (R59's) pants were too loose so he took his hand off of the walker to hold up his pants. That is when (R59) lost balance and fell . (R59) ricocheted off of the padded table onto the floor. (R59) hit his Right torso on the padded table and then landed on his Left side on the floor. That is how (R59) hit his head and got the big goose egg and Hematoma. I caused that poor man to fall. If I would have had my eyes on him, if I would have thought ahead to position (R59's) wheelchair ahead of time or if I hadn't taken my hands off of him, he would not have fallen. After (R59) fell , V18 Certified Occupational Therapy Assistant (COTA) got him up with a gait belt. (R59) did complain of a backache. I bet (R59's) back did hurt as hard as he fell . We (V18, V26) were educated afterwards on how to prevent that fall and to always use a total body mechanical lift to reposition someone after a fall. On 6/16/23 at 11:30 AM V30 Nurse Practitioner stated R59's fall could have been prevented if (V26) PTA would have not let go of (R59) or if (V26) would have got the wheelchair in position prior to having him walk away from it. V30 stated This facility absolutely caused harm to (R59) by causing the Right 10th and 11th rib fractures. This could affect (R59's) ability to take deep breaths which could cause him to get Pneumonia. (R59's) mobility has also decreased because of the fall due to (R59) is using his wheelchair more now than when he did prior to falling. This facility has a lot of falls and they (facility) need to get a handle on them. R59's undated Face Sheet documents R59's medical diagnoses as Cerebral Infarction, Aspers Disease, Spinal Stenosis, Abnormality of Gait and Mobility, Left Ear Sensorineural Hearing Loss with restricted hearing on the Right side, Dizziness, Dementia and Cognitive Communication Deficit. R59's Minimum Data Set (MDS) dated [DATE] documents R59 as severely cognitively impaired. This same MDS documents R59 requires extensive assistance of two people for transfers and extensive assistance of one person for walking in room and corridor, locomotion on and off unit. R59's Fall Risk assessment dated [DATE] documents R59 as a high fall risk. R59's Nurse Progress Note dated 4/19/23 at 11:15 AM documents Went to therapy and seen (R59) laying on left side of body. (V26) Physical Therapy Assistant (PTA) said (R59) was walking with walker and (V26) was locking wheelchair brakes and (R59) took hand off walker to fix his shorts and lost balance backwards and hit left side of head. Small Hematoma noted to left side of forehead. No other bruising noted at this time. (R59) did complain of headache. R59's Physician Order Sheet (POS) dated June 1-30, 2023, documents a physician order dated 4/20/23 of Immediate (STAT) unilateral Right Hip with pelvis X-Ray due to signs and symptoms of pain, and swelling after recent fall portable due to limited mobility R59's X- Ray of Right Chest report dated 4/19/23 documents Fractures of the anterior Right 10th and 11th ribs are noted. 2.) On 6/14/23 at 2:15 PM R10 observed sitting in wheelchair with traditional socks on. (R10) was observed without non-skid socks in place. On 6/15/23 at 1:45 PM V1 Administrator stated We (facility) did not report (R10's) fall on 5/26/23 which resulted in a major injury to the state agency. V1 Administrator confirmed R10 was supposed to be wearing non-skid socks per previous care plan intervention and was not wearing non-skid socks at time of fall. V1 Administrator stated R10 may not have fallen if R10 was wearing the non-skid socks. On 6/16/23 at 11:30 AM V30 Nurse Practitioner stated (R10's) fall could have been prevented if staff would have put on her nonskid socks. The facility caused a major injury of a Hematoma to (R10) by not following basic fall interventions. This facility has a lot of falls and they (facility) need to get a handle on them. R10's undated Face Sheet documents medical diagnoses of Dementia, Legal Blindness and Dysphagia following Cerebral Infarction. R10's Minimum Data Set (MDS) dated [DATE] documents R10 as severely cognitively impaired. This same MDS documents R10 as requiring extensive assistance of two people for transfers, bed mobility and toileting. R10's Fall Risk assessment dated [DATE] documents R10 as a high fall risk. R10's Fall investigation dated 5/26/23 documents R10 had an unwitnessed fall on 5/26/23 at 7:33 AM. This same report documents R10 has decreased safety awareness, impaired memory and gait imbalance. This same report documents (R10) was found face forward on the floor in front of (R10's) wheelchair. Injury type: Right hand bruise, face bruise, top of scalp laceration, Right Knee bruise and top of scalp Hematoma. R10's Hospital