Every finding on record at The Haven of Ridgeview

Based on interview and record review the facility failed to provide food at a palatable temperature for 6 ( R9, R10, R11, R12, R14, and R15) of 6 residents reviewed for palatable food temperatures in a sample of 18. Findings include:1. R9's admission record documents an admission date of 07/16/26 with diagnoses including: type two diabetes mellitus, chronic kidney disease, and anxiety.On 08/03/26 at 1:12 PM, R9 who was alert and oriented, stated food has been cold before. R9 stated, she does remember the food being cold a weekend ago.2. R10's admission record documents an admission date of 11/20/25 with diagnoses including: encounter for orthopedic aftercare following surgical amputation, chronic obstructive pulmonary disease, and type two diabetes mellitus.On 08/03/26 at 2:40 PM, R10 who was alert and oriented, stated the food is usually cold.3. R11's admission record documents an admission date of 05/22/24 with diagnoses including: chronic kidney disease, depression, and osteoporosis.On 08/03/26 at 2:06 PM, R11 who was alert and oriented, stated the food is cold on and off but the food was cold a couple weekends ago on both Saturday and Sunday.4. R12's admission record documents an admission date of 07/10/25 with diagnoses including: acute respiratory failure, protein calorie malnutrition, and major depressive disorder.On 08/03/26 at 2:18 PM, R12 who was alert and oriented, stated the food is cold at times and weekends can be the worst.5. R14's admission record documents an admission date of 02/01/23 with diagnoses including: hemiplegia and hemiparesis following cerebral infarction, dysphagia, and epilepsy.On 08/05/26 at 1:36 PM, R14 who was alert and oriented, stated the food is cold sometimes.6. R15's admission record documents an admission date of 03/30/23 with diagnoses including: atrioventricular block, venous insufficiency, and chronic kidney disease.On 08/05/26 at 1:42 PM, R15 who was alert and oriented, stated there are times the food is cold. R15 stated, she remembers the food being cold on the weekend.Resident council minutes dated 06/09/26 documents: dietary: food a little cold before you get it.Resident council minutes dated 05/19/26 documents: dietary: food on the hall trays comes cold.On 08/05/26 at 2:45 PM V3 (Dietary Manager) stated, she started working at the facility on 07/22/26. V3 stated, she is aware of residents stating they are receiving their food cold and that is not her expectation.The policy titled, Hot Food Service Temperature dated 05/08/18 documents: foods will be served to the residents at a temperature that is palatable to prevent injury such as burned mouth or lips. 1. Food will be prepared in methods that maintain nutritional integrity and palatability.

Based on interview and record review the facility failed to report an injury of unknown origin timely to the State Survey Agency and local law enforcement for 1 (R1) of 3 residents reviewed for abuse in the sample of 18. Findings Include: R1's admission Record documented R1 was admitted to the facility on [DATE]. Diagnoses listed include west nile virus, depression, sleep apnea, unspecified disorder of cornea, unspecified cataract, Atherosclerotic heart disease, gastro-esophageal reflux disease, osteoarthritis, pain, chronic kidney disease, and dependence on renal dialysis. R1's MDS dated [DATE] documented a BIMS (Brief Interview for Mental Status) of 15, indicating R1 is cognitively intact.On 08/06/2026 at 1:46 P.M. V16 (Licensed Practical Nurse) stated on 07/20/20226 during morning meeting, staff were reviewing the notes from the weekend. It was discussed that R1 had told the night shift that she fell, but the nurse notes documented that R1 had not had a fall. V16 stated she was asked to follow up on this allegation of a fall. V16 stated R1 had gone to dialysis that day and had an appointment. V16 stated later in the day, a staff member came to her and told her to look at R1's foot. V16 stated she went into R1's room and asked R1 about her toes and what happened. R1 stated she thought she had fallen. V16 stated R1 had her pant leg pulled up past her knee and V16 examined R1's knee. V16 stated it was not swollen, red or felt hot to the touch. V16 stated the toes were bruised and swollen.On 08/07/2026 at 1:41 P.M. V2 (Director of Nursing) stated in the evening on 07/20/2026, the nurse from the facility called me and told me that R1 had a bruise when she returned from an appointment. V2 stated she came in on 07/21/2026 and looked at R1's foot. V2 stated she wondered if R1 had a wound infection, so she called the POA (Power of Attorney) and reported she was going to swab it. V2 stated that in the meantime the nurse had got an order for an x-ray. V2 stated she did not start an investigation into the injury until after she found out the toes were broken. V2 stated she was not the director of nursing at the time, but she did not know there was an injury to report at that time. V2 stated she thought she knew why the toes were discolored and didn't know it had to be reported to the state agency or law enforcement.On 8/6/26 at 2:40 PM, R1 agreed to let this surveyor look at her right foot. R1's right foot, 4th toe was discolored, brown dark color and was observed to be swollen. R1 stated she thinks she remembers that she fell. R1 stated she thought she had gotten up to go to the bathroom, R1 thinks she made it to the bathroom door but doesn't remember what happened after that. R1 stated she does not remember being on the floor, but thinks that staff pulled her by the legs out from under something but she is not sure what. R1 stated she does not remember hitting her head, landing on the floor, or hurting her toes. R1 stated the facility staff who worked that night told her she did not fall. R1 stated it seems sketchy that she can't remember what happened.R1's initial report sent to the State Survey Agency on 07/22/2026 documented: On 07/21/2026, R1 reported pain to the right foot, toes, and pain to the right knee. X-ray was ordered, resulting in fracture to the 4th and 5th toes. Investigation Initiated. Final report to follow.R1's Final report reported to the State Survey Agency on 07/22/2027, documented: R1 is a [AGE] year old female with a history of traumatic subdural hemorrhage with loss of consciousness, hemiplegia, and hemiparesis following cerebral infarction affecting right side, diabetes mellitus with neuropathy, end stage renal disease, polyneuropathy, cognitive communication deficit, difficulty in walking, and lack or coordination. R1 has a BIMS of 15, however displays fluctuation with cognition. R1's trazadone was increased to 75 mg on 07/07/2026 with increased confusion noted. Upon investigation with staff, nursing noted that when R1 was assisted out of her chair, her feet were completely wrapped in her blanket, at this time she lost her balance. Staff finished getting her ready for dialysis, leaving before 6 a.m. During this time there were no complaints of pain and no discolorations or bruising noted. R1's husband transported R1 to dialysis and to out of state doctors' appointment. Upon returning to the facility around 4 p.m. R1 complained of pain to right foot and bruising was noted. R1's doctor was notified of bruising, request for x-rays completed. X-rays resulted in broken 4th and 5th toes. R1's POA and physician were notified. Staff educated to make sure blankets are clear from resident's surroundings area before standing. Residents care plan updated.An undated facility policy titled Abuse Prevention Policy, documented: V. Internal Reporting Requirements and Identification of Allegations . The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities if an unknown origin as soon as it is discovered.If classified as an injury of unknown source . The Department of Public Health will be notified. Time frames for reporting and investigating abuse will be followed.

Based on interview and record review the facility failed to timely initiate and thoroughly investigate an investigation into an injury of unknown origin for 1 (R1) of 3 residents reviewed for abuse in the sample of 18. Findings Include: R1's admission Record documented R1 was admitted to the facility on [DATE]. Diagnoses listed include west nile virus, depression, sleep apnea, unspecified disorder of cornea, unspecified cataract, Atherosclerotic heart disease, gastro-esophageal reflux disease, osteoarthritis, pain, chronic kidney disease, and dependence on renal dialysis. R1's MDS dated [DATE] documented a BIMS (Brief Interview for Mental Status) of 15, indicating R1 is cognitively intact.On 08/05/2026 at 1:09 P.M. V11 (Family Member) stated on 07/20/2026 she and her father went to dialysis center to pick up R1 because she had an appointment after her treatment. V11 stated she had to assist R1 more than normal. V11 stated she asked R1 what happened and R1 replied she had fallen. V11 stated she started to ask R1 questions because she had not been notified that R1 had had a fall. V11 stated R1 was complaining of her right knee and toes hurting. V11 stated that R1 explained to her that she was drug by her feet. V11 stated that R1 refused to say anything more about it. V11 stated she was sidetracked by the other appointment and forgot to ask the facility what had happened. V11 stated the next day 07/21/2026, her sister came to the facility and saw R1. V11 stated her sister reported that R1's toes were swollen, black and leaking fluid. V11 stated V2 (Director of Nursing) called her, not sure what day, to let her know they were obtaining a culture of the fluid that was leaking from R1's toes. V11 stated a nurse called a couple days later to let her know the facility was getting x-rays of the knee and toes. V11 stated the next day the facility called to tell her R1's toes were broken and asked if it was ok to send her to a doctor to get the toes looked at. V11 stated she thought the dialysis center had faxed or called the facility on 07/20/2026 to notify them of the toes. V11 stated she was told R2 heard R1 yell, so she turned on the call light. V11 stated staff came in, and then left, coming back with more staff. V11 stated R2 did not see R1 on the floor, the curtain was pulled, she only heard R1 yelling. V11 stated she was told that the facility was investigating the incident, but she has not been made aware of what the outcome was. On 8/6/26 at 2:40 PM, R1 agreed to let this surveyor look at her right foot. R1's right foot, 4th toe was discolored, brown dark color and was observed to be swollen. R1 stated she thinks she remembers that she fell. R1 stated she thought she had gotten up to go to the bathroom, R1 thinks she made it to the bathroom door but doesn't remember what happened after that. R1 stated she does not remember being on the floor, but thinks that staff pulled her by the legs out from under something but she is not sure what. R1 stated she does not remember hitting her head, landing on the floor, or hurting her toes. R1 stated the facility staff who worked that night told her she did not fall. R1 stated it seems sketchy that she can't remember what happened. R1's physician progress notes dated 07/21/2026 documented bruising and swelling to R1's 4th and 5th toe.On 08/06/2026 at 1:46 P.M. V16 (Licensed Practical Nurse) stated on 07/20/20226 during morning meeting, staff were reviewing the notes from the weekend. It was discussed that R1 had told the night shift that she fell, but the nurse notes documented that R1 had not had a fall. V16 stated she was asked to follow up on this allegation of a fall. V16 stated R1 had gone to dialysis that day and had an appointment. V16 stated later in the day, a staff member came to her and told her to look at R1's foot. V16 stated she went into R1's room and asked R1 about her toes and what happened. R1 stated she thought she had fallen. V16 stated R1 had her pant leg pulled up past her knee and V16 examined R1's knee. V16 stated it was not swollen, red or felt hot to the touch. V16 stated the toes were bruised and swollen. V16 stated she notified V2 (Director of Nursing/DON) of R1's bruising.On 08/07/2026 at 1:41 P.M. V2 (Director of Nursing) stated in the evening on 07/20/2026, the nurse from the facility called me and told me that R1 had a bruise when she returned from an appointment. V2 stated she came in on 07/21/2026 and looked at R1's foot. V2 stated she wondered if R1 had a wound infection, so she called the POA (Power of Attorney) and reported she was going to swab it. V2 stated that in the meantime the nurse had got an order for an x-ray. V2 stated she did not start an investigation into the injury until after she found out the toes were broken. V2 stated she was not the director of nursing at the time, but she did not know there was an injury to report at that time. V2 stated she thought she knew why the toes were discolored and didn't know it had to be reported to the state agency or law enforcement.On 08/07/2026 at 2:07 P.M. V1 (Administrator) stated he started back at the facility on 07/23/2026. V1 stated the investigation was already started and he started assisting in it. V1 stated staff and family members were interviewed and the only thing they can come up with was R1's feet were tangled in the blanket causing the fracture to the toes.R1's Final report reported to the State Survey Agency on 07/22/2027, documented: R1 is a [AGE] year old female with a history of traumatic subdural hemorrhage with loss of consciousness, hemiplegia, and hemiparesis following cerebral infarction affecting right side, diabetes mellitus with neuropathy, end stage renal disease, polyneuropathy, cognitive communication deficit, difficulty in walking, and lack or coordination. R1 has a BIMS of 15, however displays fluctuation with cognition. R1's trazadone was increased to 75 mg on 07/07/2026 with increased confusion noted. Upon investigation with staff, nursing noted that when R1 was assisted out of her chair, her feet were completely wrapped in her blanket, at this time she lost her balance. Staff finished getting her ready for dialysis, leaving before 6 a.m. During this time there were no complaints of pain and no discolorations or bruising noted. R1's husband transported R1 to dialysis and to out of state doctors' appointment. Upon returning to the facility around 4 p.m. R1 complained of pain to right foot and bruising was noted. R1's doctor was notified of bruising, request for x-rays completed. X-rays resulted in broken 4th and 5th toes. R1's POA and physician were notified. Staff educated to make sure blankets are clear from resident's surroundings area before standing. Residents care plan updated.An undated facility policy titled Abuse Prevention Policy documented in part: V. Internal Reporting Requirements and Identification of Allegations. The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual. Following the discovery of any suspicious bruises, laceration or other abnormalities or an unknown origin, the nurse shall completes a full assessment of the resident for other bruises, laceration, or pain. V1. Internal Investigation . 3. For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather the facts to make a determination as to whether the injury should be classified as an injury of unknown source.

