Every finding on record at The Haven on the River

Based on interview and record review, the facility failed to ensure residents are free from neglect for 1 of 6 residents (R1) reviewed for neglect in the sample of 12. The failure resulted in R1 not receiving an immediate nursing assessment and treatment for a fall resulting in a hip fracture.Findings include:R1's Face Sheet documented an admission Date of 3/18/26, and listed Diagnoses including Vascular Dementia, Atherosclerotic Heart Disease, and Chronic Obstructive Pulmonary Disease.R1's Minimum Data Set, dated [DATE], documented R1 had moderate deficits in cognition. R1's Care Plan, dated 4/30/26, documented a problem area, The resident is moderate risk for falls related to history of falls, poor safety awareness, impulsivity; resident sometimes crawls out of bed. A 3/18/26 admission Fall Risk Assessment documented that R1 was at high risk for falls.Nursing Progress Notes documented the following:5/19/26 9:36am: During morning med pass resident was resting comfortably in bed, took his meds and had no complaints. Later in the AM (morning) CNA's (Certified Nursing Assistants) got him out of bed, he was complaining about pain at the hip/femur location with verbalization of pain. I assessed and found patient to have a complaint of pain, and I notified management and obtained order for stat (immediate) x-rays of femur, hip, and pelvis. Placed resident into his recliner where he remained awaiting x-ray. Client had no complaints other than that when he got up out of bed. Created by V14 (Licensed Practical Nurse).5/19/26 4:41pm: Late Entry: Resident family arrived after being notified that he had fallen a couple days prior, once we were informed by a CNA that (V7- Agency Nurse) told her that he fell, but stated, He didn't really fall, he sat down on the floor. Upon arrival they called EMS (Emergency Management Systems) for transport to hospital. Created by V14.There was no documentation in R1's record to indicate R1 fell on 5/17/26. The was no assessment from a fall noted in R1's records for the date of 5/17/26.R1's May 2026 Physicians orders and May 2026 Medication Administration Report (MAR) both documented an order for Hydrocodone Acetaminophen Oral Tablet 5-325 Mg. (Milligrams) give 1 tablet by mouth every 6 hours as needed for pain. The MAR was left blank for the 6pm to 6am shift on 5/17/26, indicating R1's pain was not assessed, and the pain medication was not given. A (NP)Nurse Practitioner Visit Note at 5/19/26 5:45pm by V11 (NP) documented, (R1) is being seen this evening after getting a call today that he was having left hip pain again and that he possibly fell over the weekend. Awaiting on (portable x-ray) (R1) is a [AGE] year-old male with a complex medical history as seen below. He is being seen today since he is a high risk for falls and recently fractured his right acetabulum and right pubis after a fall on the 30th of April (2026). This am when day shift nurse when in to give him his meds he reported that his left hip was hurting. This provider was notified and gave order to get x-rays of hip. When this NP arrived at facility this evening Xray has not been done due to Xray company has not arrived yet. (R1) reported that he fell on Sunday and hurt his left hip. Staff was unaware of this fall. When (R1) was asked about his fall he could not give me much detail except that he landed on left hip, and it hurt. His pain at time of assessment was rated a 4/10. He received pain medication around 2pm. Left leg does look slightly externally rotated, but he is up in recliner and hard to assess. He did not want to move to bed to let me evaluate him better. He had another fall about one month ago and had left hip pain also and Xray was negative. He reported that he has been in bed since Sunday but staff report that he has been up out of bed in chair and even in his wheelchair. Today was the first day staff was aware of pain in left hip. He does get hydrocodone 5/325mg (milligrams) every 6 hours for pain in his right hip/pelvis for previous fracture. It really is unclear what happened or when it happened. In our discussion I asked him if he was ok with me sending him to hospital to get evaluated he agreed. Before this NP was able to relate plan to nursing (R1's) family had come in to see him and called EMS themselves. Daughter was at the desk when this NP came to talk with nurse that was working, and she informed me that she wants him sent out. This NP told her that was my plan, and she responded that she had already called EMS, and they were on their way.R1's 5/19/26 Emergency Department admission record documented, Patient presents with left hip pain after a fall. Patient states 2 days ago he slipped and fell landing on his left hip at the nursing home. He was not sent out at that time and has been bed-bound since. His family came to visit him and he was complaining of left leg pain and they wanted him transferred here for evaluation. Patient denies any other injuries. He denies any head injury or loss of consciousness. He denies any fevers chills nausea vomiting chest pain abdomen pain or shortness of breath. He is on chronic O2 (oxygen) for COPD (Chronic Obstructive Pulmonary Disease). Any movement causes increased pain. Nothing else has made his symptoms better or worse and they are mild in nature. Patient's left lower extremity is externally rotated and he has tenderness to palpation on the hip and pain with any movement. He does have good distal neurovascular exam. Xray of the left hip and pelvis: SI (Sacroiliac) joints are symmetric. Right total hip arthroplasty is in place with anatomic alignment. Intertrochanteric fracture of the left femur with mild impaction. Old right inferior pubic ramus fracture is stable in place. An Illinois Department of Public Health (IDPH) Final Investigation Report, dated 5/20/26, documented, Diagnosis: (R1): Hip fracture. A comprehensive investigation was conducted regarding the incident. The resident was found seated on the floor at the foot of his bed, positioned on his buttocks with blankets draped over his legs. The incident was unwitnessed and resident was unable to make a statement as to what caused the fall at that time. Licensed nursing staff immediately assessed resident. During the initial assessment the resident denied any pain or discomfort. Resident showed no signs of distress. A follow up assessment was completed at which time the resident then reported pain in the left hip area. The attending physician and POA (Power of Attorney) were promptly notified. An order was obtained to perform an X-Ray of the left hip area. Before X-Ray was performed attending physician was present to assess resident. Family chose to contact EMS (Emergency Management Systems) to transfer resident to ER (Emergency Room)for further evaluations and treatment. Administrator, Director of Nurses (DON), and IDPH were notified per facility protocol. DON contacted hospital for follow up on resident's condition, and was notified of a diagnosis of left hip fracture. Hospital reported resident was scheduled for surgery the following day. Appropriate notifications were made as indicated. A root cause analysis was completed and determined that the primary contributing factor to the fall was resident attempting to transfer without assistance due to confusion related to a diagnosis of dementia. Resident will not return to facility at this time, as resident's family has chosen to have him placed at another skilled nursing facility. Facility will continue to educate and make adjustments as necessary to ensure residents safety.On 5/22/26 at 9:15am, V4, Family Member of R1, stated R1 fell on 5/17/26 and the family did not know about it until they visited R1 on 5/19/26 and noted he was in pain and something was obviously wrong with his hip. V4 stated the family called 911 and R1 was taken to ER, where a right hip fracture was diagnosed. V4 stated R1 had hip surgery on 5/20/26 and then suffered a stroke and his condition has deteriorated. V4 stated staff was apologetic about the lack of notification of the fall. V4 stated the family has decided R1 will not be returning to the facility after he is released from the hospital. On 5/22/26 at 10:45am, V5, R1's POA, stated she and V4 went to visit R1 on 5/19/26, and R1 was in pain from his right hip and they could tell by looking at his legs there was something wrong with the hip, so they called 911 for him to be taken to the ER. V5 stated she is unhappy with the quality of care R1 received and he will be going to a different facility. On 5/22/26 at 1:05pm, V3, Certified Nursing Assistant (CNA) stated she has recently put in her 2 weeks notice as, She is tired of all the problems going on at the facility. V3 stated on 5/19/26 she arrived onto the floor at about 11:15am after being called in. V3 stated R1 was wet and soiled so she got him ready for a shower, and he was yelling out in pain. V3 stated she asked one of the CNA's about it, that is when V12, CNA, stated she had seen R1 lying on the floor by his bed on 5/17/26. V3 stated she then reported this to V2, Director of Nurses. On 5/26/26 at 9:45am, V7, Registered Nurse/Agency, stated on 5/17/26 on the 6pm to 6am shift, she and V12 were in R1's room with him, when suddenly R1 said he needed to go to the bathroom, sat up to side of bed and slid out of the bed with his buttocks making contact with the floor. V7 stated, He didn't fall, that is not considered a fall, he slid and then sat down. He said he was fine, nothing seemed to be wrong with him, he said he wasn't in any pain, so we got him back in bed, checked his vital signs, and that was about it. Since it wasn't a fall, there was no need to do an assessment. V7 stated since it was not a fall, she did not notify the Physician, R1's POA, V2, or the oncoming nurse at shift change and did not do a progress note or a fall investigation. V7 stated, Three days after the fact, management called me and said I had to do a report because it turned out he had a fractured hip. On 5/26/26 at 1:25pm, V2 (DON) stated on 5/19/26, CNAs reported R1 was having severe pain in his right hip when they were doing morning care. V2 stated it was then reported to her that R1 fell about 11:30pm on 5/17/26. V2 stated V7 told her R1 was sitting up to the edge of bed and slid down with butt making contact with the floor. V2 stated V7 did not report it to the POA, the physician, or herself nor start a fall report because she did not consider it a fall. V2 stated V7 did do vital signs and a nursing assessment but didn't document it. V2 stated she immediately notified V11, Nurse Practitioner, who ordered a portable x-ray and stated she would evaluate R1 that afternoon. V2 stated in the afternoon, R1's family came and they called 911 to ask for transport to the ER due to R1's hip pain. V2 stated she has since talked to V7 and stressed that what occurred with R1 was indeed a fall and should have been processed as such. V2 was informed V7 was still maintaining it was not a fall.On 5/27/26 at 8:30am, V11, Nurse Practitioner, stated she last saw R1 on 5/19/26 later on in the afternoon, after V2 had notified her R1 fell. V11 stated when she arrived, although she had ordered a portable x-ray, the provider had not yet been here to do it. V11 stated when she examined but R1 he was not able to tell her what happened due to issues with his memory. V11 stated he was complaining of right hip pain, and the right leg was externally rotated. V11 stated it is her understanding from staff was that a CNA found him lying on the floor by his bed on 5/17/26, and the nurse responsible for his care did not document an assessment, did not contact V11, did not contact the POA, nor facility management. V11 stated in the meanwhile R1's family came in and called 911 before she had a chance to speak with them about his condition. V11 stated it was confirmed by the hospital that R1 had a hip fracture. V11 stated R1 had a history of a previous hip/pelvis fracture from a fall. V11 stated R1's medical history documented poor bone density, and sliding onto a sitting position could definitely cause a fracture. V11 stated if V7 had assessed R1, she would have noted the external rotation, and had she contacted V11 she would have ordered him sent to ER (Emergency Room). On 5/27/26 at 9:30am, V12 (CNA) stated on 5/17/26 about 11pm or so, she was rounding doing bed checks when she saw R1 lying on floor at the foot of his bed and he couldn't say what happened. V12 stated she and V7 got R1 back in bed, got him cleaned up as he had been incontinent, and V7 checked his vitals. V12 stated R1 was in a lot of pain from his right hip. V12 stated V7 did not assess R1 for injuries. When told about the account V7 gave, V12 stated, It absolutely did not happen that way, it happened the way I explained it. I found him on the floor.On 5/27/26 at 1:55pm, V14, Licensed Practical Nurse, stated he was informed by V3 that R1 fell and V7 didn't document it or tell anybody about it. V14 stated he asked V7 about it, and she told V14, (R1) fell out of his chair. V14 stated he wrote the progress notes and V15, Regional Nurse Consultant, Gave him a 30-minute lecture about not documenting too thoroughly because if the state comes in on this fall, they could see those notes and ask too many questions, and the information was based on hearsay, not facts. V14 stated he felt V15's agenda in saying this was to encourage V14 to strike through those notes, which V14 then did.On 5/27/26 at 2:10pm, V1 (Administrator) provided a document titled, Fall, dated 5/17/26. V1 stated when the 5/17/26 fall was discovered to have happened a fall investigation was initiated on 5/19/26. V1 stated the document was dated 5/17/26 as that was when the fall occurred although the report was not done until 5/19/26.A 5/17/26 Fall document dated 5/17/26 documented, The resident was in residents' room with staff (CNA) and slipped onto the floor. Nurse assessed resident. No injuries noted. No complaints of pain. Nurse and CNA assisted resident back to bed. Resident stated he was trying to use the restroom. Staff explained he had a brief on and assisted changing him when in bed. Statement from V12, 5/19/26: (V12) reported she walked by the resident's room and observed him sitting on the floor next to the foot of his bed. She called for the nurse who completed vitals and assessment before assisting him back to bed. Statement from V7, 5/19/26: (V2) interviewed (V7) who reported CNA alerted her to resident being on floor next to his bed and presumed he crawled onto floor from bed. She completed vital signs and assessment before assisting him back to bed. His condition was monitored throughout the rest of the shift.On 5/28/26 at 9:30am, V15 was asked if he knew why V14's progress notes had been struck through, and he said no. V15 stated, I had a conversation with (V14) about charting and that he should not chart hearsay or conversations with other staff members. Nobody has the ability to strike out anybody's else's notes. V15 was asked if V14 had struck through the notes as a result of that conversation and he stated he didn't know.On 5/29/26 at 12:20pm, V1 stated V7 had not been blacklisted, was on the schedule for 5/27/26 but had called in, and V1 believed she was on the schedule for a shift tonight at 6pm. On 5/29/26 at 12:30, V1 stated he checked with V2 and she had cancelled all V7's future shifts. V1 stated he did not view V7's actions as neglect and thus did not do a neglect investigation. The facility's undated Abuse Prevention Policy documented, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents'. This will be done by: Conducting pre-employment screening of employees and pre-admission screening of residents; Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property; Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; Identifying occurrences and patterns of potential mistreatment; Identifying concerns of residents' allegations of deprivation of goods and services by staff; Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; Assuring that physical restraints are used sparingly and properly, and that chemical restraints are not used; and, filing accurate and timely investigative reports. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish (42 CFR 483.5). Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident (201 ILCS 45/1-117) including deprivation of goods and services by staff. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property is unsubstantiated. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.