Record dated 5/26/23 documents diagnoses as Closed Injury of Head and Accident due to Fall. R10's Computerized Tomography (CT) of Head and Cervical Spine without Contrast dated 5/26/23 documents Acute pathology is a large Right Frontal Scalp Hematoma. R10's Nurse Progress Note dated 6/13/23 at 3:08 PM documents (R10) had un-witnessed fall this AM at the nurse's station. (R10) was face forward on the floor in front of her wheelchair. Large Hematoma noted to center of (R10's) forehead with small laceration. (R10) complained of pain in her head. (R10) sent to emergency room . R10's Nurse Progress Notes dated 5/26/23 at 11:18 AM documents (R10) returned from emergency room (ER). Computerized Tomography (CT) scan results state large right frontal scalp Hematoma. (R10) has 1 cm laceration on Hematoma. R10's Fall Care Plan Intervention dated 3/10/23 instructs staff to apply nonskid socks while in the wheelchair. This same care plan documents a fall intervention for staff to anticipate needs. 31642 3.) On 06/13/23 between 12:05 PM - 12:45 PM, during continuous observation, R23 sat in a high back wheelchair, in the Dementia Unit full dining room. R23 was eating a pureed meal without assistance or verbal cues. V9, Certified Nursing Assistant (CNA) and V23, CNAs were feeding other residents (unidentified) at back table. R23's sat with R23's back towards V9, CNA and V23, CNA. R23's table was approximately 25 feet away from where V9, CNA and V23 CNA were seated. V9, CNA and V23 did not provide R23 physical or verbal assistance with dining. On 6/15/23 at 11:55 AM, R23 sat in a high back wheelchair, in the dementia unit full dining room. R23 was eating a pureed meal without assistance or verbal cues. V9, CNA and V22, CNA were feeding residents (unidentified) at the back table, approximately 25 feet away from R23's table. On 6/15/23 at 12:17 PM, R23 continued to attempt to eat on R23's own, without physical or verbal assistance. R23 consumed a half portion of pureed broccoli that set on the plate closest to the resident. R23 had not eaten the pureed chicken fried steak, or mashed potatoes on the far side of R23's plate. R23 had not eaten the pureed pie, in a bowl on the opposite side of resident plate. V9, CNA and V22, CNA did not offer physical or verbal assistance with dining. On 6/15/23 at 12:25, V22, CNA removed R23's food tray from R23's table to place on the food cart. V22, CNA confirmed R23 had not eaten anything but R23's pureed broccoli. V22, CNA stated We never help (R23). (R23) eats on his own. (R23) didn't eat much today, sometimes (R23) doesn't. I don't know what it says on his care plan, I did not know we needed to help him. On 6/15/23 at 12:40 PM, V21, Speech Therapist reviewed R23's Speech Therapy notes. V21, Speech Therapist stated (R23) has Dysphagia (swallow disorder). In March 2023, I (V21, Speech Therapist) clarified his (R23's) order (physician order) and completed a bed-side swallow (evaluation). The swallow study documents, sips, lidded cup and to alternate food. I think staff need to provide (R23) assistance. (R23) requires rate modification, which indicates feeding assistance which should be slow, in bolus, which means small amounts, and alternate liquids and solids. R23's Speech Therapy SLP Evaluation and Plan of Treatment dated 3/24/23 - 4/06/23 confirms V21, Speech Therapist interview and also documents the following: Supervision, how often does patient require supervision/assistance at mealtime d/t (due to) swallow safety? = (equals) 91-100% (percent) of the time. R23's Physician Order Summary Sheet (POS), dated 6/15/23 documents the following: Unspecified Dementia with Unspecified Severity, Parkinson's Disease and Dysphagia Oropharyngeal Phase and Unspecified Protein Calorie Malnutrition. The same POS documents the following diet order: Regular diet Pureed, Thin/Regular. R23's Minimum Data Set (MDS) dated [DATE] documents the following: R23's Brief Interview of Mental Status score of four, out of a possible 15, indicates severe cognitive impairment. The same MDS documents R23 requires extensive physical staff assistance with eating. The same MDS document: Swallowing Disorder: C. Coughing or choking during meals or when swallowing medications is checked marked, yes. 34058 4. On 6/13/23 at 10:05 AM, there was an unsecured/unrestrained/ free-standing E-type (680 liter, 24.96 cubic feet, capacity of compressed oxygen) metal oxygen cylinder in the corner of R6's room in the direct path of the bathroom door swing area. On 6/13/23 at 10:06 AM, V8, Licensed Practical Nurse, stated, Our oxygen tanks are supposed to be stored in our enclosed room. V8 then stated, Oh you have got to be kidding me right now, those tanks are not