Based on interview and record review the facility failed to safely transfer 1 of 3 (R1) residents reviewed for accidents in a sample of 7. This failure resulted in R1 falling out of a whole-body lift machine onto the floor and sustaining a right hip fracture, a fracture of the distal right femur and a fracture of the right tibia.This past noncompliance occurred on 1/24/2026.Findings included:R1's admission Record documents R1 was admitted to this facility on 5/20/2025 with diagnoses of dependence on dialysis, end stage renal disease, morbid obesity and chronic obstructive pulmonary disease among others.R1's MDS (minimum data set) dated 11/15/25, documents R1 needs two staff assistance for all transferring activities and the staff utilize a full body lifting machine for lifting R1. R1's MDS documents R1 has a BIMS (Brief Interview for Mental Status) of a 15 indicating R1 has no cognitive impairment.R1's care plan documents a focus area of: R1 has impaired physical mobility related to decreased strength, limited weight bearing tolerance and dependence on mechanical lift for transfers. Date initiated as 1/24/26.A facility document titled Long Term Care Facility-Serious Injury Incident Report for R1 dated 1/24/2026 documented the following in part: At approximately 0900 hours (9:00 am) two CNAs (Certified Nurse Assistants) went into the resident's room to get her out of bed using the mechanical lift. They attached the sling to the lift and raised the resident up over her bed and weighed her. After obtaining the weight on the resident they went to place her in her wheelchair. According to both CNAs, the bottom right strap slipped off the hook on the mechanical lift and the resident slid out of the sling onto the ground. R1 was transported to the hospital. Hospital called and notified the facility that R1 has suffered a hip fracture, femur and upper tibia fractures.On 1/28/2026 at 1:25pm, V5 (CNA) said on 1/24/26 around 8:45am, she and V6 were transferring R1 into her wheelchair from bed using the (mechanical) lift and a bariatric sized sling. V5 said she operated the machine while R6 maneuvered the wheelchair. V5 said while the lift machine was moving with R1 up in the air, R1's sling hook on the bottom, slipped off and R1 fell to the ground. V5 said she ran and got help while R6 stayed with R1. V5 stated R1 was transported to the local hospital emergency room (ER) via EMS (Emergency Medical Services). V5 said after R1 was sent to the ER, they looked over R1's sling and found nothing wrong with it. V5 said it was in perfect working order. On 1/29/26 at 11:00am, V6 (CNA) said on 1/24/2026 around 8:45am, R1 was ready to get out of bed after breakfast because her family was coming to spend the day with her from out of town. V6 said she and V5 (CNA) prepared R1 for transfer by placing R1's bariatric lift sling underneath R1 and hooking the sling straps to the lifting machine. V6 said she hooked the bottom straps while V5 hooked the top straps. V6 said V5 began to lift R1 up into the air with the lifting machine, while V6 got R1's wheelchair ready for R1 to be lowered down into the wheelchair. V5 said while they were moving the lift machine with R1 up in the air, the bottom right strap of R1's lift sling slid off the machine causing R1 to fall to the floor. V5 said she must not have gotten the strap on the machine correctly. V5 said the nurse immediately came and R1 was sent to the local emergency room for treatment of injuries.On 1/29/26 at 10:15am, V7 (Registered Nurse) said she worked on 1/24/26 and was the nurse providing care for R1 on that day. V7 said around 8:45am that morning, V5 and V6 were getting R1 up in her wheelchair for daily activities using a whole-body lifting machine. V7 said one of the sling straps slid off the machine and R1 fell to the ground. V7 said she could tell R1's leg was injured so no one moved R1 until EMS (emergency medical services) arrived to transport R1 to the local emergency room for evaluation. V7 said R1 ended up with a fractured right hip, right femur and right tibia.On 1/28/2026 at 11:10am, V9 (Family) said on 1/24/2026 at around 9:00am, she received a call from the nursing home reporting R1 had fallen and would be transferred to the local emergency room for evaluation of injuries. V9 said after getting to the hospital to see R1, R1 told her V5 and V6 were using the whole-body lifting machine to transfer R1 from her bed to her wheelchair, when the bottom right lifting strap slipped off the lifting machine and R1 fell to the ground.Local emergency room records for R1 dated 1/24/2026 documented R1 was seen for injuries sustained after falling from a mechanical body lift machine at the nursing home when being transferred by staff into her wheelchair. These records documented R1 was diagnosed with right hip fracture, a fractured distal femur and right tibia fracture. Prior to the survey date, the facility took the following actions to correct the noncompliance:1.The facility held a QAPI (Quality Assurance and Performance Improvement) meeting on 1/24/2026 with V1 (Administrator) and V18 (Care Plan Coordinator). The QAPI meeting note documented the following was implemented on 1/24/2026. 1.) What actions will be accomplished for the identified resident? Assessed the resident's condition immediately. Notified the medical doctor and family about the incident and sent the resident to the hospital for evaluation and treatment. Completed 1/24/26. 2.How will we identify other residents having the potential to benefit for the Quality Assurance Performance Improvement and what actions will be taken? All residents who require mechanical lifts for transfers will be identified. Their care plans will be reviewed and updated as necessary. Staff will be reminded to always seek assistance when needed and to follow proper transfer protocols. The staff involved in the above transfer will be prohibited from transferring with a mechanical lift until educated and their skills observed and checked off on the Mechanical Lift Application and Use check-off list. Completed 1/24/26. 3. What measures will be put into place or what systemic changes will be made? Re-educate all nursing staff on proper mechanical lift techniques and the importance of seeking assistance. Conduct audits to ensure staff compliance with transfer protocols. Ensure that all necessary equipment, such as mechanical lifts are readily available and in good working condition. All staff members using mechanical lifts will be observed and pass the Mechanical Lift Application and Use check-off list. A copy of the Mechanical Lift Application and Use check off list is to be placed in the CNA informational binder for reference at any time. Completed 1/24/26. 4.How the facility plans to monitor the system performance? Weekly audits for 4 weeks, monthly thereafter. The results of these audits will be reviewed by the facility's Quality Assurance Performance Improvement committee for patterns, trends and continued recommendations for process monitoring and improvement.

Based on observation, interview, and record review, the facility failed to provide a working call light for one resident of three residents (R1) reviewed for call lights in the sample of 15.Findings include:R1's Face Sheet documented an admission Date of 4/8/25 and listed Diagnoses including Hemiplegia and Hemiparesis of the left side following a CVA (Cerebral Vascular Accident), Diabetes Type 2, and Hypertension. R1's Minimum Data Set, dated [DATE] documented that R1 had minimal deficits in cognition and was dependent on staff for transfers and toileting. R1's Care Plan dated 11/13/25 documented a problem area, Self-care deficit as evidenced by needs assistance with ADLs (Activities of Daily Living), toileting related to weakness, CVA, right foot amputation, with a corresponding intervention, Encourage the resident to use bell to call for assistance.On 12/4/25 at 11:05am, R1 was observed in his room after having been transferred via mechanical lift from the wheelchair to the bed. V2, Director of Nurses, was present. When the Surveyor pointed out her observation that R1 did not have a call light, V2 acknowledged this and stated R1 is capable of using his call light. V2 stated the solution to this would be R1 asking his roommates, R2 and/or R3, to activate their call lights for R1, and that R2 had in fact done so. When the Surveyor asked R2 about this, R2, who was alert to person and place but not time, stated he was not sure.On 12/4/25 at 12:30pm, V9, family member of R3, stated if R1 were to ask R3 to push the call light, R3 would not hear him as R3 is severely hearing impaired.On 12/9/25 at 1:30pm, R1 was alert and oriented to self only. When asked what he would do in the event he needed help from staff, R1 stated he was not sure, he guessed he would lay there until somebody came to help him.On 12/11/25 at 10:50am, V1, Administrator, stated when R1 was moved into the room on 11/28/25, staff should have ensured he had a working call light. V1 stated as of 12/4/25 after the surveyor's observation that R1 did not have a call light, R1 was given a call light.The facility's Answering the Call Light Policy dated August 2008 documented, The purpose of this procedure is to respond to the resident's requests and needs. 4. Be sure the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 7. Report all defective call lights to the Maintenance Department promptly. 10. call lights must be accessible to residents from their bed or other sleeping accommodation. Call lights must be accessible to residents from each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor.

Based on interview and record review, the facility failed to provide an environment free of accident hazards for 1 (R1) of 3 residents reviewed for accidents in the sample of 6.Findings include:R1's admission Record documented an admission date of 5/30/2025 and diagnoses including lymphedema, not elsewhere classified, cellulitis, unspecified type 2 diabetes mellitus without complications and cerebral palsy, unspecified. R1's Minimum Data Set (MDS) dated [DATE], documented under section C-Brief Interview for Mental Status (BIMS) of 14, which means R1's is cognitively intact. This same document under section GG- Mobility that R1 is dependent, which means helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for a chair/bed-to chair transfer. R1's care plan documented a focus area of lymphatic ulcer of the left 2nd toe related to lymphedema and needs assistance with activity of daily living (ADLs) related to weakness, Cerebral Palsy, mechanical lift transfer. On 9/24/2025 at 10:47 AM, R1 stated on the evening of 9/11/2025, she did hit her left lower leg on her bed frame. R1 stated, V7 (Certified Nurse Assistant/CNA) and V8 (CNA) had assisted her to her room via wheelchair. R1 stated V7 had been unable to get her turned around to be ready for the mechanical lift transfer and her legs were elevated in her wheelchair. R1 stated when V7 had been trying to turn her around in the wheelchair, her left leg went under her bed and hit the bed frame on the right side. R1 stated there had been no black cap covering the square end of the frame and the sharp edge broke her skin open. R1 stated she had been sent to the local emergency room for further evaluation via ambulance. On 9/24/2025 at 12:34 PM, V4 (Wound Nurse) stated she did not work the night of 9/11/2025. V4 stated she did receive a phone call from V6 (Licensed Practical Nurse/LPN) asking her to come into the facility to assess R1. V4 stated V6 notified her that she had received a skin tear to her left lower leg during a transfer. V4 stated she arrived at the facility to assess R1. V4 stated after her assessment she notified V6 to send R1 to the local emergency room for further evaluation. V4 stated she left the facility after R1 had been sent to the local emergency room but was aware that R1 received one stitch place to the skin tear. On 9/24/2025 at 1:26 PM, V6 stated she had been the nurse working the floor on 9/11/2025 when R1 had an incident. V6 stated V7 (CNA) told her that R1 had contacted the right side of the bed frame with her left leg and caused it to bleed in the process of trying to position her for a chair to bed transfer. V6 stated there had been no black cap on the end of the bed frame, and it had sharp edges. V6 stated R1 did return to the facility that evening with 1 stitch in place and orders to keep the area dry, an antibiotic was started and stitch to be removed in 3-5 days. On 9/24/2025 at 1:38 PM, V7 (CNA) stated she had been working on 9/11/2025 when R1 had caught her left leg on her bed. V7 stated her and V8 (CNA) were in the process of getting ready to transfer R1 from her wheelchair to her bed via mechanical lift. V7 stated she tried to reposition R1 in her wheelchair by backing her up and at that time her left leg made contact with the right side of the bed frame and started to bleed. On 9/24/2025 at 1:47 PM, V8 (CNA) stated she had been working on 9/11/2025 when R1 had caught her left leg on her bed. V8 stated her and V7 (CNA) were in R1's room getting her ready for a transfer from her wheelchair to her bed with a mechanical lift. V8 stated she had been standing in front of the wheelchair and V7 had been standing behind the wheelchair. V8 stated V7 went to reposition R1 when her left leg made contact with the right side of her bed frame. V8 stated R1's bed frame on the right side did not have a black cap on the end of it and the edges were sharp. On 9/24/2025 at 1:56 PM, V2 (Director of Nursing/DON) stated she had been notified by V6 (LPN) via phone that R1 had been sent to the local emergency room for further evaluation because she had made contact with her left leg to her bed frame causing a laceration during a transfer. On 9/25/2025 at 9:49 AM, observed dressing change to R1 completed by V14 (Registered Nurse/RN) with assistance from V15 (RN) and V16 (Physical Therapy Assistant/PTA). Observed left lower left leg laceration in the process of healing. On 9/25/2025 at 10:44 AM, V1 (Administrator) stated, she had been notified via phone by V6 (LPN) that R1 had been sent out to the local emergency room on the evening of 9/11/2025 because she had hit her leg on her bed frame. V1 stated the next day in the morning meeting it was discovered that there had been a black cap missing from the bed frame on R1's bed and it was replaced. R1's Progress Note by V4 (Wound Nurse) dated 9/11/2025 at 7:18 PM documents R1 had been sent out to the local emergency room for a skin tear to left lower leg related to resident's lymphedema. R1's Local Emergency Physician Note dated 9/11/2025 documented R1's chief complaint as patient stated that leg got caught in bed at facility and suffered a significant skin tear laceration. This same document under History of Present Illness documented wound was injected with lidocaine and epinephrine with successful cessation of bleeding and one stitch added to aid in trickle of bleeding. Pain scale documented a score of 2. The facility's Incident Report dated 9/11/2025 documented during transfer R1 was being repositioned for mechanical lift and her leg came into contact with the side of the bed. The facility's Mechanical Lift policy (revised 11/1/2023) documented under PURPOSE: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device.Under Steps in the Procedure.4. Prepare the environment: b. Ensure there is enough room to pivot.