Based on interview and record review, the facility failed to provide administrative oversight to ensure the facility implemented their policy to facilitate cooperation with regulatory bodies in connection with IDPH (Illinois Department of Public Health) surveys. This failure has the ability to affect all 45 residents living at the facility. Findings include: R1's Face Sheet documented an admission Date of 3/18/26 and listed Diagnoses including Vascular Dementia, Atherosclerotic Heart Disease, and Chronic Obstructive Pulmonary Disease.R1's Minimum Data Set, dated [DATE], documented R1 had moderate deficits in cognition. R1's Care Plan, dated 4/30/26, documented a problem area, The resident is moderate risk for falls related to history of falls, poor safety awareness, impulsivity; resident sometimes crawls out of bed. A 3/18/26 admission Fall Risk Assessment documented that R1 was at high risk for falls.R1's Nursing Progress Notes, authored by V14, Licensed Practical Nurse, documented the following, with both notes being struck through (effectively deleted):5/19/26: Resident family arrived after being notified that he had fallen a couple days prior, once we were informed by a CNA (Certified Nursing Assistant) that (V7, Registered Nurse, Agency) told her that he fell, but stated he didn't really fall, he sat down on the floor. Upon arrival they called EMS (Emergency Management Systems) for transport to hospital.5/21/26: During morning hand off and reporting it was shared by (V7) as stated family was pissed about a fall that didn't happen, he didn't fall, he sat in the floor, he didn't get hurt on my watch, it happened after my shift. Then there's no way he broke anything that day. Then it was reported to me that the family called state, resident had surgery, a rod placed, and is not returning to facility, he is going to (another facility).On 5/27/26 at 1:55pm, V14, stated he was informed by V3, CNA, that R1 fell and V7 didn't document it or tell anybody about it. V14 stated he asked V7 about it, and she told V14, (R1) fell out of his chair. V14 stated he wrote the progress notes and V15, Clinical Nurse Consultant, Gave him a 30-minute lecture about not documenting too thoroughly because if the state comes in on this fall, they could see those notes and ask too many questions, and the information was based on hearsay, not facts. V14 stated the documentation was accurate and factual. V14 stated he felt V15's agenda in saying this was to encourage V14 to strike through those notes, which he then did.On 5/28/26 at 9:30am, V15 was asked if he knew why V14's progress notes had been struck through, and he said no. V15 stated, I had a conversation with (V14) about charting and that he should not chart hearsay or conversations with other staff members. V15 denied asking V14 to strike through the notes and denied making the statement that the state would ask too many questions. The Surveyor asked V15 if he believed V14 had struck through the notes as a result of the conversation, and V15 stated he didn't know. V15 stated in their computer system, only the author of the note can strike through it. On 5/28/26 at 10am, V1, Administrator, stated he felt he needed to inform the Surveyor that V14 had been terminated due to poor customer service, and he hoped the Surveyor had not been influenced by anything he might have said.A Regulatory Investigations Policy, dated January 2016, documented, Purpose: To facilitate cooperation with regulatory bodies in connection with their investigations/surveys. 1. All employees are expected to cooperate in investigations/surveys conducted by regulatory bodies.A Charting and Documentation Policy, dated August 2006, stated, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.A Resident Matrix, dated 5/22/26, documented a total of 45 residents living at the facility.

Based on observation, interview, and record review, the facility failed to immediately initiate an investigation into a resident fall and failed to ensure a door remained closed to prevent elopements from residents at risk for elopement for 7 or 7 residents (R1, R4, R8, R9, R10, R11, R12) reviewed for accidents and supervision in a sample of 12.Findings include:1. R1's Face Sheet documented an admission Date of 3/18/26, and listed Diagnoses including Vascular Dementia, Atherosclerotic Heart Disease, and Chronic Obstructive Pulmonary Disease.R1's Minimum Data Set, dated [DATE], documented R1 had moderate deficits in cognition. R1's Care Plan, dated 4/30/26, documented a problem area, The resident is moderate risk for falls related to history of falls, poor safety awareness, impulsivity; resident sometimes crawls out of bed. A 3/18/26 admission Fall Risk Assessment documented that R1 was at high risk for falls.Nursing Progress Notes documented the following:5/19/26 9:36am: During morning med pass resident was resting comfortably in bed, took his meds and had no complaints. Later in the AM (morning) CNA's (Certified Nursing Assistants) got him out of bed, he was complaining about pain at the hip/femur location with verbalization of pain. I assessed and found patient to have a complaint of pain, and I notified management and obtained order for stat (immediate) x-rays of femur, hip, and pelvis. Placed resident into his recliner where he remained awaiting x-ray. Client had no complaints other than that when he got up out of bed. Created by V14 (Licensed Practical Nurse).5/19/26 4:41pm: Late Entry: Resident family arrived after being notified that he had fallen a couple days prior, once we were informed by a CNA that (V7- Agency Nurse) told her that he fell, but stated, He didn't really fall, he sat down on the floor. Upon arrival they called EMS (Emergency Management Systems) for transport to hospital. Created by V14.There was no documentation in R1's record to indicate R1 fell on 5/17/26. The was no assessment from a fall noted in R1's records for the date of 5/17/26.A (NP) Nurse Practitioner Visit Note at 5/19/26 5:45pm by V11 (NP) documented, (R1) is being seen this evening after getting a call today that he was having left hip pain again and that he possibly fell over the weekend. Awaiting on (portable x-ray) (R1) is a [AGE] year-old male with a complex medical history as seen below. He is being seen today since he is a high risk for falls and recently fractured his right acetabulum and right pubis after a fall on the 30th of April (2026). This am when day shift nurse when in to give him his meds he reported that his left hip was hurting. This provider was notified and gave order to get x-rays of hip. When this NP arrived at facility this evening Xray has not been done due to Xray company has not arrived yet. (R1) reported that he fell on Sunday and hurt his left hip. Staff was unaware of this fall. When (R1) was asked about his fall he could not give me much detail except that he landed on left hip, and it hurt. His pain at time of assessment was rated a 4/10. He received pain medication around 2pm. Left leg does look slightly externally rotated, but he is up in recliner and hard to assess. He did not want to move to bed to let me evaluate him better. He had another fall about one month ago and had left hip pain also and Xray was negative. He reported that he has been in bed since Sunday, but staff report that he has been up out of bed in chair and even in his wheelchair. Today was the first day staff was aware of pain in left hip. He does get hydrocodone 5/325mg (milligrams) every 6 hours for pain in his right hip/pelvis for previous fracture. It really is unclear what happened or when it happened. In our discussion I asked him if he was ok with me sending him to hospital to get evaluated, he agreed. Before this NP was able to relate plan to nursing (R1's) family had come in to see him and called EMS themselves. Daughter was at the desk when this NP came to talk with nurse that was working, and she informed me that she wants him sent out. This NP told her that was my plan, and she responded that she had already called EMS, and they were on their way.R1's 5/19/26 Emergency Department admission record documented, Patient presents with left hip pain after a fall. Patient states 2 days ago he slipped and fell landing on his left hip at the nursing home. He was not sent out at that time and has been bed-bound since. His family came to visit him, and he was complaining of left leg pain, and they wanted him transferred here for evaluation. Patient denies any other injuries. He denies any head injury or loss of consciousness. He denies any fevers chills nausea vomiting chest pain abdomen pain or shortness of breath. He is on chronic O2 (oxygen) for COPD (Chronic Obstructive Pulmonary Disease). Any movement causes increased pain. Nothing else has made his symptoms better or worse and they are mild in nature. Patient's left lower extremity is externally rotated and he has tenderness to palpation on the hip and pain with any movement. He does have good distal neurovascular exam. Xray of the left hip and pelvis: SI (Sacroiliac) joints are symmetric. Right total hip arthroplasty is in place with anatomic alignment. Intertrochanteric fracture of the left femur with mild impaction. Old right inferior pubic ramus fracture is stable in place. On 5/22/26 at 9:15am, V4, Family Member of R1, stated R1 fell on 5/17/26 and the family did not know about it until they visited R1 on 5/19/26 and noted he was in pain and something was obviously wrong with his hip. V4 stated the family called 911 and R1 was taken to ER, where a right hip fracture was diagnosed. V4 stated R1 had hip surgery on 5/20/26 and then suffered a stroke and his condition has deteriorated. V4 stated staff was apologetic about the lack of notification of the fall. V4 stated the family has decided R1 will not be returning to the facility after he is released from the hospital. On 5/22/26 at 10:45am, V5, R1's Power of Attorney, stated she and V4 went to visit R1 on 5/19/26, and R1 was in pain from his right hip and they could tell by looking at his legs there was something wrong with the left hip, so they called 911 for him to be taken to the ER. V5 stated she is unhappy with the quality of care R1 received and he will be going to a different facility. On 5/22/26 at 1:05pm, V3, Certified Nursing Assistant (CNA) stated she has recently put in her 2 weeks notice as, She is tired of all the problems going on at the facility. V3 stated on 5/19/26 she arrived onto the floor at about 11:15am after being called in. V3 stated R1 was wet and soiled so she got him ready for a shower, and he was yelling out in pain. V3 stated she asked one of the CNA's about it, that is when V12, CNA, stated she had seen R1 lying on the floor by his bed on 5/17/26. V3 stated she then reported this to V2, Director of Nurses. On 5/26/26 at 9:45am, V7, Registered Nurse/Agency, stated on 5/17/26 on the 6pm to 6am shift, she and V12 were in R1's room with him, when suddenly R1 said he needed to go to the bathroom, sat up to side of bed and slid out of the bed with his buttocks making contact with the floor. V7 stated, He didn't fall, that is not considered a fall, he slid and then sat down. He said he was fine, nothing seemed to be wrong with him, he said he wasn't in any pain, so we got him back in bed, checked his vital signs, and that was about it. Since it wasn't a fall, there was no need to do an assessment. V7 stated since it was not a fall, she did not notify the Physician, R1's POA, V2, or the oncoming nurse at shift change and did not do a progress note or a fall investigation. V7 stated, Three days after the fact, management called me and said I had to do a report because it turned out he had a fractured hip. On 5/26/26 at 1:25pm, V2 stated on 5/19/26, CNAs reported R1 was having severe pain in his right hip when they were doing morning care. V2 stated it was then reported to her that R1 fell about 11:30pm on 5/17/26. V2 stated V7 told her R1 was sitting up to the edge of bed and slid down with butt making contact with the floor. V2 stated V7 did not report it to the POA, the physician, or V2 or start a fall report because she did not