supposed to be sitting around standing on the floor. On 6/13/23 at 11:40 AM, V3, Regional Clinical Nurse, provided the facility's oxygen policy and stated, I had to contact the oxygen supplier company to make sure you have the most current up to date policy. The facility's policy Storage (undated) documents, The following oxygen cylinder storage requirements are relative to the National Fire Protection Association Standards 99 Health Care Facilities. The Joint Commission has adopted these requirements and will measure for them during surveys. Cylinders must be secured in racks or by chains. This statement is repeated twice in this policy, once for oxygen storage in any room or alcove, and again for larger quantities of oxygen stored in special designated rooms. 5. On 6/14/23 at 3:39 PM, R48 was seated in a recliner in R48's own room. There was not a reacher/ grabber instrument in R48's room to assist R48 with hard-to-reach items. There was not a sign in R48's room to remind R48 to call for assistance with toileting. There was not a card on R48's walker seat to remind R48 to lock the walker wheels. On 6/14/23 at 3:44 PM, V16, Licensed Practical Nurse, searched throughout R48's room, drawers, and closet, then stated, I am not seeing a grabber and I don't think I have ever seen (R48) use one. There is no reminder sign on the wall, and there is no sign on (R48's) walker except one under the seat with (R48's) name and room number but no reminder. R48's Care Plan focus area At risk for falls and injuries r/t (related to) Medications: Narcotics, Medical Factors: dementia, dated 9/4/22 documents nursing interventions including, 11/22/22-resident will be given grabber to assist with hard to reach items, 3/6/23-Place sign in room to remind resident to call for assistance with toileting, and 5/2/23-Card placed on walker seat to remind resident to lock his walker wheels. R48's Nursing Notes document R48 had experienced 8 falls, one each on 11/21/22, 12/26/22, 12/28/22, 3/6/23, 5/2/23, 5/23/23, 6/2/23, and 6/12/23. These same nurses' notes document on 11/21/22 R48 slid off the bed while picking something up from the floor. On 12/26/22 R48 fell while standing up from a seated walker with the walker brake unlocked. On 12/28/22 R48 unwitnessed fall and was found on the floor in R48's own room. On 3/6/23 R48 fell by slipping in R48's own urine in R48's own room. On 5/2/23 R48 was found on the floor of R48's own room in front of the walker while the walker brake was unlocked. On 5/23/23 R48 fell in front of staff while ambulating back from a supervised smoking period. On 6/2/23 R48 fell outside the facility while exiting an activity door. On 6/12/23 R48 unwitnessed fall in R48's own room.

Based on record review and interview, the facility failed to provide supervision while toileting a resident. This failure resulted in R2 falling and sustaining a Cervical Fracture and a Vertebral Artery Dissection. R2 is one of six residents reviewed for falls in the sample of 16. Findings include: The Physician order [REDACTED]. R2's Minimum Data Set ((MDS) dated [DATE] documents R2 as moderately cognitively impaired. This same MDS documents that R2 is an extensive assist with staff providing weight bearing support for transfers and toileting. The facility report titled Incident Log dated August 2015 through July 12, 2016, documents that R2 has had the following falls: 1/26/16 - fell while self transferring, 3/26/16 - trying to step on a bug when in the wheelchair, 4/10/16 - self transferring to go to the toilet and 5/7/16 - resident sitting on toilet and decided to self-transfer and fell and hit head. The Incident Report Investigation dated 5/7/16 at 12:10 am documents the following: Resident was on bathroom stool and decided to transfer (self) to wheelchair .(R2) stated 'I stood up and my legs got weak and I fell hitting my head.' The following documented statement from the Certified Nursing Assistant, E14 is part of the 5/7/16 fall investigation: I got resident ready for bed and was toileting (R2). (R2) was sitting on the toilet when I heard a PCA (Personal Clip Alarm) going off from another resident's room. I told (R2) not to get up, that I would be right back. After answering the alarm, I returned to (R2's) room where I found (R2) on the floor in front of the toilet. Being the only one on the floor, I ran to the desk, called to South Hall for the nurse to come over. I then returned to (R2) and the nurse came. E15, Registered Nurse documents that R2 was found on the floor in a supine position (on back) and R2 complains of upper neck pain. E15 assessed R2 and left R2 on the floor in back-lying position. E15 documents that R2 was sent to the ER (emergency room ) for