Based on Interview and Record Review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN-CMS10055) for 1 of 3 residents (R5) reviewed for Beneficiary Protection Notification in the sample of 32.The Findings Included:R5's admission Record documented an admission date of 6/18/2025 with diagnoses including: osteomyelitis of vertebra, sacral and sacrococcygeal region, type 2 diabetes mellitus without complications, chronic kidney disease, and essential hypertension.R5's Skilled Nursing Facility Beneficiary Protection Notification Review form documents a discharge from Medicare Part A services prior to exhaustion of his benefit day allotment and a last covered day of Part A Services of 5/6/25. This form documents that a written notice of the resident's potential liability for a non-covered stay (SNFABN - CMS10055) form was not provided to R5 to explain his right to appeal the decision of discharge from Medicare Part A services prior to exhaustion of her benefit days.08/12/2025 12:19 PM, V13 (Regional Social Services) stated R5 had not been notified because the facility had been in between business office managers, and it was missed.On 08/12/2025 at 12:47 PM, V1 (Administrator) stated the facility does not have a policy for advanced beneficiary notices. V1 stated the facility follows the CMS (Centers for Medicare & Medicaid Services) guidelines.

Based on interview and record review the facility to ensure residents were free from abuse for 2 of 2 (R3 and R47) resident reviewed for abuse in the sample of 32. The findings include:The Verification of Incident Investigation/Administrative Summary dated 06/06/2025 documents an incident type of Alleged Resident to Resident with an incident date of 6/1/25. Under the summary of investigation findings it documents A comprehensive investigation was initiated and showed that staff reported that one resident (R47) with a BIMS (Brief Interview for Mental Status) of 08 had kicked resident (R3) BIMS of 05 in the knee. Upon interview neither resident could recall the incident or that even anything had ever happened. Neither resident showed any adverse effects of the incident. Other alert and oriented residents were interviewed and had no concerns regarding abuse or harm coming from staff or other residents. Medical record review reveals resident (R47) is currently being treated for a UIT [sic] (Urinary Tract Infection) with all physician orders processed and being carried out. The allegation of willful physical abuse is unsubstantiated. Under Individuals with direct knowledge of incident/event and/or those interviewed it documents the names of R3, R47, and V9 (Certified Nurse Assistant/CNA). Under Immediate Action Taken this summary documents, Residents were immediately separated. Both residents were assessed and interviewed. MD (physician) and POA (Power of Attorney) were notified. Local PD (Police Department) was notified. IDPH (State Survey Agency) office was notified, Ombudsman was notified.R3's Transfer/Discharge Report with a print date of 8/13/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include unspecified glaucoma, osteoarthritis, and unspecified dementia. R3's MDS (Minimum Data Set) dated 5/20/25 documents R3 has a BIMS (Brief Interview for Mental Status) score of 05, indicating a severe cognitive deficit. R3's current Care Plan documents a Focus area of (R3) has a psychosocial well-being problem r/t (related to) 06/01/2025 - Res (resident) to res, (R3) was kicked in knee by another Resident. Date Initiated: 06/02/2025. This Focus area documents the following interventions, Encourage participation form resident who depends on others to make own decisions. Date Initiated: 06/02/2025 .Provide opportunities for the resident and family to participate in care. Date Initiated: 06/02/2025. R47's Transfer/Discharge Report with a print date of 08/12/2025 documents R47 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, insomnia, major depressive disorder, and unspecified dementia. R47's MDS dated [DATE] documents a BIMS score of 09, indicating a moderate cognitive deficit. R47's current Care Plan documents a Focus area of (R47) has potential to be physically aggressive AEB (as evidenced by) history of resident to resident altercations. Date Initiated: 01/24/2025. This Focus area documents the following interventions, Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document .Due to past physical aggression, (R47) has a motion sensor alarm above her door to notify staff when (R47) is leaving her room On 08/10/2025 at 09:38AM, R3 stated she was kicked in the leg and she kicked them back. R3 showed this surveyor her leg and there was no obvious signs of injury. R3 was not able to provide this surveyor with any other information. On 08/12/2025 at 10:29 AM, V1 (Administrator) stated R3 and R47 used to be roommates. V1 stated after the altercation they moved R3 to a different hall. V1 stated R47 doesn't ambulate and R3 is ambulatory. On 8/14/2025 at 12:01 PM, this surveyor reviewed the abuse investigation with V1 (Administrator) and asked her why she didn't substantiate abuse. V1 stated she believed the reason she didn't substantiate abuse was because neither resident remembered it occurring. This surveyor asked about the staff member (V9/Certified Nursing Assistant) who witnessed it and V1 stated she didn't think she witnessed them make physical contact. V1 then read through the witness statement included in the investigation and stated it documents V9 saw R47 kick R3. V1 stated she didn't substantiate the allegation because neither resident remembered it occurring and both residents had dementia. The facility Abuse Policy dated 10/24/22 documents, Purpose: To provide guidance and Procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Responsibility: The administrator and/or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure 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 responsibility report any allegation or witnessed abuse Immediately to the Administrator (Abuse Coordinator).

Based on interview and record review the facility failed to provide activities that meet the interest of the residents and ensure quarterly activities assessments were completed for 1 of 1 (R9) resident reviewed for activities in the sample of 32.Findings Include:R9's Transfer/Discharge Report with a print date of 8/14/25 documents R9 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia.R9's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 10, indicating R9 has a moderate cognitive deficit.R9's current Care Plan documents a Focus area of, Activity Interests/Preferences: visiting with family, being outside when the weather is nice Date Initiated: 01/01/2025. This Focus area includes interventions of, Encourage and support the development of a new skill, interest, or hobby Give directions prn (as needed) .Provide any needed supplies and assistance for activities R9's Activity Initial assessment dated [DATE] documents under Past Activity Interest, being outside when weather is nice, visiting with family. This assessment documents R9 does not wish to participate in group activities, go on outings, or want 1:1 with staff. This same assessment documents the following accommodations, reminders of activities, encouraging her to attend, large print, sitting closer to activity to be able to hear well. R9's electronic health record does not document an activity assessment after 1/2/2025.On 08/10/2025 at 12:35 PM, V14 (Family Member) stated R9 likes to do crafts/paintings and he had spoke with staff about getting these activities for her and nothing had happened.On 08/14/2025 at 11:20 AM, V1 (Administrator) stated V4 (Activities Director/AD) was off work for a family emergency. V1 stated they do preference/activities assessments on all the residents. V1 stated they didn't have an AD for a short time and those assessments weren't completed until V4 stated in June or July. On 08/14/2025 at 11:49 AM, V13 (Resident Services) stated the AD position was open until they hired V4, who started on 6/20/25. V13 stated the activities assessments are done upon admission, quarterly, and then annually. V13 stated she gave V4 direction to complete the assessments as the MDS's came due and they did not have a quarterly assessment completed for R9.The facility policy titled Activity Assessment dated 5/10/23 documents, Purpose: To provide staff with guidance to ensure resident preference in activities are met. Policy: In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities 1. An activity assessment is conducted as part of the comprehensive evaluation to help develop an activity plan that reflects the choices and interests of the resident.

Based on interview and record review, the facility failed to provide restorative nursing services including assessments and care planning for 1 of 2 residents (R43) reviewed for restorative nursing services in the sample of 32.Findings include:R43's Transfer Sheet documented an admission Date of 7/18/17 and listed Diagnoses including Parkinson's Disease, Diabetes Type 2, and Atherosclerosis of Native Arteries of Extremities, Bilateral Legs. R43's Minimum Data Set, dated [DATE] documented that R43 has minimal deficits in cognition, and requires supervision or touching assistance for ambulation.R43's Physical Therapy Discharge summary dated [DATE] documented, Patient progress: Progress and response to treatment: Patient made substantial functional gains in response to skilled interventions. Patient responded positively to passive techniques to stimulate functional performance and enhance safety to prevent further decline, and patient's functional abilities have progressed as a result of skilled interventions. Long term goal: Patient will safely ambulate on level surfaces 50 feet using (trade name walker) with supervision or touching assistance with functional dynamic balance and with functional posture to facilitate increased participation in functional activity. (Goal was) met on 7/4/25. Discharge reason: Highest practical level/maximum potential achieved. Discharge recommendations: Patient is to be discharged to this facility with recommendations of staff to provide assist as needed and participation in restorative nursing program/functional maintenance program to provide carry over of progress and to maintain current functional status. Restorative program established/trained: Other restorative program: Patient would benefit from continuous activity including strengthening and ambulation to maintain current functional status.R43's Care Plan dated 7/31/25 documented a problem area, (R43) has a decline with bilateral lower extremity (specify: leg, knee, foot, toes specify digits: first, second, third, fourth, fifth) related to: joint mobility. This problem area did not document any interventions related to ambulation.R43's Point of Care Response History documentation for July and August 2025 documented that the only day in that period when R43 was ambulated three times daily was 7/15/25, and there were no refusals documented in that period.On 8/10/25 at 10:14am, R43 was alert and oriented to person, place, and time. R43 stated, They (staff) are supposed to be walking me to every meal, but they're not.On 8/12/25 at 10:15am, when asked if R43 is on a restorative nursing program, V12, Certified Nursing Assistant (CNA), stated the facility does not employ restorative nurses or Restorative CNA's, but the CNA working with R43 that day should walk her to each meal unless she refuses, which she sometimes does.On 08/12/2025 at 1:47 PM, V1, Administrator, stated the facility does not currently have a restorative nursing program, but they are in the process of getting services back in place now with new administration in the building. V1 confirmed R43 is to be walked to dine at each meal. When asked about the documentation in R43's record showing she is not being ambulated three times daily, V1 stated she thinks the CNA's are doing it, but they don't know how to chart refusals or that they should chart refusals.On 08/13/2025 at 11:13 AM, when asked if R43 gets any restorative nursing services, V9, CNA, stated R43 is supposed to be walked to dine for every meal, three times daily. V9 stated sometimes in the morning when they have to get everybody up and out to breakfast, it's hard to find the time to do it, and sometimes if R43 is having a bad morning, she will refuse. V9 stated R43 should be approached about walking prior to each meal, and if she refuses, it should be documented in the CNA charting with the time of the refusal. On 08/13/2025 at 11:27am, V10, Physical Therapy Assistant, stated R43 made progress in therapy, achieved maximum possible benefit, and was discharged with the recommendation that nursing staff walk her to each meal. V10 stated she has observed CNA staff doing this but does not know if it is happening consistently.On 08/14/2025 at 9:54am, V5, Minimum Data Set/Care Plan Coordinator, stated she started in the position in July of 2025 and is still in training. V5 stated next week her training is to begin on adding restorative nursing services to the care plan.A Restorative Program/Range of Motion Policy dated 2/3/22 documented, Purpose: To provide resident with limited range of motion, appropriate treatment, and services to increase or prevent further decrease in range of motion. Responsibility: It is the responsibility of the nurse who completes the quarterly Restorative Assessment to identify a resident's need for range of motion exercise. It is the responsibility of the CNA to perform exercises as identified. It is the responsibility of the Care Plan Coordinator for addressing the Care Plan.On 08/14/2025 at 11:44am, V1 stated the facility has not been doing quarterly Restorative Assessments as per the facility's policy but will begin doing so.

Based on observation, interview, and record review the facility failed to ensure that residents had alternative meal options similar or equivalent nutritive value of the main meal selection for 3 of 3 residents (R25, R42, and R46) reviewed for nutrition in a sample of 32. The Findings Include:On 8/10/2025 at 12:29 PM, V7 (Cook) was observed serving residents their lunch meal that included herb roasted pork loin, herb stuffing, green beans and peach crisp from the steam table in the dining room. V7 was observed not serving the vegetable green beans or cream corn on R42, R46 and R25's trays.On 08/10/2025 12:40 PM, R42 was observed sitting in the dining room eating a regular mechanical soft diet that included ground herb roasted pork loin with gravy and soft herb stuffing with gravy and peach crisp. There were no vegetables observed on R42's lunch tray.On 8/10/2025 at 12:42 PM, R46 was observed being served a CCHO (Controlled Carbohydrate Diet) mechanical soft diet that included ground herb roasted pork loin with gravy and soft herb stuffing with gravy and peach crisp. There were no vegetables observed on R46's lunch tray.On 8/10/2025 at 12:45 PM, R25 was observed in the dining room eating a regular mechanical soft diet that included ground herb roasted pork loin with gravy and soft herb stuffing with gravy and peach crisp. There were no vegetables observed on R25's lunch tray.On 8/10/2025 at 12: 44 PM, V7 (Cook) stated R42, R46 and R25 do not like green beans. V7 stated, she does not know what is supposed to be served in place of green beans if the residents do not like them.08/10/2025 12:44 PM, V6 (Dietary Manager) stated any resident who does not want green beans should have been served the alternative vegetable of cream corn.08/11/2025 12:07 PM, V8 (District Dietary Manager) stated any resident that does not like the vegetable being served that day, should be offered the alternative vegetable for the day.The facility meal cards for R42, R46 and R25 does not document a dislike of green beans. The facility policy titled Food Preference and Portions dated (issued 09/01/2021) documented under Guidelines.3. The Food Preference Interview will be entered into the medical record. 4. Food allergies, food intolerance, food dislikes and food and fluid preferences will be entered into the resident profile in the menu management software system. 7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances and preferences. 8.Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value.