consider it a fall. V2 stated V7 did do vital signs and a nursing assessment but didn't document it. V2 stated she notified V11, Nurse Practitioner, who ordered a portable x-ray and stated she would evaluate R1 that afternoon. V2 stated in the afternoon, R1's family came, stating they had heard about the fall from a CNA, and they called 911 to ask for transport to the ER. When asked what was determined as the root cause of the fall, V2 stated, I would assume toileting. V2 stated she has since talked to V7 and stressed that what occurred with R1 was indeed a fall and should have been processed as such. On 5/27/26 at 8:30am, V11 stated she last saw R1 on 5/19/26 later on in the afternoon, after V2 had notified her that R1 fell. V11 stated when she arrived, although she had ordered a portable x-ray, the provider had not yet been here to do it. V11 stated when she examined R1 he was not able to tell her what happened due to issues with his memory. V11 stated he was complaining of right hip pain, and the right leg was externally rotated. V11 stated it is her understanding from staff was that a CNA found him lying on the floor by his bed on 5/17/26, and the nurse responsible for his care did not document an assessment, did not contact V11, did not contact the POA, nor facility management. V11 stated in the meanwhile R1's family came in and called 911 before she had a chance to speak with them about his condition. V11 stated it was confirmed by the hospital that R1 had a hip fracture. V11 stated R1 had a history of a previous hip/pelvis fracture from a fall. V11 stated R1's medical history documented poor bone density, and sliding onto a sitting position could definitely cause a fracture. V11 stated if V7 had assessed R1, she would have noted the external rotation, and had she contacted V11 she would have ordered him sent to ER. On 5/27/26 at 9:30am, V12 stated on 5/17/26 about 11pm or so, she was rounding doing bed checks when she saw R1 laying on floor at the foot of his bed and couldn't say what happened. V12 stated she and V7 got R1 back in bed, got him cleaned up as he had been incontinent, and V7 checked his vitals. V12 stated R1 was in a lot of pain from his right hip. V12 stated V7 did not check R1 for injuries. When told about the account V7 gave, V12 stated, It absolutely did not happen that way, it happened the way I explained it. I found him on the floor.On 5/27/26 at 2:10pm, V1 (Administrator) provided a document titled, Fall, dated 5/17/26. V1 stated when the 5/17/26 fall was discovered to have happened a fall investigation was initiated on 5/19/26. V1 stated the document was dated 5/17/26 as that was when the fall occurred although the report was not done until 5/19/26.A 5/17/26 Fall document, dated 5/17/26, documented, The resident was in residents' room with staff (CNA) and slipped onto the floor. Nurse assessed resident. No injuries noted. No complaints of pain. Nurse and CNA assisted resident back to bed. Resident stated he was trying to use the restroom. Staff explained he had a brief on and assisted changing him when in bed. Statement from V12, 5/19/26: (V12) reported she walked by the resident's room and observed him sitting on the floor next to the foot of his bed. She called for the nurse who completed vitals and assessment before assisting him back to bed. Statement from V7, 5/19/26: (V2) interviewed (V7) who reported CNA alerted her to resident being on floor next to his bed and presumed he crawled onto floor from bed. She completed vital signs and assessment before assisting him back to bed. His condition was monitored throughout the rest of the shift. A Falls Clinical Protocol Policy, dated August 2008, documented, As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. In addition, the nurse shall assess and document/report the following: a. Vital signs b. Recent injury, especially fracture or head injury, c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in cognition or level of consciousness e. Neurological status f. Pain g. Frequency and number of falls since last physician visit h. Precipitating factors, details on how fall occurred i. All current medications, especially those associated with dizziness or lethargy. j. All active diagnoses. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. a. Falls should be categorized as a) those that occur while trying to rise from a sitting or lying to an upright position, b) those that occur while upright and attempting to ambulate, and c) other circumstances such as sliding out of a chair or rolling from a low bed to the floor. They should also be identified as witnessed or unwitnessed events. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall.2. On 5/22/26 at 9:15am, V4, Family Member of R1, stated the family has a friend who is a CNA at the facility who told them that about two weeks prior, R1 got out onto the smoking patio and was not noticed missing for 4 hours, and by the time he was found, R1 was freezing, his fingertips were blue from having gone without his oxygen, and his oxygenation level was low. V4 stated she did not want to reveal the CNAs identity as she feared losing her job.On 5/22/26 at 10:45am, V5, R1's Power of Attorney, stated she found out from V3, CNA, that on date and time unknown, (R1) had got out of the building and into the smoking area, they are not sure how it happened, and apparently there is no incident report on it. V5 stated when R1 was found he was cold and had blue fingertips. V5 stated she was told, They didn't send him to the ER (Emergency Room) but they thought about it. V5 stated the facility is known to prop open the smoking area door so independent smokers can go in and out on their own.On 5/22/26 at 1:05pm, V3 stated she was not sure of the date, but R1, Ended up in the smoker's area for about 4 hours and nobody realized he was out there. V3 stated she had found him there. V3 stated, He had been without his oxygen that whole time, and his fingertips were blue. It wasn't cold out, it was in the 80s. V3 stated R1 is a supervised smoker and she doesn't know if staff left him out there, if another resident helped him get out there, or if he self-propelled out there. V3 stated sometimes the alarmed door leading onto the patio is propped open with a rock so the independent smokers can go in and out without staff. V3 stated R1 was wearing a personal perimeter alarm, and V3 didn't remember if the door was propped open. V3 stated V9, Registered Nurse, checked his oxygenation level, and it was 87, and V9 put his oxygen back on him. V3 stated R1's oxygen level returned to his baseline within a few minutes. V3 stated it is her understanding that V2, Director of Nurses, was investigating the incident. V3 stated she informed R1's family about the incident.On 5/26/26 at 12:10pm, V8, RN, stated she does not remember the day, but does recall one of the CNA's telling her of finding R1 alone outside on the back smoking area and nobody knew how long he had been out there. V8 stated she did not recall him being blue or cold but did recall his blood oxygenation level being in the 80s. V8 stated staff put him in bed, put his oxygen on him and it returned to the 90's quickly. V8 stated she did not call the physician or the POA, nor document it, nor start an investigation, but one of the CNA's who is friends with the family called the family and reported it. V8 stated she didn't recall reporting it to the oncoming nurse at shift change. V8 stated she was not sure how he got out there but the residents often prop the door open so the unsupervised smokers can go in and out freely. V8 stated R1 could possibly have gone out by himself if the door was propped open. On 5/26/26 at 1:25pm, V2, when asked about the staff and family reports of R1 being left alone in the smoker's area, stated she had not heard anything about it. On 5/27/26 at 9:45am and 5/29/26 at 11:20am, there was a rock holding open the door to the smoker's patio. On both occasions, the Surveyor walked out onto the patio and back in without moving the rock, and the door alarm didn't sound. The adjacent fence gate did not have a lock and was easily opened, accessing a parking lot area.On 5/27/26 at 9:50am, R5 and R6, both alert and oriented, were observed on the smoker's patio and interviewed. Both stated they were acquainted with R1 and that he was a supervised smoker. Both stated they had never noticed him unsupervised on the patio. Both stated residents often prop the door open with a rock so that unsupervised smokers can come and go as desired. Both stated several residents know the door code to get out onto the area, but to get back in you must hit a buzzer to notify staff to let you back in the building. On 5/27/26 at 11:15am, V1, Administrator, stated he was unaware of any incident involving R1 and the smoker's patio. V1 stated he interviewed V3 and V8, and was told by V3 that V13, CNA, had also been working with R1 when it happened. V1 stated based on his interviews, date unknown, V3 asked V13 to locate R1 and R1 was located in the dining room by himself in his wheelchair. V1 stated these three interviews comprised the totality of the investigation. V1 was informed about finding the rock propping open the door and the gate with no lock. V1 stated there are cameras in the facility including the dining room, but it would take a long time to review them since the date of occurrence was unknown. On 5/27/26 at 1:05pm, V13 stated at about 1:30pm, date unknown, V3 asked him to look for R1, whom V13 stated was sitting in the dining room drinking coffee. V13 stated he was not blue or cold and was in no distress but tired. V13 stated they put him in bed, put his oxygen on him and checked his pulse oximetry which was 78. V13 stated they checked it again in 15 minutes and it was up to 88, and within a few more minutes it was in the high 90s. V13 stated he was unaware of any instances of R1 being alone on the patio for an extended period. V13 stated nobody is supposed to be propping open the patio door with a rock but, it is not being enforced. On 5/27/26 at 2:10pm, V1 stated V3 had requested to be reinterviewed. On 5/27/26 at 2:35pm, V3 stated she needed to clarify her previous interview. V3 stated she did not find R1 on the smoking patio alone, that V13 found him. V3 stated she was not aware of R1 being on the patio alone nor of R1 being without oxygen for an extended period. V3 stated she did not call R1's family to notify them of R1's fall or the smoking patio incident. On 5/28/26 at 920am, V1 stated based on the staff working, he had determined the date of the alleged incident with the smoker's patio was 5/13/26. V1 stated he had checked video footage and noted that on that date at 12:59pm, R1 had been taken out to smoke with a housekeeping staff member and came back in the building with her at 1:20pm and was then in the dining room until retrieved by V13.On 5/29/26 at 10:20am-10:50am with V1 and V2 present, the video footage was observed from 5/13/26 at 11:55am. R1 was observed sitting in his wheelchair directly in front of the door of the smoker's patio. At 11:59am, a staff member was observed bringing the cart with smoking supplies into the dining room. R1 was then observed independently self-propelling through the door onto the patio. At 1:20pm, the staff member opens the door and R1 self-propels back into the building through the dining room and out of the cameras view.A 6/2/26 Elopement Risk Residents List provided by the facility identified R4, R8, R9, R10, R11, and R12 as residents who were confused, ambulatory, and at high risk for elopement.An Elopement and Search Guidelines Policy, dated 9/4/24, documented, 1. All nursing personnel are responsible for: A. Knowing the whereabouts of residents for which they are assigned. C. Staff are responsible for keeping the nurse informed of a resident's whereabouts. D. Observations are made at no less than two-hour intervals by nursing staff during scheduled activity programs, at meals, bedtime, and during medication and treatment administration. 3. Residents are not permitted to leave the building alone unless a physician order is present.