evaluation by ambulance. The hospital report dated 5/7/16 documents that R2 arrived in the emergency room at 1:10 am and a Computerized Topography (CT) was performed. The following documented results are as follows: The Cervical Spine demonstrates a non-displaced fracture involving the right (first cervical) C1 arch does extend into the foramen .transfer ordered to (larger trauma hospital). The trauma hospital does not provide a written report or a copy of R2's CT for review. However, the discharge instructions dated 5/7/16 confirms the [DIAGNOSES REDACTED]. On 7/13/16 at 12:15 pm E2, Director of Nursing stated (R2 should not have been left on the toilet (alone). E2 also acknowledged there was only one Certified Nursing Assistant on R2's hall at the time of R2's fall. On 7/13/16 at 2:10 pm Z1, Primary Care Physician of R2, stated that the fall in the bathroom at the facility caused R2's C1 fracture and Vertebral Artery Dissection. Z1 stated (R2) should never have been left unsupervised on the toilet (R2) has had previous falls from trying to self-transfer.

Based on record review, observation and interview the facility failed to fix a faulty automated hinged mechanism on a central bath door. This failure resulted in R1 sustaining a severed finger tip. R1 is one of three residents reviewed for incidents and accidents on the sample of six. Findings include: R1's, Physician order [REDACTED]. The same POS documents (Acetaminophen) 300 milligrams (mg) / Codeine 30 mg (narcotic analgesic), two tablets by mouth, every 6 hours as needed for pain and Augementin (antibiotic) 875 mg, 1 tablet, by mouth every 12 hours. R1's Minimum (MDS) data set [DATE], documents moderate cognitive impairment and physical assistance of one staff member for all activities of daily living. The facility Incident / Accident Report dated 8/31/15, 12:25 pm, documents the following: CNA (Certified Nursing Assistant) was assisting resident (R1) out of the central bath when (R1)'s pinky finger got stuck in the door and cut finger tip off .Central bath door shutting too fast. The same report documents finger tip came off in the door .Right, fifth digit distal tip severed .finger tip placed on ice. R1's, (Local Hospital) emergency room Report dated August 31, 2015 documents the following: Tip of right fifth digit (small finger) amputated behind nail distal to the dip joint. An attached radiology X-ray report documents There is a displaced fracture, distal metaphysis (wide portion of the long bone) of the distal phalanx (finger) . Resident referred to Z3, Hand Surgeon. Z3's, Surgical Assessment Report dated 9/1/15 at 10:02 am, documents the following: Nail bed ablation and revision amputation with direct closure. On 9/30/15 at 1:12 pm, E6 (CNA) assisted R1 to the bathroom. After care, R1 washed her hands at the sink. R1's right, pinky finger amputation/surgical site was open to air. There were five dissolvable sutures exposed through a dark scab. On 10/02/15 at 12:15 pm. Z6, Z3's Hand Specialist / Medical Assistant stated, This injury was obviously a significant impact. We see a lot of hand traumas, I would not think the door could cause this extensive of an injury. On 10/2/15 at 1:50 pm, Z7, Physician, stated, (R1's finger injury) would have been a very hard impact to completely sever (R1's) finger. A wood door would have had to close completely to have caused this damage. On 9/30/15 at 12:00 pm, E6 (CNA) stated, I took (R1) to the bathroom that day (8/31/15). (R1)'s fingers were in the hinged part of the door when the door slammed. The door slammed previous to that for the last six months. On 9/30/15 at 1:50 pm, E9 (CNA) stated, The central bath door slammed shut like that for six months to a year. On 9/30/15 at 3:00 pm, E8 (CNA) stated, I know that door slammed a lot for the past six to eight months. On 10/02/15 at 10:05 am, E4, Maintenance Director, stated, I did not know about the central bath door prior to the incident (8/31/15). That door should have been taken out of service. There is no documentation on the maintenance log back to January (2015). On 10/02/15 at 12:25 pm, E3, Alzheimer Unit Manager stated I was aware that the central bath door shut too fast. All staff including myself are responsible to enter a maintenance issue on the log. I did not do that and am not aware of any staff that specifically logged the door shutting too quickly. The facility undated policy Maintenance Policy and Procedure documents the following: All Maintenance needs will be written on a clip board that is available at each nurses station. Maintenance Director or designee will check each list daily and document when the task has been completed. Maintenance logs are kept in a binder.