Based on observation, interview, and record review the facility failed to ensure residents were equipped with a working call light for 1 of 1 residents (R27) reviewed for call lights in the sample of 32.Findings Include:R27's Transfer/Discharge Report with a print date of 8/12/25 documents R27 was admitted to the facility on [DATE] with diagnoses that include osteoporosis, chronic obstructive pulmonary disease, atrial fibrillation, contracture of left lower leg, major depressive disorder, and malignant neoplasm.R27's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating R27 is cognitively intact.R27's current Care Plan documents a Focus area of (R27) has Self-Care Deficit as Evidenced by: Needs (extensive) assistance with ADL's (Activities of Daily Living) Related to impaired mobility, weakness. Date Initiated: 01/12/2023. This Focus area includes the intervention, Encourage the resident to use bell to call for assistance. Date Initiated: 01/12/2023.On 08/10/2025 at 10:36 AM, R27 was sitting in bed, there was a cow bell noted sitting on the table located next to R27's bed. R27 stated the facility staff took his call light and gave it to his roommate a couple of weeks ago. R27 stated they gave him the cow bell and he can call the facility from his phone. R27 stated this happened a couple of weeks ago.On 08/13/2025 at 11:19 AM, V9 (Certified Nursing Assistant/CNA) stated she was aware R27 had a cow bell to use instead of a call light. V9 stated she wasn't sure why R27 didn't have a call light, she guessed it wasn't working. This surveyor walked with V9 to R27's room and there was a cow bell present on his over the bed table located next to his bed and no call light present near his bed.On 08/14/2025 at 10:41 AM, V1 (Administrator) stated the button on R27's call light broke and when they tried to order a replacement light the type they need has been discontinued. V1 stated they have a call out to a technician who has ordered the part and as soon it comes in he will replace the call system in that room. When asked if they had that scheduled for repair yet, V1 stated she would have to check on the date. V1 stated in the meantime R27 has his cell phone that he uses and he had been care planned to call the facility if he needed assistance and he had a cow bell in his room that he can use. After reviewing R27's current Care Plan, this surveyor asked V1 where the intervention to use his cell phone and cow bell was located at on the Care Plan. V1 stated it was just added to the care plan this morning.The facility Call Light Guidance Policy dated 8/20/22 documents, Purpose: To provide guidance to all facility staff on the use, response and placement of call lights Procedure: 1. When initiated, the system will light up in the room, outside the room and on a central panel. An audible sound will also be engaged. 2. A call light activation device shall be kept within resident reach while in resident rooms and bathrooms 4. The call light activation device shall be appropriate for resident's condition. Alternative buttons, pads, etc. may be utilized when warranted.

Based on observation, interview, and record review the facility failed to allow residents to smoke at the times they chose for 1 (R26) of 5 residents reviewed for smoking in a sample of 32.The Findings include:R26's admission Record documented an admission date of 11/22/24 with diagnoses including peripheral vascular disease, unspecified, chronic kidney disease, vitamin D deficiency, personal history of transient ischemic attack and cerebral infarction, and anxiety disorder, unspecified.R26's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R26 was cognitively intact.R26's Safe Smoking Screening dated 5/3/2025, documented under cognition, has the following questions marked no: Does the resident exhibit signs of confusion? The following questions were marked yes on this same form: Does the resident have the ability to make himself/herself understood? Can the resident verbalize or demonstrate an understanding of the living center's smoking policy? Can the resident verbalize or demonstrate an understanding of the living center's times and place to smoke? Does the resident remain alert during the course of smoking at all times? Is the resident able to communicate the need for help if lit materials fall on them? On 08/13/2025 at 9:57 AM, R26 stated she is independent and would be able to open the door on her own if given the code to get outside. R26 stated, that she is upset about not able to go outside by herself for smoking, especially when they miss a scheduled time to go outside to smoke.On 08/11/2025 at 1:30 PM, V4 (Social Services Director/SSD) stated she does complete the smoking evaluations on residents. V4 stated the resident is screened for independent or needs supervision, but all resident in the facility is supervised at this time. V4 stated R26's current safe smoking assessment dated [DATE] documented she can do everything by herself and is independent.On 8/11/2025 at 2:00 PM, V3 (Regional Director) stated all residents are supervised during smoking times even if they are deemed independent on their smoking assessments.On 8/11/2025 at 1:20 PM, R26 was observed sitting in her wheelchair in her room applying makeup. R26 was observed self-propelling wheelchair in room.On 08/12/2025 at 11:30 AM, R26 was observed self-propelling wheelchair outside for smoke time with supervised smoke break. R26 had been handed her cigarettes and lighter from V4 (SSD). R26 observed lightening own cigarette and distinguishing cigarette in a safe manner.The facility Smoking Policy (revised 3/10/25) documented under Policy: To provide a safe and healthy living environment with respect for the health, well-being and personal choice of each resident, staff member and visitor.

Based on interview and record review, the facility failed to implement interventions to prevent the development of pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 7. This failure resulted in R1 developing facility acquired moisture associated skin damage to the buttocks, a stage 2 pressure ulcer to the Left Ischium, a stage 3 pressure ulcer to the Right Ischium, and a stage 3 pressure ulcer to the Sacrum. Findings include: R1's Admission Record documented an initial admitted [DATE] and a readmitted [DATE]. Diagnoses listed include Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Right Dominant Side, Type 2 Diabetes, Chronic Kidney Disease Stage 4 (Severe), Morbid Obesity, Epilepsy, and Aphasia. R1's 12/11/24 Braden Scale for Predicting Pressure Ulcer Risk documented a score of 11, indicating R1 is at high risk for the development of pressure ulcers. R1's Minimum Data Set, dated dated dated [DATE] documented that R1 is severely cognitively impaired to the extent that a Brief Mental Status Score could not be performed, was always incontinent of bowel and bladder, required substantial/maximal staff assistance for bed mobility, and was totally dependent on staff for transfers. The same MDS documents in Section M, Skin Conditions, that R1 is at risk for pressure ulcers/injuries and that R1 did not have any pressure ulcers/injuries. R1's Care Plan dated 12/8/24 documented a Focus area of, Pressure Ulcers, sites: Left Ischium, Right Ischium, Coccyx, with corresponding interventions, Repositioning every 2 hours and PRN (as needed). The same Care Plan also documents a Focus area of Potential for impaired skin integrity related to: Cognitive deficits, Decreased sensation, PVD (Peripheral Vascular Disease), DM (Diabetes Mellitus), hemiplegia right side, Impaired mobility, Incontinence. Documented interventions include Monitor Incontinence and provide pericare. R1's Wound Assessment and Plan Notes, authored by V6, Wound Care Nurse Practitioner, documented the following: 12/1/24: Wound location: Bilateral Buttocks, MASD (Moisture Associated Skin Damage) Wound onset date, 11/28/24. Irritant Contact Dermatitis due to dual incontinence. Coccyx, pressure injury, stage 3. Wound onset date, 11/28/24. 12/10/24:Wound location: Sacrum, pressure injury, stage 3. Declined. Wound onset date 11/28/24. Location changed (from Coccyx) to more accurately reflect current wound. Wound location: Bilateral Buttocks: Healed. Wound location: Left Ischium, pressure injury, stage 2. Onset date 12/10/24. Wound location: Right Ischium, pressure injury, stage 3. Onset date 12/10/24. R1's Nurses Notes dated 12/11/24 at 10:30pm stated, Resident not responding during care, lethargic. Resident had blood in urine and fever of 101.2. Sending resident to ER (emergency room ) for evaluation and treatment. Power of Attorney and MD (Medical Doctor) aware. R1's (local hospital) ED (Emergency Department) Note, Physician, dated 12/11/24 documented, It was brought to my attention that the family wanted the patient to stay locally. However, after reviewing the patients chart, the patient is noted to have elevated [NAME] (Blood Cell) Count of 19.3 and continues, And white (blood) cells in the urine which may indicate sepsis with abnormality in other organs. I ordered Ceftriaxone and the family was informed that the patient willing to be transferred for a higher level of care (at a regional hospital). Assessment: Dehydration, severe. Hypernatremia. UTI (Urinary Tract infection). A (Regional Hospital) Admitting Physician History and Physical Examination dated 12/12/24 documented, [AGE] year old female with a past history significant for Diabetes Type 2, Bilateral Carotid Stenosis, Hypertension, Seizure Disorder, PVD (Peripheral Vascular Disease) presented to (Regional Hospital) on 12/12/24 with Altered Mental Status. Assessment/Plan: Altered Mental Status,Hypernatremia, UTI, Sepsis present outside facility with respiratory rate of 25, Altered Mental Status, elevated [NAME] (Blood Cell) Count of 19.3, Sacral Decubitus Ulcer present on admission, AKI (Acute Kidney Injury) on CKD (Chronic Kidney Disease). On 12/26/24 at 9:20am, V4, R1's Power of Attorney, stated on 12/11/24, V2, Director of Nurses, calledV4 to state R1 had recently developed pressure areas, had experienced a deterioration in status, and the facility was sending R1 to hospital for treatment, where R1 was found to have a UTI. V4 stated she was told by V2 that R1's pressure wounds were [NAME] Ulcers, and V2 stated these were as a result of R1 being near the end of her life. V4 stated she does not believe this is accurate as R1 has since improved and has not been under hospice care. V4 stated V4 believed R1 developed pressure wounds due to not being repositioned and changed often enough, based on V4's history of working many years as a CNA (Certified Nursing Assistant). V4 stated as an example, V4 informed staff she wanted R1 get up to the wheelchair for meals, but when V4 visited, R1 often ate meals in bed. V4 stated staff told V4 that R1, Was a fall risk, had to be transferred with a mechanical lift, and they did not have enough staff to be able to supervise her while up. V4 stated she felt the facility was leaving R1 in bed all day for staff convenience. V4 stated after R1 was discharged from the hospital on 12/18/24, V4 had R1 sent to a different facility, where R1's wounds and overall condition have improved. On 12/27/24 at 9:35am, V9, CNA, stated she primarily works the 6am to 6pm shift. V9 stated incontinent residents on the 6:00pm to 6:00am shift are not being changed and repositioned often enough. V9 stated most mornings when V9 arrives, including the morning of 12/27/24, incontinent, confused residents are urine soaked, with dried brown rings on bed linens, and dried feces. V9 stated although there are supposed to be at least 3 CNAs and one nurse on the 6:00pm shift, at times there are 2 CNAs and one nurse, and such was the case the previous night. V9 stated when she has verbalized concern about care and staffing to Administration, she was told to call the corporate hotline to complain. On 12/27/24 at 10:15am, V8, CNA, stated she primarily works the 6am to 6pm shift. V8 stated the facility definitely does not have enough CNAs on the 6pm to 6am shift. V8 stated when she begins her shift at 6:00am, confused incontinent residents are frequently urine soaked, with brown rings on linens, and dried feces. V8 stated R1 was always incontinent of both bowel and bladder and was unable to reposition herself. When asked about R1 developing pressure wounds, V8 stated, She probably got them from not being turned and changed enough. V8 stated in regard to R1, They just tried to turn her as best they could when they remembered and tried to keep her clean and dry. On 1/2/25 at 11:40am, V12, CNA, stated she generally works the 6am shift but has also worked the 6pm shift as well. V12 stated both shifts are often short of CNAs. V12 stated when she started her shift that morning (1/2/25), several incontinent residents were soaked with urine and had odor and brown rings on linens due to the 6:00pm shift not changing them. V12 stated, There are definitely issues with people not getting turned and changed every 2 hours. V12 stated on the 6:00pm shift, They don't do bed checks like they are supposed to. Everybody is in bed by 8:00pm or 9:00pm, then they are to do bed checks at 11:00pm, 1:00am, 3:00am, and 5:00am. They always skip the 11:00pm bed check, they do a bed check at 1:00am, then they start getting people up at 4:30am, so technically there is only one bed check, at 1am. V12 said there are times when perineal care is not done when changing incontinent residents due to time constraints, incontinence briefs are changed but the perineal area is not cleansed. This is happening a lot, mostly to confused residents who can't tell anybody what is going on. In regard to R1, V12 stated, She for sure did not get turned every two hours. She (urinated) a lot, but we did try to keep her dry, although she may not have got her perineal area cleaned. V12 stated R1's family wanted her to get up to the wheelchair for meals, and when she (V12) worked with R1, she got her up. V12 stated complaints to Administration about staffing and care, Go nowhere. Nothing ever changes. On 1/2/25 at 2:25pm, V2, Director of Nurses, stated as far as she is aware, all dependent incontinent residents are being changed, receive perineal care, and are repositioned every two hours, including on the 6:00pm shift, and she has not heard otherwise. V2 stated R1's family would not have been told R1 couldn't be gotten up due to being a fall risk or not having enough staff to supervise her as those statements would not be accurate. V2 stated R1 developed MASD (Moisture Associated Skin Damage) to both buttocks and a stage 3 pressure wound to the Coccyx on 11/28/24 and was therefore referred to V6. V2 stated R1 went on to develop a stage 3 pressure area to the Right Ischial Tuberosity and a stage 2 pressure area to the Left Ischial Tuberosity, both acquired on 12/10/24. V2 stated she assumed all of these pressure areas were [NAME] Ulcers, associated with tissue breakdown at the end of life. V2 stated R1's condition continued to deteriorate and she was sent to the hospital on 12/11/24 due to nausea and vomiting and change in mental status. V2 stated a Urinalysis obtained prior to the hospital admission showed evidence of UTI. V2 stated at some point in December 2024, V4 had told V1, Administrator, that R1 would not be returning to the facility after hospitalization . On 1/3/24 at 10:15am, V1, Administrator, stated V4 came to the facility in December 2024, date unknown, to state that V4 did not believe that R1's wounds could have occurred that quickly and to that extent unless R1 was not being turned and changed frequently. V1 stated V4 said R1 would therefore not be returning to the facility. V1 stated as far as she knew, R1 was being changed and turned. V1 stated she told V4 that her understanding was that R1's areas were [NAME] Ulcers. On 1/3/24 at 11:05am, V6, Wound Care Nurse Practitioner, stated she evaluated R1 on 12/1/24 for facility acquired MASD to both buttocks, and a facility acquired stage 3 pressure wound to the Coccyx, both acquired 11/28/24. V6 stated she evaluated R1 again on 12/10/24, and found the MASD to the buttocks had resolved but R1 had a facility acquired stage 2 pressure area to the Left Ischium and a facility acquired stage 3 pressure area to the Right Ischium, both acquired 12/10/24. V6 stated on 12/10/24 the Coccyx wound had deteriorated to involve the entire Sacrum at a stage 3. V6 stated within December 2024, following R1's hospitalization , she resumed treating R1, at a different facility, and last evaluated R1 on 12/31/24. V6 stated all the pressure areas are now healing and R1's overall condition has improved. V6 stated she does not endorse the use of the term [NAME] Ulcers, and would not say R1 is currently at the end of life. V6 stated overall at the time the pressure areas developed, R1's overall health was in decline. V6 stated residents should be repositioned frequently to improve blood flow, but not necessarily every two hours, the time to reposition residents varies with each individual. V6 stated not being changed frequently and the perineum not being cleansed of urine and feces would be very damaging to the skin, probably more so than not being frequently repositioned. An Incontinence Care Policy dated 5/16/22 documented, All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor. Incontinence care will be provided as required. 8. Wash all soiled skin areas and dry very well, especially between skin folds. 11. Change linen as needed. The facility policy titled Skin Integrity Protocol (undated) documents Preventative Measures: 1. Turning, positioning and pressure redistribution {off-loading) will be utilized for all residents who have been identified of being at risk for developing pressure ulcers . 3. Minimizing exposure to moisture.