Based on record review and interview, the facility failed to notify a residents POA (Power of Attorney) and Nurse Practitioner of a fall and a decrease in oxygen saturation for 1 of 3 residents (R1) reviewed for notification in a sample of 12. Findings include:1. R1's Face Sheet documented an admission Date of 3/18/26, and listed Diagnoses including Vascular Dementia, Atherosclerotic Heart Disease, and Chronic Obstructive Pulmonary Disease.R1's Minimum Data Set, dated [DATE], documented R1 had moderate deficits in cognition. R1's Care Plan, dated 4/30/26, documented a problem area, The resident is moderate risk for falls related to history of falls, poor safety awareness, impulsivity; Resident sometimes crawls out of bed. A 3/18/26 admission Fall Risk Assessment documented R1 was at high risk for falls.Nursing Progress Notes documented the following:5/19/26 9:36am: During morning med pass resident was resting comfortably in bed, took his meds and had no complaints. Later in the AM (morning) CNA's (Certified Nursing Assistants) got him out of bed, he was complaining about pain at the hip/femur location with verbalization of pain. I assessed and found patient to have a complaint of pain, and I notified management and obtained order for stat (immediate) x-rays of femur, hip, and pelvis. Placed resident into his recliner where he remained awaiting x-ray. Client had no complaints other than that when he got up out of bed. Created by V14 (Licensed Practical Nurse).5/19/26 4:41pm: Late Entry: Resident family arrived after being notified that he had fallen a couple days prior, once we were informed by a CNA that (V7- Agency Nurse) told her that he fell, but stated, He didn't really fall, he sat down on the floor. Upon arrival they called EMS (Emergency Management Systems) for transport to hospital. Created by V14.There was no documentation in the record to indicate R1 fell on 5/17/26, nor that the Nurse Practitioner or the POA was notified.A (NP) Nurse Practitioner Visit Note at 5/19/26 5:45pm by V11 (NP) documented, (R1) is being seen this evening after getting a call today that he was having left hip pain again and that he possibly fell over the weekend. Awaiting on (portable x-ray) (R1) is a [AGE] year-old male with a complex medical history as seen below. He is being seen today since he is a high risk for falls and recently fractured his right acetabulum and right pubis after a fall on the 30th of April (2026). This am when day shift nurse when in to give him his meds he reported that his left hip was hurting. This provider was notified and gave order to get x-rays of hip. When this NP arrived at facility this evening Xray has not been done due to Xray company has not arrived yet. (R1) reported that he fell on Sunday and hurt his left hip. Staff was unaware of this fall. When (R1) was asked about his fall he could not give me much detail except that he landed on left hip, and it hurt. His pain at time of assessment was rated a 4/10. He received pain medication around 2pm. Left leg does look slightly externally rotated, but he is up in recliner and hard to assess. He did not want to move to bed to let me evaluate him better. He had another fall about one month ago and had left hip pain also and Xray was negative. He reported that he has been in bed since Sunday, but staff report that he has been up out of bed in chair and even in his wheelchair. Today was the first day staff was aware of pain in left hip. He does get hydrocodone 5/325mg (milligrams) every 6 hours for pain in his right hip/pelvis for previous fracture. It really is unclear what happened or when it happened. In our discussion I asked him if he was ok with me sending him to hospital to get evaluated, he agreed. Before this NP was able to relate plan to nursing (R1's) family had come in to see him and called EMS themselves. Daughter was at the desk when this NP came to talk with nurse that was working, and she informed me that she wants him sent out. This NP told her that was my plan, and she responded that she had already called EMS, and they were on their way.R1's 5/19/26 Emergency Department admission record documented, Patient presents with left hip pain after a fall. Patient states 2 days ago he slipped and fell landing on his left hip at the nursing home. He was not sent out at that time and has been bed-bound since. His family came to visit him, and he was complaining of left leg pain, and they wanted him transferred here for evaluation. Patient denies any other injuries. He denies any head injury or loss of consciousness. He denies any fevers chills nausea vomiting chest pain abdomen pain or shortness of breath. He is on chronic O2 (oxygen) for COPD (Chronic Obstructive Pulmonary Disease). Any movement causes increased pain. Nothing else has made his symptoms better or worse and they are mild in nature. Patient's left lower extremity is externally rotated and he has tenderness to palpation on the hip and pain with any movement. He does have good distal neurovascular exam. Xray of the left hip and pelvis: SI (Sacroiliac) joints are symmetric. Right total hip arthroplasty is in place with anatomic alignment. Intertrochanteric fracture of the left femur with mild impaction. Old right inferior pubic ramus fracture is stable in place. On 5/22/26 at 9:15am, V4, Family Member of R1, stated R1 fell on 5/17/26 and the family did not know about it until they visited R1 on 5/19/26 and noted he was in pain and something was obviously wrong with his hip. V4 stated the family called 911 and R1 was taken to ER, where a right hip fracture was diagnosed. V4 stated R1 had hip surgery on 5/20/26 and then suffered a stroke and his condition has deteriorated. V4 stated staff was apologetic about the lack of notification of the fall. V4 stated the family has decided R1 will not be returning to the facility after he is released from the hospital. On 5/22/26 at 10:45am, V5, R1's Power of Attorney, stated she and V4 went to visit R1 on 5/19/26, and R1 was in pain from his right hip and they could tell by looking at his legs there was something wrong with the left hip, so they called 911 for him to be taken to the ER. V5 stated she is unhappy with the quality-of-care R1 received and he will be going to a different facility. On 5/26/26 at 9:45am, V7, Registered Nurse/Agency, stated on 5/17/26 on the 6pm to 6am shift, she and V12 were in R1's room with him, when all of a sudden, he said he needed to go to the bathroom, he sat up to side of bed and slid out of the bed with his buttocks making contact with the floor. V7 stated, He didn't fall, that is not considered a fall, he slid and then sat down. He said he was fine, nothing seemed to be wrong with him, he said he wasn't in any pain, so we got him back in bed, checked his vital signs, and that was about it. V7 stated since it was not a fall, she did not notify the Physician, R1's POA, V2 (Director of Nursing), or the oncoming nurse at shift change and did not do a progress note or a fall investigation. On 5/26/26 at 1:25pm, V2 stated on 5/19/26, CNA's reported R1 was having severe pain in his right hip when they were doing morning care. V2 stated it was then reported to her that R1 fell about 11:30pm on 5/17/26. V2 stated V7 told her that R1 was sitting up to edge of bed and slid down with butt making contact with the floor. V2 stated V7 did not report it to the POA, the physician, or to her nor did she start a fall report because she did not consider it a fall. On 5/27/26 at 8:30am, V11 stated she last saw R1 on 5/19/26 later on in the afternoon, after V2 had notified her that R1 fell on 5/17/26. V11 stated she was not notified of the fall on 5/17/26. 2. R1's May 2026 Physicians Orders documented an order for oxygen at 3 Liters/Minute per nasal cannula, maintain oxygen saturation at 90 percent or greater. On 5/26/26 at 12:10pm, V8, Registered Nurse, stated she did not remember the date but did recall a CNA finding that R1 had been out of his room without portable oxygen for an unknown period of time. V8 stated she recalled R1's pulse oximetry reading in the 80's. V8 stated they put R1 in bed and put oxygen on him and the reading came back up to the 90s. V8 stated she did not notify the nurse practitioner. On 5/27/26 at 8:30am, V11, Nurse Practitioner, stated V8 should have contacted her when R1's oxygen saturation dropped below 90. On 5/27/26 at 1:05pm, V13 (CNA) stated at about 3:30pm, date unknown, R1 was sitting in the dining room and had been without his oxygen for an unknown period. V13 stated R1 was not blue and was in no distress but tired. V13 stated he notified V8, and they put him in bed, put his oxygen on him, and his oxygen saturation measured 78, rose to 88 after 15 minutes, and a few minutes later had risen to the high 90s. On 5/28/26 at 9:20am, V1, Administrator, stated based on the description of the above events and the staff involved as well as video evidence, the incident regarding V1 and the oxygen situation occurred on 5/13/26 at 3:30pm. There was no documentation in R1's chart of R1's oxygen saturation on 5/13/26 after 11:36am.A Notification of Change Guideline Policy, dated 10/1/21, stated, It is the practice of this facility that changes in a resident condition or treatment are immediately shared with the resident and/or the resident's representative, according to their authority, and are reported to and consulted with the attending physician. Requirements for notification of resident, the resident's representative, and their physician: A significant change in the resident's physical, mental, or psychosocial status. A significant change includes deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications. A need to alter treatment significantly. A significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. An accident involving the resident, which results in injury and has the potential for requiring physician intervention.