Based on interview and record review the facility failed to ensure that one of one residents (R27) reviewed for injuries in a sample of 16 was provided with the physician-ordered protective wraps to their lower extremities to protect them from injury during transfers. This resulted in an injury to the posterior lower right leg requiring 7 sutures. Findings include: R27's Incident/Accident Report of 11-14-12 at 1:00pm stated " (Certified Nurses Aides/CNA's) transferring (R27) from (wheelchair) to bed when CNA assisted (R27) (with) undressing noticed blood to posterior (right lower extremity). (R27) received 6 by 6 (centimeter) laceration (deep tissue)." R27's November 2012 Physician order [REDACTED]. an order for [REDACTED]." R27's Medication Administration Record indicates the treatment of [REDACTED]. On 7-26-13 at 11:00am E14, CNA stated that on 11-14-12 just after lunch both she and (E15, CNA) were transferring R27 back into bed from her wheelchair. E14 stated they had removed the foot pedals and the side rail on the bed. E14 stated "it was a perfect transfer, I was on the bottom half. When I took off her pants that's when we saw the blood, she didn't have the (flexible bandage) with the gauze wraps, it was just her pants. I just saw the gash in her leg. Her legs were just full of edema. They are usually wrapped. I don't know why they weren't on. It looked like she hit the frame of the bed." E14 then pointed to the place where the bed adjusts to raise the head up and stated this was the place where the blood was on the frame. The Hospital emergency room report for R27 on 11-14-12 at 2:02pm states "...an injury, a laceration, 6 cm (centimeters), clean, simple..affect the right of the calf...resulted from a direct blow...Skin closed with 7 3-0 sutures."

Based on interview and record review the facility failed to serve R11 a Gluten Free diet as prescribed by the Physician. R11 is one of six residents sampled for therapeutic diet out of a total sample of 17. Over a period of several months R11 has complained of severe abdominal pain, gas, and distention that continues to the present. Findings include: The June 2011 physician's orders [REDACTED]. The April 2011 Minimum Data Set (MDS) shows R11 has moderately impaired cognition and is able to feed herself. On 6/22/11 at 12:30 PM R11 ate her noon meal which included pureed ham and pureed cake. R11 ate over half of her ham and 75% of her cake. On 6/22/2011 at 9:48 AM the ham was pureed by E10, facility cook. At that time chicken broth was added for the purpose of pureeing the ham. At 2:00 PM on 6/22/2011 the ingredients of the chicken broth base (located on the side of the container) was reviewed and it was verified the chicken broth base contained gluten. In addition, the dietary manager E9 stated at the same time that R11 should not have received the cake for dessert. E9 stated the cake was made from a mix that contained gluten. A "Physician Notification" dated 3/8/2011 states, "... Res on [MEDICATION NAME] and still c/o (complaining of) indigestion and upset stomach- [MEDICATION NAME] given PRN after almost every meal..." E12, Licensed Practical Nurse (LPN) stated on 6/23/11 at 1:00 PM that R11, "...has a lot of complaints of pain involving her stomach..." A nurses note dated 4/6/2011 states, "...Resident's POA (Power of Attorney) stated resident has been c/o (complaining of) abdominal discomfort for 3 weeks. Stated she wanted Resident to have an 'x-ray or ultrasound' to see if anything is wrong...Writer asked CNA (Certified Nurses Assistant) if resident has been having bowel movements and she (CNA) stated 'yes, about three per day'..." A hospital "Radiology Report" dated 4/21/2011 states, "...Impression: Unremarkable ultrasound but there are some limitations due to bowel gas. Suggestion (might want to consider computerized tomography scan imaging as an option) ..." R11 stated on 6/23/2011 at 2:30 PM that she (R11) gets gas and abdominal cramps of an extent that "It hurts so bad I cry. I have shed a lot of tears over stomach pains. It will start in the front (of my stomach) and move around to the back - that is when it really hurts..." Z1, Physician stated on 6/23/2011 at 1:00 PM that, "...if I order a gluten free diet I expect her to get that diet. Gluten could cause this lady abdominal problems and increase the number of bowel movements she has..."