Based on interview and record review, the facility failed to provide sufficient direct care staff for meeting resident needs in a timely fashion. This has the ability to effect all 50 residents living at the facility. Findings include: 1. R1's Admission Record documented an initial admitted [DATE] and a readmitted [DATE], and listed diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Right Dominant Side, Type 2 Diabetes, Chronic Kidney Disease Stage 4 (Severe), Morbid Obesity, Epilepsy, and Aphasia. R1's 12/11/24 Braden Scale for Predicting Pressure Ulcer Risk documented a score of 11, indicating R1 is at high risk for the development of pressure ulcers. R1's Minimum Data Set, dated dated dated [DATE] documented that R1 is severly cognitively impaired to the extent that a Brief Mental Status Score could not be performed, required substantial/maximal staff assistance for bed mobility, totally dependent on staff for transfers, and is always incontinent of bladder and bowel. Section H, Bladder and Bowel, documents that R1 is always incontinent R1's Care Plan dated 12/8/24 documented a problem area, Pressure Ulcers, sites: Left Ischium, Right Ischium, Coccyx, with corresponding interventions, Repositioning every 2 hours and PRN (as needed). On 12/26/24 at 9:20am, V4, R1's Power of Attorney, stated that she believed R1 developed pressure wounds due to not being repositioned and changed often enough, based on V4's history of working many years as a CNA (Certified Nursing Assistant). V4 stated as an example, V4 informed staff she wanted R1 get up to the wheelchair for meals, but when V4 visited, R1 often ate meals in bed. V4 stated staff told V4 that R1, Was a fall risk, had to be transferred with a mechanical lift, and they did not have enough staff to be able to supervise her while up. On 12/27/24 at 9:35am, V9, CNA, stated she primarily works the 6am to 6pm shift. V9 stated incontinent residents on the 6:00pm to 6:00am shift are not being changed and repositioned often enough. V9 stated most mornings when V9 arrives, including the morning of 12/27/24, incontinent, confused residents are urine soaked, with dried brown rings on bed linens, and dried feces. V9 stated although there are supposed to be at least 3 CNAs and one nurse on the 6:00pm shift, at times there are 2 CNAs and one nurse, and such was the case the previous night. V9 stated when she has verbalized concern about care and staffing to Administration, she was told to call the corporate hotline to complain. On 12/27/24 at 10:15am, V8, CNA, stated she primarily works the 6am to 6pm shift. V8 stated the facility definitely does not have enough CNAs on the 6pm to 6am shift. V8 stated when she begins her shift at 6:00am, confused incontinent residents are frequently urine soaked, with brown rings on linens, and dried feces. V8 stated in regard to R1, They just tried to turn her as best they could when they remembered and tried to keep her clean and dry. On 1/2/25 at 11:40am, V12, CNA, stated she generally works the 6am shift but has also worked the 6pm shift as well. V12 stated both shifts are often short of CNAs. V12 stated when she starts at 6:00am, incontinent residents are frequently soaked with urine and have odor and brown rings on linens due to the 6:00pm shift not changing them. V12 stated, There are definitely issues with people not getting turned and changed every 2 hours. V12 stated on the 6:00pm shift, They don't do bed checks like they are supposed to. Everybody is in bed by 8:00pm or 9:00pm, then they are to do bed checks at 11:00pm, 1:00am, 3:00am, and 5:00am. They always skip the 11:00pm bed check, they do a bed check at 1:00am, then they start getting people up at 4:30am, so technically there is only one bed check, at 1:00am. V12 stated there are times when perineal care is not done when changing incontinent residents due to time constraints, incontinence briefs are changed but the perineal area is not cleansed due to insufficient time to provide care. V12 stated, This is happening a lot, mostly to confused residents who can't tell anybody what is going on. In regard to R1, V12 stated, She for sure did not get turned every two hours. She (urinated) a lot, but we did try to keep her dry, although she may not have got her perineal area cleaned.V12 stated the 6:00pm shift CNA staff are to clean wheelchairs, which they are not doing. V12 stated complaints to Administration about staffing and care, Go nowhere. Nothing ever changes. On 1/3/25 at 9:10am, V2, Director of Nurses, confirmed she is the staff member responsible for scheduling nursing and CNA staff. V2 stated the facility requires a minimum of 5-6 CNAs and 2 nurses on 6:00am to 6:00pm shift, and 1 nurse and 3 CNAs on the 6:00pm to 6:00am shift, and that they are meeting this requirement, Most of the time. V2 acknowledged difficulty attracting and retaining CNA staff and stated call ins are a problem. On 1/3/25 at 12:50pm, V1, Administrator, stated complaints about call lights have come up in Resident Council for the past few months. V1 stated they are always hiring CNA staff, but the new hires frequently call in or no show. Resident Council Meeting Minutes documented the following: 11/6/24: Wheelchairs not being washed, call lights taking a long time to be answered. 12/4/24: Wheelchairs not being washed, call lights taking a long time to be answered. A Grievance Summary dated 11/6/24 documented the following: (Filed by an anonymous resident): Call lights taking a long time at times to answer. Summary of findings: At times it does take a little longer for the call lights to be answered, depending on the time of day and staffing. A December 2024 Staff schedule documented that on Sunday 12/1/24 from 6:00am to 6:00pm, there were three CNAs and one nurse working, with an additional nurse working 8:00am to 4:00pm. On Saturday 12/14/24 from 6:00am to 6:00pm, there were three CNAs and one nurse working, with a second nurse working from 8:00am to 4:00pm. A Daily Assignment Sheet dated Friday 12/27/24 documented that from 1:00am to 6:00am, two CNAs and one nurse worked. 2. R7's Admission Record documented an admitted [DATE] and listed diagnoses including Parkinson's Disease and Diabetes Type 2. R7's Minimum Data Set, dated dated dated [DATE] documented that R7 has no deficits in cognition and requires partial or moderate assistance from staff for toileting and transfers. On 1/3/24 at 10:35am, V2 stated it is her expectation that call lights should be answered within 15 to 20 minutes. On 1/3/25 at 1:10pm, R7 was alert and oriented to person, place, time, and purpose. R7 stated she has been complaining about call lights and staffing for the past few months, but it never improves. R7 stated she often waits an hour on her call light to get toileting assistance, and when CNAs finally respond, they tell her, They can't help it because they are short staffed. Sometimes they say what do you expect, theres nobody assigned to this hall, or there are only 2 CNAs in the whole building. R7 stated trying to get help is worse at bedtime, from about 7:00pm to 9:00pm. The facility's Staffing Policy dated 6/13/23 documented,The facility has developed and assigned duty hours for the nursing services department based on state/federal requirements and utilizing the staffing calculator. 3. Departmental work schedules may be revised by the Director of Nursing Services when deemed necessary and appropriate to ensure that each residents needs are met. A Call Light Guidance Policy dated 8/20/22 stated, Resident call lights shall be responded to within a reasonable amount of time. A Facilty Matrix dated 12/26/24 documented a total of 50 residents living at the facility.