Based on observation, interview, and record review, the facility failed to ensure pain medication was available for 1 of 3 (R1) residents reviewed for pain in the sample 10. This failure resulted in R1's pain not being controlled post knee replacement surgery, causing R1 to become restless and anxious. R1 stated when he doesn't have the pain medication he doesn't move as much because of the pain.Findings Include:R1's admission Record, with a print date of 4/14/26, documents R1 was admitted to the facility on [DATE], with diagnoses that include infection and inflammatory reaction due to internal right knee prosthesis, after care following knee joint prosthesis, fracture of right patella, depression, anxiety, heart failure, and seizures.R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 15, indicating R1 is cognitively intact. This same MDS documents R1 had a recent knee replacement surgery and the Pain Assessment Interview documents R1 has frequent pain that occasionally effects his sleep, interferes with therapy activities, occasionally limits his day-to-day, and the intensity of the pain is rated a 08 on a scale of 1-10.R1's current Care Plan documents a Focus area of, BEHAVIOR: (R1) was noted to show frustration r/t (related to) not completely understanding the processes of the nursing facility setting and confusion of an event that had occurred mixed w/ anxiousness, worry and poor impulse control. Staff had to explain what happened and normal processes in a calm and reassuring manor and approach. **Also restlessness. ** Incident which prompted this plan was he told staff he was frustrated and worried about how things were done in a facility r/t (related to) his health. He thought he may have to go without meds and if this happened it was going to be the facility's fault. Facility was on top of situation and fixed issue of his ortho (orthopedic) physician initially sending script to the wrong pharmacy (not ours - name of pharmacy). He was easily redirected and apologetic. Date Initiated: 03/30/2026. This Focus area includes the intervention of, Explain care and how things work as needed. Use a calm and reassuring voice and approach while letting him know everything will be alright. Encourage him to continue to express needs, fears and concerns in a calm manor. Involve the SS (social services) and Act (activities) depts (departments) as needed. Date Initiated: 04/10/2026. This same Care Plan documents a Focus area of, The resident has chronic pain r/t infection and inflammation of right knee prosthesis.Date Initiated: 03/28/2026. This Focus area includes the intervention of, Administer analgesia as per orders. Give 1/2 hour before treatments or care. Date Initiated: 03/28/2026.R1's Order Summary Report, with active orders as of 4/14/26, includes the following physician orders, Pain monitoring every shift, with a start date of 3/27/26 and oxycodone HCI Capsule 5 mg (milligrams) give 2 tablets by mouth every 4 hours as needed for pain, with a start date of 3/31/26.R1's Weights and Vitals Summary, dated 3/1/26 to 3/31/26, documents pain scales beginning on 3/28/26 at 12:28 AM. The pain intensities are documented as ranging from 0-8.R1's Weights and Vitals Summary, dated 4/1/26 to 4/30/26, document pain intensities ranging from 0-10.On 4/13/26 at 10:52 AM, R1 stated he recently had knee replacement surgery. R1 stated he went 2-3 days without his pain medication when he was admitted to the facility, and he doesn't currently have any pain medication. R1 stated they run out every weekend. R1 stated he doesn't move as much when he doesn't have them because he is in pain.From 3/27/26 to 3/28/26, R1's Progress Notes document the following:3/27/26 11:55 PM: (name of pharmacy) contacted for one time access to oxy (oxycodone) for pain relief for resident, as he is asking all staff that introduce them self for a pain pill. Pharmacist reports to not have process his orders yet and will call back with a code.3/27/26 9:22 PM: This nurse called (name of pharmacy) to request access code to pull oxycodone from (name of emergency med system) per resident request. Pharmacy reports they have not received script. Signed by V2 (Director of Nurses/DON)3/27/26 11:30 PM: Called (resident's discharging hospital) to inquire about pharmacy not receiving script. House supervisor states the order will need to come from the resident's surgeon and they will have to call him tomorrow. Resident remains awake at this time, complains of discomfort but appears to not be in distress. Able to converse with this nurse and perform ADLs (Activities of Daily Living) with supervision. Offered PRN (as needed) Tylenol but resident states he has had oxycodone every 4 hours and 'Tylenol won't touch it.' Distracting himself with smoking frequently. Encouraged to elevate legs in recliner. Did accept ice pack and other scheduled mediations pulled from (name of emergency drug dispensing machine).3/28/26 11:49 AM: Resident resting in recliner and sleeping while hooked to iv. Resident has been up dressed, complete other adls (activities of daily living) with no assistance required, using walker and walking the halls, has not missed a smoke break, wearing leg brace with wound covered by wound vac (vacuum). Resident rates his pain as unbearable but his body language, actions, and ability to participate in his chosen activity's with no difficulty. He has received all medications ordered at this time except prn (as needed) oxy (oxycodone). signed by V3 (Assistant Director of Nurses/ADON)On 4/14/26 at 6:00 PM, V2 (Director of Nurses) stated she worked night shift on 3/27/26 when R1 was admitted to the facility. V2 stated she had to pull R1's medications from the emergency supply kit. When asked why R1's pain medication was not available at times, V2 stated yesterday (4/13/26) they needed to get a new prescription. V2 stated the pharmacy can usually get the medication to them within four hours of them ordering it. V2 stated she wasn't sure if the pharmacy was available to deliver medications 24 hours a day, 7 days a week.R1's Progress, dated 3/29/26, document the following:3/29/26 1:01 AM: Late Entry: Resident c/o (complains of) not having pain medication. This nurse called pharmacy (name of pharmacy) who stated they never received the script. This nurse went through admission paperwork and no script found. DON (V2) notified. Called on call MD (physician) number for (name of on call agency) and asked MD if she could call in a verbal script of possibly print one from (name of electronic record system) sign and send to pharmacy or this nurse some home send to pharmacy [sic]. I explained that resident had no pain medication available without script and if she could do either a verbal or get script to pharmacy they would be able to let me pull one from the ekit (emergency medication kit) on site so resident would have something. MD aviced [sic] me to use tablet and call. This nurse attempted to call 3 times with no MD joining. Resident is beyond upset and requested to go to hospital. Resident is alert and oriented. DON (V2) updated. EMS (emergency medical services) alerted to transport. Resident wanting to go to (name of hospital) ER (emergency room). EMS is out with both ambulances so ETA (estimated time of arrival) unknown. Resident done [sic] stated if it takes too long he will be calling someone to come get him.3/29/26 1:09 AM: Resident refused IV (intravenous) ABT (antibiotic) tx (treatment) due to pain.3/29/26 1:26 AM: EMS arrived at approx. (approximately) 0120 (1:20 AM) resident left via stretcher and EMS transport.3/29/26 10:18 AM: resident arrives via stretcher and transport team from (name of EMS), they state is he always like this he was driving us nuts, good luck with this one, the resident then starts talking about how he doesn't think anyone works around here and his displeasure about being here and not getting his pain pill. Upon arrival to his room, he gets off of cart and goes to the toilet and immediately gets in w/c (wheelchair) following them, 'signs out' of visitor book and goes out to smoke. As I am charting this, he is demanding to know if we have his script lined out now, he gets pain pills every 4 hours. I asked about his pain level, and he refused to elaborate and said do you have my pills or not. signed by V3 (ADON).3/29/26 10:27 AM: no script in return paperwork. Resident mad and cussing as he returns to his room. Resident educated that he was given his medications yesterday and some of them are to help with pain, his leg was iced and Tylenol given along with muscle relaxers and elevation. He did not miss antibiotic treatment and is ordered bid (twice daily) not tid (three times daily) as he was telling ER (emergency room). The only medication is 5 mg oxy he was taking at Friday [sic]. Resident does not express himself as being in pain but wanting a pill. Signed by V3 (ADON)3/29/26 10:36 AM: (name of pharmacy) called, no current order. Faxed script as he called me an idiot I decided to not request a one-time dose until the order is processed by (name of pharmacy). Signed by V3 (ADON).3/29/26 11:00 AM: pharmacy called to say the script from (name of hospital) was incomplete, the DEA (Drug Enforcement Agency) # (number) was missing letters. (name of hospital) called (name of hospital nurse) to notify (name of hospital physician) by text, saying he was not working today. That's all she could do. Resident now sleeping soundly with legs elevated in recliner. Signed by V3 (ADON).3/29/26 12:18 PM: Resident demanding his medications, all missed meds given.when he realized his oxycodone was not in the cup of pills he started shaking, got red faced and starting name calling and explaining he has had surgery, says he was orders [sic] for the pills and he is going to take them. He has no uncontrolled pain he speaks of, will not accept ice or elevation, walks and goes outside to smoke unassisted. Situation of missing DEA number explained waiting (name of physician) to complete information. Signed by V3 (ADON).On 4/13/26 at 2:20 PM: V3 (Assistant Director of Nurses/ADON) stated she faxed R1's oxycodone prescription to the pharmacy on the day he returned from the hospital (3/29/26). V3 stated R1 started talking hateful to her and she had other residents to provide care to, so she waited to call the pharmacy for a one-time dose out of the emergency medication supply until the pharmacy had time to process the order. V3 stated the prescription was missing part of the DEA number so she wasn't able to get a one-time dose. V3 stated she wasn't sure if R1 currently had oxycodone available at the facility.R1's Progress Notes from 3/30/26 to 4/12/26 document the following:3/30/26 6:56 AM: residents oxycodone medication arrived this am. Signed by V3 (ADON)3/30/26 10:45 AM: I spoke with (R1) regarding an issue that he had brought to my attention r/t his admission and his medications being delivered by pharmacy. I told (R1) that there had been a hold up at our pharmacy d/t (due to) the script already being filled at another pharmacy. (R1) stated that he had his script sent to the hospital pharmacy and that he had forgot to go pick it up before he came to our building. I explained to him that this was causing a hold up because of it flagging to make sure that scripts are not filled at multiple pharmacies. I assured him that we would get everything sorted out and make sure the scripts were all sent to the proper place. (R1) stated he understood and said that he feels much better, and that he was content with everything now that he understands what was going on. Signed by V1 (Administrator)4/9/26 10:31 AM: Resident currently prescribed PRN (as needed) Oxycodone HCI 5mg for pain management. All 6 tablets previously stocked in the medication dispensing system were utilized last week as ordered. Refill request had been submitted; however, medication has not yet been received. Pharmacy was contacted regarding status of refill for dispensing system and for the resident. Pharmacy staff reported that the medication had not yet been restocked in the dispensing system. They advised that the refill is scheduled to be sent out tonight and delivered in the morning. Per pharmacy instruction, a new prescription order will be submitted for the next refill cycle. Resident is anticipated to be discharged in approximately 10 days from today. Pharmacy was notified of this time frame and instructed to ensure an adequate quantity of medication is provided to cover the remainder of the residents stay. Resident status will continue to be monitored. Nursing will follow up to ensure medication is received and available for administration as ordered. At this time, Resident was offered Extra Strength Tylenol x2 tablets for pain as an alternative and was accepted by the resident. Signed by V4 (Licensed Practical Nurse/LPN).4/9/26 4:37 PM: Client meds came in and he is requesting it 3/10 (pain intensity).4/12/26 9:15 AM: Resident (R1) presented to the locked unit at approximately 0914 (9:14 AM) requesting pain medication. Resident stated he was unable to walk due to pain. However, resident was observed ambulating to the unit without difficulty and continued to ambulate in the halls throughout the day without noted impairment. Narcotic count completed; no Oxycodone available in narcotic box. Chart review confirmed prior attempts to obtain refill. Message was left for (name of physician) on 04/09 with no return call. Reorder request was placed again on 04/11; medication had not yet arrived.Pharmacy (name of pharmacy) was contacted and reported that the (name of emergency medication dispensing system) had not yet been restocked; therefore, no narcotic medication was available for