Based on interview and record review, the facility failed to notify a residents POA (Power of Attorney) of a change in condition for 1 of 3 residents (R1) reviewed for POA notification in the sample of 7. Findings include: R1's Admission Record documented an initial admitted [DATE] and a readmitted [DATE], and listed diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Right Dominant Side, Type 2 Diabetes, Chronic Kidney Disease Stage 4 (Severe), Morbid Obesity, Epilepsy, and Aphasia. The same Admission Record identified V4 (family member) as R1's POA. R1's Wound Assessment and Plan Notes, authored by V6, Wound Care Nurse Practitioner, documented the following: 12/1/24: Wound location: Bilateral Buttocks, MASD (Moisture Associated Skin Damage) Wound onset date, 11/28/24. Irritant Contact Dermatitis due to dual incontinence. Coccyx, pressure injury, stage 3. Wound onset date 11/28/24. 12/10/24:Wound location: Sacrum, pressure injury, stage 3. Declined. Wound onset date 11/28/24. Location changed (from Coccyx) to more accurately reflect current wound. Wound location: Bilateral Buttocks: Healed. Location: Left Ischium, pressure injury, stage 2. Onset date 12/10/24. Wound location: Right Ischium, pressure injury, stage 3. Onset date 12/10/24. R1's Nurses Notes for November and December 2024 contained no documentation to indicate V4 was notified of R1's pressure ulcers. On 12/26/24 at 9:20am, V4, R1's Power of Attorney, stated on 12/11/24, V2, Director of Nurses, called V4 to state R1 had recently developed pressure areas, had experienced a deterioration in status, and the facility was sending R1 to hospital for treatment of a UTI (Urinary Tract Infection). V4 stated this was the first she had heard of R1 having pressure ulcers. On 1/2/25 at 2:25pm, V2 stated she believes that on the 4th or 5th of December, she had a conversation with V4 about R1 having developed pressure wounds. V2 stated apparently she did not document the conversation. On 1/3/25 at 11:05am, V6 (Wound Care Nurse Practitioner) stated she generally relies on facility nursing staff to communicate with resident's families. V6 stated she did not speak with V4 about R1's pressure ulcers. The facility policy titled Change of Condition Protocol (revision date 1/23/23) documents 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 .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 provide incontinence care and timely toileting assistance for dependent residents for 2 of 7 residents (R1, R7) reviewed for ADL (Activities of Daily Living) care in the sample of seven. Findings include: 1. R1's Admission Record documented an initial admitted [DATE] and a readmitted [DATE]. Documented diagnoses include: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Right Dominant Side, Type 2 Diabetes, Chronic Kidney Disease Stage 4 (Severe), Morbid Obesity, Epilepsy, and Aphasia. R1's 12/11/24 Braden Scale for Predicting Pressure Ulcer Risk documented a score of 11, indicating R1 is at high risk for the development of pressure ulcers. R1's Minimum Data Set, dated dated dated [DATE] documented that R1 is severely cognitively impaired to the extent that a Brief Mental Status Score could not be performed, required substantial/maximal staff assistance for bed mobility, totally dependent on staff for transfers, and is always incontinent of bladder and bowel. R1's Care Plan dated 12/8/24 documents a Focus area of Potential for impaired skin integrity related to: Cognitive deficits, Decreased sensation, PVD (Peripheral Vascular Disease), DM (Diabetes Mellitus), hemiplegia right side, Impaired mobility, Incontinence. Documented interventions include Monitor Incontinence and provide pericare. The same Care Plan also documents a Focus area of (R1) has Self-Care Deficit As Evidenced by: Needs extensive assistance with ADL's related to impaired mobility, CVA, and Hemiplegia right dominate side. Documented interventions include: Bed Mobility - Assist to turn & reposition every 2 hours in bed & wheelchair, two person assist for pulling resident up in bed; may require one or two person assist for repositioning in bed depending on resident condition, and transfer: Mechanical Lift required. On 12/26/24 at 9:20am, V4, R1's Power of Attorney, stated V4 believed R1 developed pressure wounds due to not being repositioned and changed often enough, based on V4's history of working many years as a CNA (Certified Nursing Assistant). V4 stated as an example, V4 informed staff she wanted R1 get up to the wheelchair for meals, but when V4 visited, R1 often ate meals in bed. V4 stated staff told V4 that R1, Was a fall risk, had to be transferred with a mechanical lift, and they did not have enough staff to be able to supervise her while up. V4 stated she felt the facility was leaving R1 in bed all day for staff convenience. On 12/27/24 at 9:35am, V9, CNA, stated she primarily works the 6am to 6pm shift. V9 stated incontinent residents on the 6:00pm to 6:00am shift are not being changed and repositioned often enough. V9 stated most mornings when V9 arrives, including the morning of 12/27/24, incontinent, confused residents are urine soaked, with dried brown rings on bed linens, and dried feces. On 12/27/24 at 10:15am, V8, CNA, stated she primarily works the 6am to 6pm shift. V8 stated the facility definitely does not have enough CNAs on the 6pm to 6am shift. V8 stated when she begins her shift at 6:00am, confused incontinent residents are frequently urine soaked, with brown rings on linens, and dried feces. V8 stated R1 was always incontinent of both bowel and bladder and was unable to reposition herself. When asked about R1 developing pressure wounds, V8 stated, She probably got them from not being turned and changed enough. V8 stated in regard to R1, They just tried to turn her as best they could when they remembered and tried to keep her clean and dry. On 1/2/25 at 11:40am, V12, CNA, stated she generally works the 6am shift but has also worked the 6pm shift as well. V12 stated both shifts are often short of CNAs. V12 stated when she started her shift that morning (1/2/25), several incontinent residents were soaked with urine and had odor and brown rings on linens due to the 6:00pm shift not changing them. V12 stated, There are definitely issues with people not getting turned and changed every 2 hours. V12 stated on the 6:00pm shift, They don't do bed checks like they are supposed to. Everybody is in bed by 8:00pm or 9:00pm, then they are to do bed checks at 11:00pm, 1:00am, 3:00am, and 5:00am. They always skip the 11:00pm bed check, they do a bed check at 1:00am, then they start getting people up at 4:30am, so technically there is only one bed check, at 1am. V12 said there are times when perineal care is not done when changing incontinent residents due to time constraints, incontinence briefs are changed but the perineal area is not cleansed. This is happening a lot, mostly to confused residents who can't tell anybody what is going on. In regard to R1, V12 stated, She for sure did not get turned every two hours. She (urinated) a lot, but we did try to keep her dry, although she may not have got her perineal area cleaned. 2. R7's Admission Record documented an admitted [DATE]. Documented diagnoses include: Parkinson's Disease and Diabetes Type 2. R7's Minimum Data Set, dated dated dated [DATE] documented that R7 has no deficits in cognition and requires partial or moderate assistance from staff for toileting and transfers. R7's Care Plan with a revision date of 12/15/24 documented a problem area, (R7) has self-care deficit as evidenced by: Needs extensive assistance with ADLs related to contracture, weakness, impaired mobility, with a corresponding documented interventions including: Encourage the resident to use call bell for assistance and Toilet-use-one person physical assist required. On 1/3/24 at 10:35am, V2 stated it is her expectation that call lights should be answered within 15 to 20 minutes. On 1/3/25 at 1:10pm, R7 was alert and oriented to person, place, time, and purpose. R7 stated she has been complaining about call lights and staffing for the past few months, but it never improves. R7 stated she often waits an hour on her call light to get toileting assistance, and when CNA's finally respond, they tell her, They can't help it because they are short staffed. Sometimes they say what do you expect, there's nobody assigned to this hall, or there are only 2 CNAs in the whole building. R7 stated trying to get help is worse at bedtime, from about 7:00pm to 9:00pm. A Call Light Guidance Policy dated 8/20/22 stated, Resident call lights shall be responded to within a reasonable amount of time. An Incontinence Care Policy dated 5/16/22 documented, All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor. Incontinence care will be provided as required. 8. Wash all soiled skin areas and dry very well, especially between skin folds. 11. Change linen as needed. An undated Repositioning Procedure documented, Interventions. 3. Residents who are in bed should be on an at least every two hour repositioning schedule.

Based on interview and record review the facility failed to notify the physician prior to a residents discharge for 1 of 3 residents (R1) reviewed for discharge planning in a sample of 5. Findings Include: Review of R1's Admission Record documented R1's initial admitted to the facility as 08/02/2024 . The same document lists diagnoses for R1 as the following: other acute osteomyelitis, left foot and ankle, essential hypertension, alcohol use, and patient's other noncompliance with medication regimen. R1's Minimum Data Set (MDS) with an Assessment Reference Date of 08/09/2024 documented a Brief Interview for Mental Status Score of 15, indicating R1 is cognitively intact. A Progress Note dated 09/14/2024 with a time of 12:24 P.M. authored by V5 (Registered Nurse) documented R1 left the facility at 12:20 P.M., belongings, meds and narcotics sent with R1. R1 was educated on care of his wound and given his follow up appointment schedule, R1 voiced understanding. R1 left the facility via private car with friend. A form tiled (name of company)-Discharge Plan and Instruction with a date of 09/12/2024 documented that R1 had follow up appointments with the locations, date and times. The form goes on to document no home health care services were set up, no medical equipment needed, and medications were discussed with R1. R1's Order Summary Report with a Active Orders as of 09/14/2024 printed on 10/30/2024, documented an order dated 08/02/2024, for PICC (Peripherally Inserted Central Catheter) to be used for antibiotic use. The same document documented an order dated 08/02/2024, for Ertapenem 1 GM(Gram) intravenously every 24 hours for infection for 6 weeks. There were no orders documented on R1's Order Summary Report from V7 regarding R1's discharge or follow up care for the management of the PICC line. R1's Care Plan with and initiation date of 08/17/2024 has a Focus area of: Potential for infection related to IV (intravenous) use of PICC Line. The same document listed Goal: Will have no signs and symptoms of IV related complications. The same document goes on to list the interventions as administer medications as ordered, change catheter site dressing as required, change IV tubing as ordered, change sterile cap as ordered, labs as ordered, and monitor the site for redness, swelling, and or drainage. The same document went on to list a Focus Area of: The resident wishes to return/be discharged to home. The Goal is listed as: The resident will communicate an understanding of the discharge plan and describe the desired outcome. The same document went on to list the interventions as: encourage the resident to discuss feelings and concerns with discharge, evaluate the residents motivation to return to the community, make arrangements with required community resources to support independence post discharge, and prepare and give the resident contact numbers for all community referrals. On 10/30/2024 at 9:40 A.M. V3 (Hospital Social Service Worker) stated that R1 presented to the emergency roiagnom on [DATE] with the same PICC line in that was supposed to be taken out before he left the facility. V3 stated that R1 was discharged from the hospital and admitted to the facility on [DATE] for IV antibiotics. R1 was supposed to be discharged from the facility with the PICC line discontinued due to R1 having a history of being a known drug user and homeless. V3 stated that according to the discharge instructions that the facility was given from the hospital when R1 was admitted to the facility, R1 was to complete his antibiotics on 09/12/2024. V3 stated that R1 had an infection of his foot that required weeks of IV (Intravenous) antibiotics. V3 stated that once R1 was discharged from the facility there was no one caring for the PICC line and that R1 was living off of friends' couches. V3 stated that R1 told the emergency room staff that he was tying a belt around the PICC line to keep it from hanging down. V3 stated that once R1 was readmitted to the hospital on 10/20/2024, they completed a culture of his foot where the wound was and placed a new PICC line for further treatment with IV antibiotics. V3 stated that R1 was discharged to another facility for further treatment. Review of Progress Note from local hospital dated 10/21/2024 timed 10:08 P.M. authored by V4 (Hospital Emergency Department Physician) documented Patient reportedly left the nursing home with PICC line, possibly AMA case management consulted and will be investigating. On 10/30/2024 at 1:53 P.M., an attempt was made to contact R1 at the number provided on R1's facility Admission Record and the number is not a working phone number. On 10/30/2024 at 12:13 P.M. V1 (Administrator) stated that R1 was in the facility with a PICC line to receive IV antibiotics related to an infection he had in his foot. V1 stated that R1 was reported to be homeless before coming to the facility. V1 stated that the local hospital had called on 10/23/2024 to ask questions about R1. V1 stated that she verified to the hospital that R1 had completed his antibiotic and she believed that his PICC line was taken out before he was discharged . V1 then stated that she verified with V2 (Director of Nursing) if the PICC line was removed before discharge. V1 did state that the hospital asked her if R1's discharge was planned and V1 stated that she explained the process to the case manager at the hospital. V1 stated that she verified to the hospital that R1 had completed his antibiotic and she believed that his PICC line was taken out before he was discharged . On 10/30/2024 at 12:40 P.M. V2 (Director of Nursing) stated that R1 was at the facility for IV antibiotics related to osteomyelitis of his foot. V2 stated that he was supposed to be discharged after his last dose of antibiotics, but his ride couldn't come get him for a day or two. V2 stated that the plan was for R1 to return to his girlfriend's house after antibiotics were completed. V2 stated that R1 was sent home with medications and dressing supplies so he could do the dressings on his foot. R1 was also sent home with all of his medical follow up appointments. V2 stated that she was pretty sure the PICC line was taken out on the day the antibiotics were completed. V2 stated R1's last dose of antibiotics would have been 09/12/2024. V2 stated that it was her understanding that the PICC line was discontinued before R1 was discharged . On 10/30/2024 at 1:30 P.M. V5 (Registered Nurse) stated she was R1's nurse the day of discharge. V5 stated that she went over in length the importance of following up with all of his medical appointments when he is discharged . V5 stated that she is not sure if R1 still had his PICC line when he was discharged . V5 stated she did not do a skin check like you would on admission. V5 stated that she really did not know one way or another if R1 still had his PICC line and she can't really answer the question. V5 stated that she did not call the physician for discharge orders because she just thought they were already on the chart. V5 stated that she did not look to see if there were orders or not. On 10/30/2024 at 2:11 P.M. V6 (Registered Nurse) stated that she gave R1 his last dose of IV antibiotic on 09/12/2024. V6 stated she did not pull the PICC line out at that time. V6 stated she was off the next two days and did not take care of R1 anymore after 09/12/2024. On 10/31/2024 at 9:20 A.M. V1 stated she cannot find documentation in the chart for R1 to be discharged or for the PICC line to be removed. V1 stated that she is not sure why there is not an order in the electronic medical record for R1 to be discharged . V1 stated that R1's discharge was planned. V1 stated that all staff and V7 (Medical Doctor) was aware that R1 was going to leave as soon as his antibiotics were completed. V1 stated that R1 was given (company name)- Discharge Plan and Instructions form as well as a current medication list. On 10/31/2024 at 10:22 A.M. V7 (Medical Director) stated that she saw R1 on 09/04/2024 at the facility. V7 stated that she was made aware on 09/04/2024 by R1 and the facility that R1 wanted to be discharged after he completed his IV antibiotics. V7 stated there was no direct communication with the facility to her office about R1 going home. V7 stated that she did not give orders to the facility for R1 to be discharged . V7 stated that she has an office nurse who is responsible for her facility patients and the nurse was not made aware that the facility needed discharge orders. V7 stated that she would have expected the facility to discontinue R1's PICC line prior to him being discharged . V7 stated that it is standard routine care to discontinue a PICC line once the course of IV antibiotics were completed. On 10/31/2024 at 10:37 A.M. V2 (Director of Nursing) stated that it is her expectation for the nursing staff obtain discharge orders prior to discharge. V2 also stated that it is her expectation for PICC lines to be discontinued before discharge. V2 stated that there should be orders for these in the electronic medical record. The facility policy titled Discharge / Transfer Policy with a revision date of 08/15/2022 documented under the section titled purpose, 1. When the facility transfers or discharges resident under any circumstances, appropriate documentation shall be made in the resident's clinical record. The attending physician shall give orders for the transfer / discharge. 3. A written or telephone order is required from the attending physician for the transfer or discharge of a resident except in emergency situations.