administration. Resident was offered Extra Strength Tylenol per PRN order for pain management. Resident accepted and medication was administered without issue. Resident continues to be monitored. Signed by V4 (LPN)4/12/26 5:51 PM: Resident (R1) presented requesting pain medication. Narcotic count completed; no Oxycodone available in narcotic box at this time. Review of prior documentation confirms ongoing delay in refill from pharmacy (name of pharmacy) with (name of emergency dispensing system) not yet restocked. Resident was again offered Extra Strength Tylenol per PRN order for pain management. Resident accepted and medication was administered without issue. At follow-up, resident observed resting in recliner in room with eyes closed, respirations even and unlabored. No signs or symptoms of pain or distress noted. Based on presentation, current pain management appears effective. Resident continues to be monitored. Signed by V4 (LPN)4/12/26 7:26 PM: Resident (R1) continues to persistently request Oxycodone despite observed clinical presentation inconsistent with reported pain levels. Resident verbalized that the medication 'does not give him the buzz he used to get' and continues to request increased or more frequent dosing. Resident refuses prescribed alternative medications, including muscle relaxer, and selectively refuses PRN Tylenol when Oxycodone is available. Resident repeatedly reports severe pain, stating inability to ambulate or participate in therapy. However, resident is consistently observed ambulating throughout the facility without difficulty, no guarding, no noted distress, and no functional limitations beyond expected weakness, use of assistive device for stability, and normal recovery consistent with history of multiple knee surgeries. Resident also completes therapy sessions without incident or limitation. When in room, resident is frequently observed resting or asleep in recliner or bed, with respirations even and unlabored and no observable signs of pain or discomfort. When Oxycodone is unavailable or when reported pain level does not meet administration parameters per order, resident will accept Tylenol at times. When Oxycodone is available, resident refuses non-opioid alternatives and continues to request narcotic medication, even when reporting mild pain. Behavior, statements, and medication requests are inconsistent with observed functional status and objective findings. Pattern of requests, expressed desire for euphoric effect, and selective medication acceptance noted. Findings documented for provider review and further evaluation of pain management plan. Resident continues to be monitored. Signed by V4 (LPN).R1's Medication Administration Record (MAR), dated 3/1/26 to 3/31/26, documents a physician order for oxycodone 5 mg (milligrams) two tablets to be administered every four hours as needed for moderate pain with a start date of 3/27/26 and a discontinue date of 3/29/26. There are no signatures indicating R1 did not receive any oxycodone from this physician order. This same MAR documents a second order for oxycodone 5 mg give two tablets every four hours for pain, with a start date of 3/31/26. There are signatures indicating this medication was administered on 3/31/26 at 7:02 PM and 11:02 PM with a pain intensity of 8 and 10.R1's MAR, dated 4/1/26 to 4/30/26, documents a physician order for oxycodone 5 mg give 2 tablets every four hours for pain. There are signatures indicating R1 received the medication on the following dates and times with corresponding reported pain level.4/1- 6:57 AM -pain intensity 6, 11:11 AM - pain intensity 4, 8:01 PM - pain intensity 6,4/2 - 2:59 AM pain intensity 3, 8:00 AM pain intensity 5, 5:51 PM pain intensity 4,4/3 - 5:33 AM pain intensity 5, 10:31 AM pain intensity 4, 10:10 PM pain intensity 7,4/4- 7:49 AM pain intensity 4, 1:45 PM pain intensity 0,4/5 - 12:07 AM pain intensity 10, 11:00 AM pain intensity 6, 3:39 PM pain intensity 6, 8:35 PM pain intensity 5,4/6 - 1:36 AM pain intensity 4, 8:09 AM pain intensity 4,4/7 - 1:30 PM pain intensity 3, 4/8 - 11:09 AM pain intensity 4, 4:30 PM pain intensity 9, 10:53 PM pain intensity 7,4/9 - 4:37 PM pain intensity 3, 9:30 PM pain intensity 7,4/10 - 2:14 AM pain intensity 6, 7:57 AM pain intensity 5, 9:31 PM pain intensity 8,4/11 - 5:37 AM pain intensity 7, 1:18 PM, pain intensity 3, 6:45 PM pain intensity 6,4/12 - 5:40 Am pain intensity 3, 8:35 AM pain intensity 1,4/13 - 7:00 PM pain intensity 7, 11:00 PM pain intensity 6,4/14 - 5:00 AM pain intensity 7.On 4/13/26 at 3:57 PM, R1's medication cart was observed with V2 (Director of Nurses). R1 did not have any oxycodone available for administration in the narcotics lock box in the medication cart.On 4/14/26 at 12:11 PM, V4 (LPN) stated R1 was quite difficult with his medications. V4 stated when R1 was first admitted to the facility he called a complaint in because he didn't get his pain medication and then discovered it was because they had called it to the hospital pharmacy instead of the facility pharmacy and he didn't pick it up before he left the hospital. V4 stated then R1 ran out of the oxycodone on 4/9/26. V4 stated he contacted the pharmacy and they delivered it around 4 pm.On 4/14/26 at 1:54 PM, when asked why R1 did not have the oxycodone available in the facility, V3 (ADON) stated, He had taken all they sent him. This surveyor reviewed with V3 that R1 had run out of oxycodone more than once while at the facility and asked if she knew why they weren't available. V3 (ADON) stated she wasn't sure how to answer the question. V3 stated they would text the physician for prescriptions for the residents when they needed them.On 4/14/26 at 3:31 PM, V5 (RN/Registered Nurse) stated she knew residents had complained they were running out of narcotics. V5 stated it can take a while to get prescription refills. V5 stated R1 takes two tablets with each dose, so he runs out quicker. V5 stated R1 tries to take them every four hours because of his recent surgery. V5 stated R1 wants to stay active in physical therapy. V5 stated when she got to work on 4/13/26, R1 reported to her he was out of the oxycodone, but the pharmacy delivered them, so she administered them to R1. Based on the administration times located on April 2026 MAR, this indicates R1 did not have oxycodone available for administration from the dose administered at 8:35 AM on 4/12/26 until the does administered at 7:00 PM on 4/13/26.On 4/16/26 at 1:10 PM, V1 (Administrator) stated he would expect pain medication to be available in the facility to be administered as ordered. On 4/15/26 at 9:36 AM, V8 (Nurse Practitioner) stated she didn't understand why R1 was running out of the oxycodone. V8 stated she orders a seven day supply each time she writes a prescription, and she is in the building at least five hours a week on at least two different days. V8 stated she had noticed an issue with the facility ensuring pain medication was available, and she knew it wasn't always the nursing staff's fault. V8 stated sometimes they send the prescription to the pharmacy, and the pharmacy doesn't send the medications to the facility. When asked what kind of impact not getting pain medications as ordered could have on R1, V8 stated, It slows healing and the anxiety and not being able to sleep and it is a proven fact if you are in a lot of pain, you won't heal as well. V8 stated she thought R1 had a history of abusing his medications as well but just after surgery he would need the pain medication as ordered.The facility policy Pain Management Program, dated July 2019, documents, Purpose: To establish a program with a multi-level approach to pain management to assist the facility in delivering safe, individualized pain care. Policy: It is the policy of the facility to facilitate resident safety, independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish the goals through an effective pain management program.

Based on observation, interview, and record review, the facility failed to ensure pain medication was available for administration as ordered and antibiotics were administered timely for 1 of 3 (R1) residents reviewed for pharmacy services in the sample of 10. Findings Include:1. R1's admission Record, with a print date of 4/14/26, documents R1 was admitted to the facility on [DATE] with diagnoses that include infection and inflammatory reaction due to internal right knee prosthesis, after care following knee joint prosthesis, fracture of right patella, depression, anxiety, heart failure, and seizures.R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 15, indicating R1 is cognitively intact. This same MDS documents R1 had a recent knee replacement surgery and the Pain Assessment Interview documents R1 has frequent pain that occasionally effects his sleep, interferes with therapy activities, occasionally limits his day-to-day and the intensity of the pain is rated a 08 on a scale of 1-10.R1's Care Plan documents a Focus area of, The resident has chronic pain r/t infection and inflammation of right knee prosthesis.Date Initiated: 03/28/2026. This Focus area includes the intervention of, Administer analgesia as per orders. Give 1/2 hour before treatments or care. Date Initiated: 03/28/2026.R1's Order Summary Report, with active orders as of 4/14/26, includes the following physician orders, Pain monitoring every shift with a start date of 3/27/26 and oxycodone HCI Capsule 5 mg (milligrams) give 2 tablets by mouth every 4 hours as needed for pain, with a start date of 3/31/26.R1's Weights and Vitals Summary, dated 3/1/26 to 3/31/26, documents pain scales beginning on 3/28/26 at 12:28 AM. The pain intensities are documented as ranging from 0-8.R1's Weights and Vitals Summary, dated 4/1/26 to 4/30/26, document pain intensities ranging from 0-10.On 4/13/26 at 10:52 AM, R1 stated he recently had knee replacement surgery. R1 stated he went 2-3 days without his pain medication when he was admitted to the facility, and he doesn't currently have any pain medication. R1 stated they run out every weekend. R1 stated he doesn't move as much when he doesn't have them because he is in pain.From 3/27/26 to 3/28/26, R1's Progress Notes document the following:3/27/26 11:55 PM: (name of pharmacy) contacted for one time access to oxy (oxycodone) for pain relief for resident, as he is asking all staff that introduce them self for a pain pill. Pharmacist reports to not have process his orders yet and will call back with a code.3/27/26 9:22 PM: This nurse called (name of pharmacy) to request access code to pull oxycodone from (name of emergency med system) per resident request. Pharmacy reports they have not received script. Signed by V2 (Director of Nurses/DON)3/27/26 11:30 PM: Called (resident's discharging hospital) to inquire about pharmacy not receiving script. House supervisor states the order will need to come from the resident's surgeon and they will have to call him tomorrow. Resident remains awake at this time, complains of discomfort but appears to not be in distress. Able to converse with this nurse and perform ADLs (Activities of Daily Living) with supervision. Offered PRN (as needed) Tylenol but resident states he has had oxycodone every 4 hours and 'Tylenol won't touch it.' Distracting himself with smoking frequently. Encouraged to elevate legs in recliner. Did accept ice pack and other scheduled mediations pulled from (name of emergency drug dispensing machine).3/28/26 11:49 AM: Resident resting in recliner and sleeping while hooked to iv. Resident has been up dressed, complete other adls (activities of daily living) with no assistance required, using walker and walking the halls, has not missed a smoke break, wearing leg brace with wound covered by wound vac (vacuum). Resident rates his pain as unbearable but his body language, actions, and ability to participate in his chosen activity's with no difficulty. He has received all medications ordered at this time except prn (as needed) oxy (oxycodone). signed by V3 (Assistant Director of Nurses/ADON)On 4/14/26 at 6:00 PM, V2 (Director of Nurses) stated she worked night shift on 3/27/26 when R1 was admitted to the facility. V2 stated she had to pull R1's medications from the emergency supply kit. When asked why R1's pain medication was not available at times, V2 stated yesterday (4/13/26) they needed to get a new prescription. V2 stated the pharmacy can usually get the medication to them within four hours of them ordering it. V2 stated she wasn't sure if the pharmacy was available to deliver medications 24 hours a day, 7 days a week.R1's Progress, dated 3/29/26, document the following:3/29/26 1:01 AM: Late Entry: Resident c/o (complains of) not having pain medication. This nurse called pharmacy (name of pharmacy) who stated they never received the script. This nurse went through admission paperwork and no script found. DON (V2) notified. Called on call MD (physician) number for (name of on call agency) and asked MD if she could call in a verbal script of possibly print one from (name of electronic record system) sign and send to pharmacy or this nurse some home send to pharmacy [sic]. I explained that resident had no pain medication available without script and if she could do either a verbal or get script to pharmacy they would be able to let me pull one from the ekit (emergency medication kit) on site so resident would have something. MD aviced [sic] me to use tablet and call. This nurse attempted to call 3 times with no MD joining. Resident is beyond upset and requested to go to hospital. Resident is alert and oriented. DON (V2) updated. EMS (emergency medical services) alerted to transport. Resident wanting to go to (name of hospital) ER (emergency