Based on interview and record review, the facility failed to assess and manage pain for 1 (R198) of 2 residents reviewed for pain management in the sample of 34. This failure resulted in R198 experiencing severe pain and anxiety, resulting in a transfer to the ER (emergency room ). Findings include: 1. R198's Admission Record documented an admitted [DATE] and listed diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety Disorder. R198's Minimum Data Set, dated dated dated [DATE] documented that R198 has no deficit in cognition A Hospice Center Discharge Instructions Sheet dated 9/21/24 documented, Medications: Ativan 2mg. (milligrams) per ml. (milliliter), give 0.5ml by mouth every hour prn (as needed) for anxiety. Morphine Sulfate 20mg./ml. give 0.5ml by mouth every hour prn for pain/SOB (Shortness of Breath). R198's September 2024 Physician's Orders documented an order, Pain assessment every shift using 1-10 scale with a start date of 9/21/24. There were no medications documented to be started on 9/21/24. A September 2024 Medication Administration Record (MAR) contained no documentation that Ativan or Morphine were administered in that month. The same MAR documented that R198's pain was not assessed until 9/23/24 on the 6pm to 6am shift, at which time it was 2 on a scale of zero to ten. R198's Nursing Progress Notes documented the following: 9/21/24, 11:00am: Report received from hospice nurse. Nurse states that the resident is not eating any food but will occasionally sip on water or tea. She has a (name of indwelling urine catheter) in place. 2L NC (Oxygen at 2 liters, per nasal canula) for comfort. A&O x2 (Alert and oriented to person and place) intermittent confusion. Taking morphine for pain and ativan for agitation round the clock. Nurse states that the resident is being discharged from hospice and all orders will need to come from the admitting physician. 9/21/2024, 1:33pm: The resident arrived (to the facility) via EMS (Emergency Medical Services). 9/24/24, 5:30pm: Resident and family request to go to the ER for pain control. There was no documentation in the Progress Notes between 9/21/24 and 9/24/24 referencing R198's pain or anxiety. R198's Emergency Department (ED) Note dated 9/24/24 documented, (R198) presented to the Emergency Department for evaluation of lower abdominal pain that has been going on intermittently for the last few days. The pain is dull, 8 out of ten. Under Assessment/Plan it documents Abdominal pain, acute; acute cystitis; hypokalemia; Diagnosis: Cystitis (Urinary Tract Infection); abdominal pain; generalized weakness. Under Medication Reconciliation it documents Cephalexin 500mg.(miligram) oral every 12 hours for 10 days and Acetaminophen/Hydrocodone (Norco) 325mg-5mg, one tablet as needed every 6 hours for pain. Buspar 5mg. one tablet 3 times daily as needed for anxiety. On 10/08/24 at 12:01 PM, R198 was alert and oriented. R198 stated she was admitted on Saturday 9/21/24. R198 stated she was transferred from a hospice facility and was on round the clock medications for pain and anxiety. R198 stated she was told by facility staff that they would not be able to get these medications over the weekend. R198 stated shortly after her admission, she began to experience, Terrible pain in my abdomen, and anxiety, which exacerbated her breathing problems. R198 stated finally on 9/24/24 her family asked that she be sent to the ER to get the pain and anxiety under control. R198 stated the ER physician put her on new medications for pain and anxiety. On 10/09/24 at 9:18 AM, V2, Director of Nurses, stated when R198 was admitted on Saturday 9/21/24, she was transferred from a hospice program. V2 stated R198 had been on round the clock Ativan and Morphine, but came without medications. V2 stated normally when they get a new resident on the weekend they make sure they have the residents medication by Friday, but in this case, they were told R198 would be there on Friday, but she did not show up. V2 stated she was called the next day to say that R198 had arrived without medication. V2 stated she called the Medical Director on 9/21/24 to get medication orders for R198, but hard copy prescriptions were needed to get the medications and there was no way to obtain them. V2 further stated the pharmacy was closed, and even to take the medications out of the emergency kit, a written script was needed. V2 stated she is not sure why she did not document this call to the Medical Director. V2 stated on Monday 9/24/24, R198 was sent to the ED at the request of her family, where she was given orders for the Norco and Buspar. V2 stated every resident should have their pain assessed at least once every 12 hour shift. A Management of Pain Policy dated 5/16/22 documented, Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. A Medication Administration Policy dated 9/27/22 stated, Medications 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.

Based on interview and record review, the facility failed to provide sufficient direct care staff to meet resident's needs. This has the potential to effect all 49 residents living at the facility. Findings include: R1's Admission Record documented an admitted [DATE] and listed Diagnoses including Congestive Heart Failure and Diabetes Type 2. R1's Minimum Data Set (MDS) dated [DATE] documented that R1 has no deficits in cognition and requires partial/moderate assistance for toileting and transfers. On 10/02/2024 at 11:11 a.m., R1, who was alert and oriented, stated the staff are slow to answer the call lights. R1 stated she will wait 30 minutes to an hour for staff to answer the call light. R1 stated that there are times she will be in the bathroom waiting for 30 minutes for the staff to answer her call light. R198's Admission Record documented an admitted [DATE] and listed Diagnoses including Chronic Obstructive Pulmonary Disease (COPD)and Anxiety Disorder. R198's Minimum Data Set, dated dated dated [DATE] documented that R198 has no deficit in cognition and is dependent on staff for toileting and transfers. On 10/02/2024 at 10:55 a.m., R198 was alert and oriented. R198 stated the wait for call lights to be answered is very long. R198 stated there are days she waits up to 1 hour for the staff to answer her call light. R198 stated she does not feel it is one shift or a particular day. R198 stated she experiences discomfort while holding urine/feces while waiting for staff. R198 said the facility is not fully staffed to take care of the residents. R19's Admission Record documented an admitted [DATE] and listed Diagnoses including COPD and Glaucoma. R19's MDS dated [DATE] documented that R19 has moderate deficits in cognition and is independent for toileting and transfers. On 10/02/2024 at 11:08 am, R19, who was alert and oriented, stated the facility staff are slow to answer call lights. R19 stated it all depends on who is working how fast the staff answer the call lights. R19 stated there have been days she has waited over an hour for staff to answer the call light and take her to the bathroom. R3's Admission Record documented an admitted [DATE] and listed Diagnoses including Parkinson's Disease and Diabetes Type 2. R3's MDS dated [DATE] documented R3 has minimal deficits in cognition and requires partial/moderate assistance for toileting and transfers. On 10/02/2024 at 11:22 a.m., R3, who was alert and oriented, stated there have been 3-4 times recently that she has waited up to an hour for the staff to answer her call light. R3 stated the facility needs more help in order to be able to answer the call lights quickly. R21's Admission Record documented an admitted [DATE] and documented Diagnoses including COPD and Diabetes Type 2. R21's MDS dated [DATE] documented that R21 has no deficits in cognition and is totally dependent on staff for toileting and transfers. On 10/03/2024 at 11:00 a.m., R21, who was alert and oriented, stated that she has to wait a long period of time for the staff to answer her call light. R21 will have incontinence episodes waiting on her call light to be answered. R21 stated she has had 4 episodes of incontinence today waiting on the call light to be answered. On 10/08/24 at 1:05pm, V2, Director of Nurses, stated she is the staff member responsible for scheduling the nurses and CNA's (Certified Nursing Assistants). V2 stated she schedules two nurses and 5 CNA's on the 6am to 6pm shift, and one nurse and 2 CNA's on the 6pm to 6am shift, with an additional CNA working 6pm to 10pm. V2 stated she has asked corporate for additional CNA's on the 6pm shift, and has been denied. On 10/9/24 at 9:18am, V2, Director of Nurses, stated call lights should be answered as soon as possible, within 15 minutes at most. An October 2024 Schedule documented that on 10/5/24 and 10/6/24, two CNA's and one nurse worked the 6pm to 6am shifts, including the period from 6pm to 10pm. A Staffing Policy dated 6/13/23 stated,3. Departmental work schedules may be revised by the Director of Nursing Services when deemed necessary and appropriate to ensure that each resident's needs are met. A Call Light Guidance Policy dated 8/20/22 documented, Resident call light shall be responded to within a reasonable amount of time. It is the responsibility of all staff to respond to call lights. The Long-Term Care Facility Application for Medicare and Medicaid form provided by the facility on 10/03/2024 documents the facility has 49 residents residing at the facility

Based on interview and record review, the facility failed to notify the physician in a timely manner for 1 (R2) of 3 residents reviewed for physician notification. This failure resulted in the hospitalization of R2 for 2 days with a diagnosis of cellulitis of the right abdominal pannus and left lower extremity cellulitis, and insertion of a Peripherally Inserted Central Catheter (PICC) line for intravenous (IV) antibiotic therapy. The findings include: R2 ' s face sheet documents that R2 was admitted to the facility on [DATE] with a primary diagnosis of Morbid (Severe) Obesity due to excess calories. R2 ' s Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score of 15, indicating that R2 is cognitively intact. Section GG of the same MDS, Functional Abilities and Goals, documents that R2 is independent with eating, setup/clean-up assistance with oral hygiene, dependent with toileting hygiene, showering, lower body dressing, bed mobility, transfers, and partial/moderate assistance with upper body dressing. R2's Progress Notes dated 1/07/2024 documents in part . R2 reports she has a mass on her lower right side that has been constantly growing . Mass upon examination is hard, tender to palpation, warm to touch, and appears over twice the size of her left side .Nurse will reassess area tomorrow and call primary physician to determine the next steps. R2's Progress Notes has no further documentation that the primary physician was notified regarding R2's change in condition from 1/07/2024 - 1/09/2024. R2's Progress Notes dated 1/9/2024 documents in part .spoke with primary physician related to red, warm area to R2's right lower quadrant .New order to start Levaquin 500 milligrams (mg) twice daily x 10 days and probiotic x 10 days and add R2 to primary physician's rounding list of patients to see. R2's Progress Notes dated 1/11/2024 documents in part .Primary physician in house to examine R2 .New order for Clindamycin 300mg three times daily related to cellulitis to right lower quadrant. R2's Medication Administration Record (MAR) dated 1/12/2024 - 1/25/2024 documents R2 receiving ordered Clindamycin 300mg three times daily. R2's Progress Notes dated 1/11/2024 - 1/24/2024 reviewed with no further documentation after ordered Clindamycin was administered on 1/12/2024 assessing improvement of right lower abdominal pannus. R2's Progress Notes dated 1/25/2024 documents in part .R2's cellulitis to right trunk and left lower extremity persists with no improvement .R2 would like to go to the emergency department and get assessed as it is not improving .R2 is own responsible party and agreeable. Primary physician notified and aware. On 1/25/2024 at 11:00 AM, R2 was observed lying in her bed wearing a nightgown. R2's right lower abdomen and left posterior thigh has redness. R2 stated that her right side is warm to touch, and she has been taking antibiotics for two weeks now. R2 stated that her left thigh is red, warm to touch and hard to touch. R2's Progress Notes dated 1/25/2024 at 12:44 PM by V2 (Director of Nursing) documents Resident started with area to RLQ (Right Lower Quadrant) cellulitis, PO (by mouth) ATB (antibiotic) initiated. No improvement occurred; area began to grow. A new area was noted on right posterior calf as well. The same note further documents Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Send to ED (Emergency Department) for evaluation R/T (related to) failed outpatient PO ATB therapy for cellulitis to RLQ and new right calf cellulitis. R2's Hospital Record dated 1/25/2024 documents in part . presenting to the ED on 1/25/24 with complaints of worsening cellulitis of the right abdominal pannus and left lower extremity cellulitis. R2 reports she has been on antibiotics 3 times a day since 1/11/2024 (14 days). She reports worsening pain of the right lower abdomen with thickening of the skin . As patient failed oral antibiotic therapy for treatment of her cellulitis, she will need to continue IV antibiotic therapy for total of 10 days. PICC line was placed, and she was subsequently transitioned to IV antibiotics 24 hours prior to discharge. R2's Progress Notes dated 1/27/2024 documents in part .R2 returned from local hospital via ambulance with new orders for IV antibiotic to treat cellulitis to right pannus and left lower extremity .dual lumen PICC to right upper extremity. On 1/29/2024, at 1:20 PM, V2 (DON) stated that antibiotic monitoring is documented in the resident's progress notes. The facility's Antibiotic Stewardship Program Policy dated 12/13/2023 documents in part .4. Antibiotic Stewardship Actions .iv. Antibiotic time-out. At 72 hours of antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration of antibiotic need, duration, selection, and de-escalation potential .Completion of antibiotic time-out must be recorded in the resident record. On 1/30/2024, at 1:30 PM, V11 (Primary Physician) stated that if R2 was assessed on 1/07/2024 and was found to have a mass that was hard to touch, red, warm to touch, and appeared twice the size as the other side, I should have been notified on 1/07/2024, not wait until 1/09/2024. V11 stated that if an antibiotic is not improving, I should be notified right away so that a different treatment can be determined. The facility's Change of Condition Policy dated 10/07/2022 documents in part .Policy - The resident's physician and responsible party will be notified of any changes that occur in the resident's condition by licensed personnel as warranted. These changes are to include but are not limited to: Symptoms of infectious process.