room). EMS is out with both ambulances so ETA (estimated time of arrival) unknown. Resident done [sic] stated if it takes too long he will be calling someone to come get him.3/29/26 1:09 AM: Resident refused IV (intravenous) ABT (antibiotic) tx (treatment) due to pain.3/29/26 1:26 AM: EMS arrived at approx. (approximately) 0120 (1:20 AM) resident left via stretcher and ems transport.3/29/26 10:18 AM: resident arrives via stretcher and transport team from (name of ems), they state is he always like this he was driving us nuts, good luck with this one, the resident then starts talking about how he doesn't think anyone works around here and his displeasure about being here and not getting his pain pill. Upon arrival to his room he gets off of cart and goes to the toilet and immediately gets in w/c (wheelchair) following them, 'signs out' of visitor book and goes out to smoke. As I am charting this he is demanding to know if we have his script lined out now, he gets pain pills every 4 hours. I asked about his pain level and he refused to elaborate and said do you have my pills or not. signed by V3 (ADON).3/29/26 10:27 AM: no script in return paperwork. Resident mad and cussing as he returns to his room. Resident educated that he was given his medications yesterday and some of them are to help with pain, his leg was iced and Tylenol given along with muscle relaxers and elevation. He did not miss antibiotic treatment and is ordered bid (twice daily) not tid (three times daily) as he was telling ER (emergency room). The only medication is 5 mg oxy he was taking at Friday [sic]. Resident does not express himself as being in pain but wanting a pill. Signed by V3 (ADON)3/29/26 10:36 AM: (name of pharmacy) called, no current order. Faxed script as he called me an idiot I decided to not request a one-time dose until the order is processed by (name of pharmacy). Signed by V3 (ADON).3/29/26 11:00 AM: pharmacy called to say the script from (name of hospital) was incomplete, the DEA (Drug Enforcement Agency) # (number) was missing letters. (name of hospital) called (name of hospital nurse) to notify (name of hospital physician) by text, saying he was not working today. That's all she could do. Resident now sleeping soundly with legs elevated in recliner. Signed by V3 (ADON).3/29/26 12:18 PM: Resident demanding his medications, all missed meds given.when he realized his oxycodone was not in the cup of pills he started shaking, got red faced and starting name calling and explaining he has had surgery, says he was orders [sic] for the pills and he is going to take them. He has no uncontrolled pain he speaks of, will not accept ice or elevation, walks and goes outside to smoke unassisted. Situation of missing DEA number explained waiting (name of physician) to complete information. Signed by V3 (ADON).On 4/13/26 at 2:20 PM: V3 (Assistant Director of Nurses/ADON) stated she faxed R1's oxycodone prescription to the pharmacy on the day he returned from the hospital (3/29/26). V3 stated R1 started talking hateful to her and she had other residents to provide care to, so she waited to call the pharmacy for a one-time dose out of the emergency medication supply until the pharmacy had time to process the order. V3 stated the prescription was missing part of the DEA number so she wasn't able to get a one-time dose. V3 stated she wasn't sure if R1 currently had oxycodone available at the facility.R1's Progress Notes from 3/30/26 to 4/12/26 document the following:3/30/26 6:56 AM: residents oxycodone medication arrived this am. Signed by V3 (ADON)3/30/26 10:45 AM: I spoke with (R1) regarding an issue that he had brought to my attention r/t his admission and his medications being delivered by pharmacy. I told (R1) that there had been a hold up at our pharmacy d/t (due to) the script already being filled at another pharmacy. (R1) stated that he had his script sent to the hospital pharmacy and that he had forgot to go pick it up before he came to our building. I explained to him that this was causing a hold up because of it flagging to make sure that scripts are not filled at multiple pharmacies. I assured him that we would get everything sorted out and make sure the scripts were all sent to the proper place. (R1) stated he understood and said that he feels much better, and that he was content with everything now that he understands what was going on. Signed by V1 (Administrator)4/9/26 10:31 AM: Resident currently prescribed PRN (as needed) Oxycodone HCI 5mg for pain management. All 6 tablets previously stocked in the medication dispensing system were utilized last week as ordered. Refill request had been submitted; however, medication has not yet been received. Pharmacy was contacted regarding status of refill for dispensing system and for the resident. Pharmacy staff reported that the medication had not yet been restocked in the dispensing system. They advised that the refill is scheduled to be sent out tonight and delivered in the morning. Per pharmacy instruction, a new prescription order will be submitted for the next refill cycle. Resident is anticipated to be discharged in approximately 10 days from today. Pharmacy was notified of this time frame and instructed to ensure an adequate quantity of medication is provided to cover the remainder of the residents stay. Resident status will continue to be monitored. Nursing will follow up to ensure medication is received and available for administration as ordered. At this time, Resident was offered Extra Strength Tylenol x2 tablets for pain as an alternative and was accepted by the resident. Signed by V4 (Licensed Practical Nurse/LPN).4/9/26 4:37 PM: Client meds came in and he is requesting it 3/10 (pain intensity).4/12/26 9:15 AM: Resident (R1) presented to the locked unit at approximately 0914 (9:14 AM) requesting pain medication. Resident stated he was unable to walk due to pain. However, resident was observed ambulating to the unit without difficulty and continued to ambulate in the halls throughout the day without noted impairment. Narcotic count completed; no Oxycodone available in narcotic box. Chart review confirmed prior attempts to obtain refill. Message was left for (name of physician) on 04/09 with no return call. Reorder request was placed again on 04/11; medication had not yet arrived.Pharmacy (name of pharmacy) was contacted and reported that the (name of emergency medication dispensing system) had not yet been restocked; therefore, no narcotic medication was available for administration. Resident was offered Extra Strength Tylenol per PRN order for pain management. Resident accepted and medication was administered without issue. Resident continues to be monitored. Signed by V4 (LPN)4/12/26 5:51 PM: Resident (R1) presented requesting pain medication. Narcotic count completed; no Oxycodone available in narcotic box at this time. Review of prior documentation confirms ongoing delay in refill from pharmacy (name of pharmacy) with (name of emergency dispensing system) not yet restocked. Resident was again offered Extra Strength Tylenol per PRN order for pain management. Resident accepted and medication was administered without issue. At follow-up, resident observed resting in recliner in room with eyes closed, respirations even and unlabored. No signs or symptoms of pain or distress noted. Based on presentation, current pain management appears effective. Resident continues to be monitored. Signed by V4 (LPN)4/12/26 7:26 PM: Resident (R1) continues to persistently request Oxycodone despite observed clinical presentation inconsistent with reported pain levels. Resident verbalized that the medication 'does not give him the buzz he used to get' and continues to request increased or more frequent dosing. Resident refuses prescribed alternative medications, including muscle relaxer, and selectively refuses PRN Tylenol when Oxycodone is available. Resident repeatedly reports severe pain, stating inability to ambulate or participate in therapy. However, resident is consistently observed ambulating throughout the facility without difficulty, no guarding, no noted distress, and no functional limitations beyond expected weakness, use of assistive device for stability, and normal recovery consistent with history of multiple knee surgeries. Resident also completes therapy sessions without incident or limitation. When in room, resident is frequently observed resting or asleep in recliner or bed, with respirations even and unlabored and no observable signs of pain or discomfort. When Oxycodone is unavailable or when reported pain level does not meet administration parameters per order, resident will accept Tylenol at times. When Oxycodone is available, resident refuses non-opioid alternatives and continues to request narcotic medication, even when reporting mild pain. Behavior, statements, and medication requests are inconsistent with observed functional status and objective findings. Pattern of requests, expressed desire for euphoric effect, and selective medication acceptance noted. Findings documented for provider review and further evaluation of pain management plan. Resident continues to be monitored. Signed by V4 (LPN).R1's Medication Administration Record (MAR), dated 3/1/26 to 3/31/26, documents a physician order for oxycodone 5 mg (milligrams) two tablets to be administered every four hours as needed for moderate pain with a start date of 3/27/26 and a discontinue date of 3/29/26. There are no signatures indicating R1 did not receive any oxycodone from this physician order. This same MAR documents a second order for oxycodone 5 mg give two tablets every four hours for pain with a start date of 3/31/26. There are signatures indicating this medication was administered on 3/31/26 at 7:02 PM and 11:02 PM with a pain intensity of 8 and 10.R1's MAR, dated 4/1/26 to 4/30/26, documents a physician order for oxycodone 5 mg give 2 tablets every four hours for pain. There are signatures indicating R1 received the medication on the following dates and times with corresponding reported pain level.4/1- 6:57 AM -pain intensity 6, 11:11 AM - pain intensity 4, 8:01 PM - pain intensity 6,4/2 - 2:59 AM pain intensity 3, 8:00 AM pain intensity 5, 5:51 PM pain intensity 4,4/3 - 5:33 AM pain intensity 5, 10:31 AM pain intensity 4, 10:10 PM pain intensity 7,4/4- 7:49 AM pain intensity 4, 1:45 PM pain intensity 0,4/5 - 12:07 AM pain intensity 10, 11:00 AM pain intensity 6, 3:39 PM pain intensity 6, 8:35 PM pain intensity 5,4/6 - 1:36 AM pain intensity 4, 8:09 AM pain intensity 4,4/7 - 1:30 PM pain intensity 3, 4/8 - 11:09 AM pain intensity 4, 4:30 PM pain intensity 9, 10:53 PM pain intensity 7,4/9 - 4:37 PM pain intensity 3, 9:30 PM pain intensity 7,4/10 - 2:14 AM pain intensity 6, 7:57 AM pain intensity 5, 9:31 PM pain intensity 8,4/11 - 5:37 AM pain intensity 7, 1:18 PM, pain intensity 3, 6:45 PM pain intensity 6,4/12 - 5:40 Am pain intensity 3, 8:35 AM pain intensity 1,4/13 - 7:00 PM pain intensity 7, 11:00 PM pain intensity 6,4/14 - 5:00 AM pain intensity 7.On 4/13/26 at 3:57 PM, R1's medication cart was observed with V2 (Director of Nurses). R1 did not have any oxycodone available for administration in the narcotics lock box in the medication cart.On 4/14/26 at 12:11 PM, V4 (LPN) stated R1 was quite difficult with his medications. V4 stated when R1 was first admitted to the facility he called a complaint in because he didn't get his pain medication and then discovered it was because they had called it to the hospital pharmacy instead of the facility pharmacy and he didn't pick it up before he left the hospital. V4 stated then R1 ran out of the oxycodone on 4/9/26. V4 stated he contacted the pharmacy and they delivered it around 4 pm.On 4/14/26 at 1:54 PM, when asked why R1 did not have the oxycodone available in the facility, V3 (ADON) stated, He had taken all they sent him. This surveyor reviewed with V3 that R1 had run out of oxycodone more than once while at the facility and asked if she knew why they weren't available. V3 (ADON) stated she wasn't sure how to answer the question. V3 stated they would text the physician for prescriptions for the residents when they needed them.On 4/14/26 at 3:31 PM, V5 (RN/Registered Nurse) stated she knew residents had complained they were running out of narcotics. V5 stated it can take a while to get prescription refills. V5 stated R1 takes two tablets with each dose so he runs out quicker. V5 stated R1 tries to take them every four hours because of his recent surgery. V5 stated R1 wants to stay active in physical therapy. V5 stated when she got to work on 4/13/26 R1 reported to her he was out of the oxycodone but the pharmacy delivered them, so she administered them to R1. Based on the administration times located on April 2026 MAR this indicates R1 did not have oxycodone available for administration from the dose administered at 8:35 AM on 4/12/26 until the does administered at 7:00 PM on 4/13/26.On 4/16/26 at 1:10 PM, V1 (Administrator) stated he would expect pain medication to be available in the facility to be administered as ordered. On 4/15/26 at 9:36 AM, V8 (Nurse Practitioner) stated she didn't understand why R1 was running out of the oxycodone. V8 stated she orders a seven day supply each time she writes a prescription, and she is in the building at least five hours a week on at least two different days. V8 stated she had noticed an issue with the facility ensuring pain medication was available and she knew it wasn't always the nursing staff's fault. V8 stated sometimes they send the prescription to the pharmacy, and the pharmacy doesn't send the medications to the facility. When asked what kind of impact not getting pain medications as