Based on interview, observation, record review, the facility failed to follow fall interventions for 1 (R1) of 3 residents reviewed for falls. This failure resulted in R1 experiencing a fall and receiving a broken rib. Findings: 1. R1's face sheet documents that R1 admitted to the facility on [DATE] with a diagnosis of Other Idiopathic Peripheral Autonomic Neuropathy. R1's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score is 13, indicating that R1 is cognitively intact. Section GG, Functional Abilities and Goals, documents that R1 is independent with eating, dependent with oral hygiene, partial/moderate assistance with toileting hygiene, showering, upper/lower body dressing, bed mobility, sit to stand, chair/bed/chair transfer, toilet transfer, supervision/touching assistance with walking 50 feet with two turns. Section GG, dated 12/22/2023 documents that R1 requires set-up/clean-up assistance with eating, dependent with oral hygiene, substantial/maximal assistance with toileting hygiene, showering, partial/moderate assistance with upper/lower body dressing, personal hygiene, bed mobility, sit to stand, chair/bed/chair transfer, toilet transfer, tub/shower transfer, walk 10 feet/50 feet with two turns. R1's Care Plan documents in part . R1 is at risk for falls related to confusion, impaired mobility, incontinence, medications, osteoporosis, arthritis, and narcolepsy with a revision date of 10/23/2023; Goal: Decrease risk of fall and/or minimize injuries from falls x 90 days with a target date of 12/28/2023; Interventions: 2/01/2023 - Staff re-educated on importance of gait belt usage; 12/08/2023 - R1 is to be a two assist with all transfers until therapy is able to evaluate; 12/11/2023 - Transfer status changed to two assist until physical therapy is able to evaluate; 12/22/2021 - Educate to use walker with all transfers; 7/3/2022 - Educate staff to stay with her .Encourage use of call light; Give medications as ordered; Keep call light within reach; Keep environment free of clutter; Keep personal belongings within reach; Observe for side effects of medications; Observe for unsteady gait and balance; OT evaluate and treat if indicated; Provide adequate lighting; PT evaluate and treat if indicated. The facility's final fall investigation report dated 12/08/2023 documents A comprehensive investigation was completed and found on 12/08/2023, at approximately 4:40 PM, (R1) sustained a witnessed ground level fall in her bathroom. (R1) was being assisted by 1 staff member with her walker when her knees gave out. Licensed nursing staff immediately assessed (R1). Upon initial assessment, (R1) noted to have skin tears to right elbow, right hand, and right great toe. (R1) initially had no complaints of pain. On 12/11/2023, (R1) voiced complaint of pain to right knee and right side. Power of Attorney and Primary Physician were notified with an order obtained to complete an x-ray of right knee and right ribs. Results of the x-ray showed right lateral 9th rib fracture. The facility has completed a root cause analysis, which showed (R1) had become weak during transfer and was lowered to the ground. An appropriate intervention has been put into place in which (R1) was changed from a 1 person assist to a 2 person assist with a gait belt and walker to rest room. R1's X-ray report dated 12/11/2023 documents in part .1. Acute fracture right lateral ninth rib. R1's Fall Risk Assessment (Admission) dated 12/20/2021, documents fall risk score of 3 (low risk). R1's Fall Risk assessment dated [DATE], documents a fall risk score is 14 (high risk) and further documents that if the total score is 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. On 1/25/2024, at 10:45 AM, R1 stated that she had a fall last month and broke one of her ribs. R1 stated that the nursing staff was helping her roommate and told her to take herself to the bathroom. R1 stated that she walked to the bathroom with her walker by herself and when she got to the sink and turned around, she fell to the floor. R1 stated that she yelled and the nursing staff came to help her off the floor. R1 stated that she was wearing non-skid footwear when she had her fall. R1 stated that she did not have any pain after the fall. R1 stated that the pain came later. R1 stated that she started having pain on her right side and an x-ray was taken that revealed a broken rib. R1 stated that she did not have a gait belt on and walked to the bathroom by herself. R1 stated that she feels that she can walk to and from the bathroom with no problem even before the fall. R1 stated that she has walked to the bathroom by herself before her fall. R1 stated that she is working with therapy now. On 1/25/2024, at 11:58 AM, V3 (Certified Nurse Aide), stated that she and V9 (Certified Nurse Aide), were in R1's room assisting R1's roommate in getting up and observed R1 take herself to the bathroom. V3 stated that R1 attempted to turn herself, fell and her arm got stuck in walker/sink and R1's foot got stuck causing a skin tear to her toe. V3 stated that R1 did not have a gait belt on. On 1/25/2024, at 9:20 AM, attempted to contact V9, left message to return call back with no call back during this survey. R1's Witnessed Fall Report dated 12/8/23 documents a witness statement from V9 stating Residents knee gave out. fell on walker into sink. Got right arm stuck in between sink and walker. Feet bent still holding walker with left hand. On 1/29/2024, at 12:00 PM, V5 (Therapy Director) stated that the last time R1 was discharged from therapy was on 4/28/2023 and it was recommended at that time R1 would be an assist of 1 person with a gait belt & walker for transferring and ambulating. V5 stated that R1 is currently in therapy at this time since her fall on 12/8/2023. V5 stated that she is currently an assist x 2 with a gait belt and walker for transferring and ambulating. On 1/29/2024, at 12:45 PM, V7 (Certified Nurse Aide), & V8 (Certified Nurse Aide), were observed assisting R1 without the use of a gait belt, and walker to ambulate R1 to her bathroom.

Based on interview and record review, the facility failed to ensure residents are free from significant medication errors for one (R6) of eight residents reviewed for medication errors in the sample of eight. This failure resulted in a 15-day delay, from 6/5/23 to 6/19/23, in the initiation of R6's antibiotic therapy, with R6 experiencing pain and burning on urination during that period and being at risk of developing sepsis. Findings include: R6's Face Sheet documented an admitted [DATE], and diagnoses including Congestive Heart Failure, Diabetes Type 2, and Anxiety Disorder. On 6/20/23 at 11:05am, V3 (Licensed Practical Nurse/LPN) stated she works 6pm to 6am on Thursday through Sunday. V3 stated the facility has issues with running out of resident medications on the weekends, as the pharmacy is closed on weekends. On 6/20/23 at 1:15pm, V12 (LPN) stated she works 6am to 6pm varying days from Monday through Friday. V12 stated there is an ongoing problem with getting resident medications from the pharmacy in a timely manner. V14 stated that R6 was just started on an antibiotic for a UTI (Urinary Tract Infection) yesterday that had been ordered several days ago. On 6/20/23 at 1:40pm, R6 was alert and oriented to person, place, and time. R6 stated she did not feel well that day as she was having severe burning and pain on urination. R6 stated she had been diagnosed several days ago, with a UTI. R6 stated she was initially put on an IV (Intravenous) antibiotic, but she preferred to have a pill or a shot to the IV, so the IV antibiotic order was never administered. R6 stated, They just started me yesterday on something else, it's in a shot (intramuscular injection). Meanwhile, it burns like fire when I (urinate). This has been going on for days now. R6's Nurses Notes read as follows: 6/2/2023: New order received from (V16, Physician) for Urinalysis (UA) and C&S (Culture and Sensitivity) if indicated related to resident complaining of dysuria and frequency. 6/2/2023: New order received from (V16) for (Levaquin) 250 milligrams (mg) by mouth once daily for seven days for UTI .will attempt to obtain (the medication) from back up pharmacy tomorrow. The June POS (Physicians Order Sheet) documented a 6/2/23 order for Levaquin 250mg one tablet by mouth every 24 hours. The June 2023 MAR (Medication Administration Record) documented the Levaquin was administered 6/3/23, 6/4/23, and 6/5/23. A 6/3/23: UA (Urinalysis) with C&S (Culture and Sensitivity) documented the urine was cloudy with the presence of red and white blood cells and proteus organisms, with the organism being resistant to Levaquin. The Nurses Notes continued as follows: 6/3/23: Received preliminary report of UA, faxed to (V16's) office. 6/5/23: Received (order) to discontinue Levaquin and start Ertapenem 500 mg IV daily for 14 days. The June POS documented a 6/5/23 order for Ertapenem Sodium Solution Reconstituted, use 500 mg intravenously one time a day for UTI for 14 days. R6's June 2023 MAR documented the following: 6/6/23, 6/7/23, 6/8/23:MN-Medicine Not Available. (Not Administered.) There was no entry on 6/5/23 to indicate if the medication had been administered or if it was available. The Nurses Notes continued as follows: 6/9/23: Resident refusing to allow nurses to place peripheral IV access to administer her antibiotic per (V16) orders. Resident states (V16) can give her something oral for her UTI .This nurse called (V16) office and updated (about) resident's condition and refusal of IV medication, awaiting call back at this time. 6/10/23: Obtained new order to discontinue IV medication related to resident refusal and start IM (Intramuscular) Ertapenem once daily for 14 days .unable to obtain medication due to pharmacy being closed. The June POS documented a 6/10/23 order for Ertapenem Sodium injection solution reconstituted inject 500 mg IM daily at bedtime. The June 2023 MAR documented the following: 6/12/2023, 6/13/23, 6/15/23, 6/16/23: (All these entries are identical): Ertapenem Sodium Injection Solution Reconstituted. Inject 500 milligrams intramuscularly at bedtime for UTI for 14 Days: (Not given); Medicine not available. There was no documentation to indicate if the medication was available or given on 6/10/23 and 6/11/23. The Nurses Notes continued as follows: 6/16/2023: Changed residents IM (trade name Ertapenem) to start on Monday 06/19/23 due to unavailable until then. 6/19/2023: First dose of IM antibiotic given in left buttock with no adverse effects noted . On 6/20/23 at 2:10pm, V2 (Director of Nurses/DON) stated she is aware of problems with residents not having medications available. V2 verified the above documentation of the delay in R6's antibiotic. V2 stated the pharmacy is not open on the weekend, and their backup pharmacy at a local hospital is not able to deliver medications. V2 stated the pharmacy only does one route per day, so if medications are needed later in the day, they cannot be delivered. V2 stated she became aware of the issue with R6's antibiotic on 6/16/23 at which time she called the pharmacy, they said they had to order it and it would be in on 6/19/23. V2 stated her staff had, in error been contacting the pharmacy the facility uses only for IV medications, who were apparently not returning their calls. V2 stated she and V1 (Administrator) have notified corporate staff that they are having problems with the pharmacy, but they are unable to obtain services from a different pharmacy without corporate approval. On 6/22/23 at 10:25am, V19 (Pharmacist) stated she is aware the facility is having difficulty getting resident medications timely. V19 stated when the facility entered into a contractual agreement with them in November 2022, the facility was well aware of the pharmacy's limitations, such as being closed on weekends, being located 30 minutes away from the facility, and only having one driver who runs a set route only once a day. V19 stated additional delivery trips can be made at a cost of $50 per trip, which the facility has never utilized. V19 stated the pharmacy at a local hospital is able to fill medications on the weekend, but they do not offer delivery, narcotics, nor IV medications. V19 stated her pharmacy also does not have the capability to do IVs, and the facility has a different pharmacy for that. V19 stated apparently the facility was contacting the IV pharmacy to try to obtain the IM Ertapenem instead of calling them. V19 stated an additional concern is that facility staff don't think ahead about what medications residents are going to need, and it is not at all unusual for staff to call them on a Friday at 4:00pm. V19 stated they service 4 assisted living facilities with none of these issues. On 6/22/23 at 4:00pm, V16 (Physician) stated he was not aware the facility was having issues with pharmacy services. V16 stated R6 has a history of UTIs, the most recent as outlined above has proteus in the urine. V16 stated R6 going without antibiotic therapy for several days would definitely result in continued symptoms of pain and burning as well as a potential for sepsis. On 6/23/23 at 10:30am, V1 (Administrator) stated she was unaware of the extent of the problem with residents not getting their medications timely. V1 stated she and corporate staff have met with the pharmacy to try to work out problems, and she feels another meeting is probably needed. On 6/26/23 at 1:40pm, V1 stated the facility met with the pharmacy this morning. The pharmacy will be working with a pharmacy in the same town to provide resident medications more timely, and the facility is looking for a different backup pharmacy for weekend coverage. V1 stated V2 will more closely monitor resident medication orders. A Medication Error Policy dated 10/23/22 stated, A Medication error shall be defined as any variation in administration of medication from the physicians orders and/or facility policy.