ordered could have on R1, V8 stated, It slows healing and the anxiety and not being able to sleep and it is a proven fact if you are in a lot of pain, you won't heal as well. V8 stated she thought R1 had a history of abusing his medications as well but just after surgery he would need the pain medication as ordered.2. R1's Order Summary Report with active orders as of 4/14/26 documents a physician order for vancomycin 1000 milligrams, 1.5 grams twice daily. Per pharmacy: Please admin (administer) within a 30 min (minute) window. If given over 30 min past due time, please call pharmacy for retime orders to avoid inaccurate vanc (vancomycin) troughs and dosing. This order has a start date of 4/5/26.R1's Medication Admin (Administration) Audit Report dated 3/1/26- 4/14/26 documents Vancomycin was ordered to be administered at 6:30 AM and 6:00 PM. This same report documents Vancomycin was administered late on the following dates and times: The 6 AM dose administered at 11:22 AM on 3/28, 9:42 AM on 3/29, 8:14 AM on 3/30, 1:41 PM on 3/31, 2:07 PM on 4/1, 11:11 AM on 4/2, and 10:37 AM on 4/3 and the 6 PM dose administered at 12:07 AM on 3/27, 10:14 PM on 3/29, 11:01 PM on 3/30, and 11:30 PM on 4/2/26.On 4/13/26 at 10:52 AM, R1 stated he was on intravenous (IV) antibiotics for an infection in his knee. R1 stated he didn't get the antibiotics the way he should when he first moved to the facility.On 4/13/26 at 2:20 PM, V3 (Assistant Director of Nurses/ADON) stated R1 had not missed any antibiotic doses. V3 stated R1 only needed one dose on his day of admission to the facility (3/27/26). V3 stated she was not aware of R1's antibiotics being administered at incorrect times.R1's Progress Note documents on 4/3/26 at 8:58 PM, Resident approached nurses station voicing concerns that his IV (intravenous) vanc (vancomycin) was given later than due time. Resident states She gave it at 2:30 and I want you to call the pharmacy while I'm right here to see what they say about it. Resident expresses frustration over the above information provided and states I know you guys are busy but I know when this is supposed to be done and I'm gonna stay on top of it. I utilized active listening to diffuse the situation and called (name of pharmacy) pharmacy per resident request to inquire their guidance on the above scenario and spoke to Pharmacist . Pharmacist states If that's accurate then his vanc trough will be off which would lead to incorrect dosing. Pharmacist gave specific instructions that the medication must be administered within a 30 min (minute) window and if the med is given 30 min past due time the RN (Registered Nurse) should call pharmacy for retiming orders.On 4/14/26 at 3:31 PM, V5 (RN/Registered Nurse) stated she remembered vancomycin timing being strictly regulated when she worked in the hospital. V5 stated on an unknown day R1 told her he didn't get his vancomycin until 2 pm. V5 stated she was concerned about giving him his next dose, so she called the pharmacy for clarification. V5 stated she adjusted the time she gave the next dose of vancomycin, changed the times on the physician orders, let V2 (Director of Nurses) know, and put a note on the communication board for the other staff to be aware.On 4/14/26 at 6 PM, V2 (Director of Nurses/DON) stated V5 had notified her of the time discrepancy and that it was the pharmacy's idea to change the administration times. V2 stated R1's antibiotic had been administered late at times when they didn't have a Registered Nurse working. When asked how often that happened, V2 stated it had happened maybe a couple of times. V2 stated it may also be a documentation error and the medication was administered at the correct time but not documented at the time of administration.On 4/16/26 at 1:10 PM, V1 (Administrator) stated he would expect medications to be available and administered as ordered. On 4/15/26 at 8:45 AM, V6 (Pharmacist) stated it is important the vancomycin be administered at the time it is ordered. V6 stated the pharmacy makes recommendations but does not adjust the dosage times. V6 stated it needs to be administered timely to ensure the appropriate clearance is maintained and they have a good baseline for the trough levels.On 4/15/26 at 9:36 AM, V8 (Nurse Practitioner) stated she had received R1's trough levels that check for appropriate dosing of the vancomycin and they had all been within normal limits. V8 stated R1 isn't missing any doses and his infection is improving. V8 stated as long as his trough levels are within normal limits then he is getting a good dosing of the vancomycin. The facility policy titled Medication Administration Policy, dated March 2014, documents, Policy: to authorize licensed nursing personnel (RN, LPN/Licensed Practical Nurse) and Qualified Medication Aides (QMA) to prepare and administer drugs and biologicals. Policy specifications: 1. Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates.Medications shall be administered one (1) hour before/after of the medication schedule unless specifically ordered otherwise.20. Medications shall be recorded on the MAR promptly after each administration by the individual who administered the drug.

Based on interview and record review, the facility failed to ensure antibiotics were administered as ordered by the physician for 1 of 3 (R1) residents reviewed for medication administration in the sample of 10.Findings Include:R1's admission Record, with a print date of 4/14/26, documents R1 was admitted to the facility on [DATE] with diagnoses that include infection and inflammatory reaction due to internal right knee prosthesis, after care following knee joint prosthesis, fracture of right patella, depression, anxiety, heart failure, and seizures.R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 15, indicating R1 is cognitively intact. This same MDS documents R1 had a recent knee replacement surgery.R1's current Care Plan documents a Focus area of, The resident has infection of the right knee prosthesis. Date Initiated: 03/28/2026. This Focus area includes Intervention of, Administer antibiotic as per MD (physician) orders. Date Initiated: 03/28/2026.R1's Order Summary Report with active orders as of 4/14/26 documents a physician order for vancomycin 1000 milligrams, 1.5 grams twice daily. Per pharmacy: Please admin (administer) within a 30 min (minute) window. If given over 30 min past due time, please call pharmacy for retime orders to avoid inaccurate vanc (vancomycin) troughs and dosing. This order has a start date of 4/5/26.When asked for the physician orders documenting R1's original Vancomycin order on admission to the facility this surveyor was provided with R1's Medication Administration Record (MAR) dated 3/1/26 to 3/31/26 that documents a physician order of Vancomycin 1000 milligrams (mg) 1.5 grams to be administered twice daily for infection with a start date of 3/27/26 and a discontinue date of 4/4/26. There is no time of administration documented on this MAR.On 4/13/26 at 10:52 AM, R1 stated he was on intravenous (IV) antibiotics for an infection in his knee. R1 stated he didn't get the antibiotics the way he should when he first moved to the facility.R1's Medication Admin (Administration) Audit Report, dated 3/1/26- 4/14/26, documents Vancomycin was ordered to be administered at 6:30 AM and 6:00 PM. This same report documents Vancomycin was administered late on the following dates and times. The 6 AM dose administered at 11:22 AM on 3/28, 9:42 AM on 3/29, 8:14 AM on 3/30, 1:41 PM on 3/31, 2:07 PM on 4/1, 11:11 AM on 4/2, and 10:37 AM on 4/3 and the 6 PM dose administered at 12:07 AM on 3/27, 10:14 PM on 3/29, 11:01 PM on 3/30, and 11:30 PM on 4/2/26.On 4/13/26 at 2:20 PM, V3 (Assistant Director of Nurses/ADON) stated R1 had not missed any antibiotic doses. V3 stated R1 only needed one dose on his day of admission to the facility (3/27/26). V3 stated she was not aware of R1's antibiotics being administered at incorrect times.R1's Progress Note documents on 4/3/26 at 8:58 PM, Resident approached nurses station voicing concerns that his IV (intravenous) vanc (vancomycin) was given later than due time. Resident states 'She gave it at 2:30 and I want you to call the pharmacy while I'm right here to see what they say about it.' Resident expresses frustration over the above information provided and states 'I know you guys are busy but I know when this is supposed to be done and I'm gonna stay on top of it.' I utilized active listening to diffuse the situation and called (name of pharmacy) pharmacy per resident request to inquire their guidance on the above scenario and spoke to Pharmacist . Pharmacist states 'If that's accurate then his vanc trough will be off which would lead to incorrect dosing.' Pharmacist gave specific instructions that the medication must be administered within a 30 min (minute) window and if the med is given 30 min past due time the RN (Registered Nurse) should call pharmacy for retiming orders.On 4/14/26 at 3:31 PM, V5 (RN/Registered Nurse) stated she remembered the timing of vancomycin administration being strictly regulated when she worked in the hospital. V5 stated R1 told her he didn't get his vancomycin until 2 pm. V5 stated she was concerned about giving him his next dose, so she called the pharmacy for clarification. V5 stated she adjusted the time she gave the next dose of vancomycin, changed the times on the physician orders, let V2 (Director of Nurses) know, and put a note on the communication board for the other staff to be aware.On 4/14/26 at 6 PM, V2 (Director of Nurses/DON) stated V5 had notified her of the time discrepancy and that it was the pharmacy's idea to change the administration times. V2 stated R1's antibiotic had been administered late at times when they didn't have a Registered Nurse working. When asked how often that happened, V2 stated it had happened maybe a couple of times. V2 stated the medication may have been administered at the correct time but not documented as administered at the time of administration.On 4/16/26 at 1:10 PM, V1 (Administrator) stated he would expect medications to be administered as ordered. On 4/15/26 at 8:45 AM, V6 (Pharmacist) stated it is important the vancomycin be administered at the time it is ordered. V6 stated the pharmacy makes recommendations but does not adjust the dosage times. V6 stated it needs to be administered timely to ensure the appropriate clearance is maintained and they have a good baseline for the trough levels.On 4/15/26 at 9:36 AM, V8 (Nurse Practitioner) stated she had received R1's trough levels that check for appropriate dosing of the vancomycin and they had all been within normal limits. V8 stated R1 isn't missing any doses and his infection is improving. V8 stated as long as his trough levels are within normal limits then he is getting a good dosing of the vancomycin. The facility Medication Administration Policy, dated March 2014, documents, Policy: to authorize licensed nursing personnel (RN, LPN/Licensed Practical Nurse) and Qualified Medication Aides (QMA) to prepare and administer drugs and biologicals. Policy specifications: 1. Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates.Medications shall be administered one (1) hour before/after of the medication schedule unless specifically ordered otherwise.20. Medications shall be recorded on the MAR promptly after each administration by the individual who administered the drug.

Based on interview and record review, the facility failed respond to a pharmacy review for an as needed psychotropic medication and failed to document the indication of use for the psychotropic medication for 1 of 3 resident (R2) reviewed for chemical restraints in a sample of 17. Findings include:R2's admission record, dated 3/18/26, documents an admission date of 1/19/26. R2's admission record documents diagnoses including but not limited to unspecified dementia, unspecified severity, with agitation; generalized anxiety disorder; Alzheimer's disease; and depression, unspecified.R2's physician order sheet, dated 3/18/26, documents orders for medications including but not limited to trazodone 50 milligram/mg tablet- take 1 tablet by mouth at bedtime with a start date of 3/14/26; pregabalin 25mg capsule - take 1 capsule two times per day for sleep with a start date of 1/27/26; citalopram 20mg tablet - take 1 tablet every day with a start date of 2/3/26.R2's Electronic Health Record (EHR) included an order, dated 1/20/26, for Ativan by V38, Medical Director, of facility for 0.5milligrams/mg to be administered every 12 hours as needed for nausea related to depression.R2's EHR included an order, dated 2/19/26, for Ativan by V30, Nurse Practitioner/NP, for 0.5 mg tablet to be given every 12 hours as needed for comfort related to Alzheimer's.R2's EHR included an order, dated 3/9/26, for Ativan ordered by V38, Medical Doctor/MD, for 0.5mg to be administered every 12 hours routinely for anxiety, aggression, and agitation related to generalized anxiety disorder.R2's most recent care plan documents a focus area for behaviors including anxiousness and restlessness dated 1/27/26. Interventions for this focus area include to administer medications as ordered and anticipating and meeting the resident's needs both dated 1/27/26. Another focus area on same care plan documents resident has behaviors of destructiveness including toward the building and/or items in the building dated 3/13/26. Interventions for this focus area include but aren't limited to administering medications as ordered and anticipating the needs of the resident both dated 3/13/26. R2's care plan documents a focus area R2 has potential risk to be physically aggressive which includes possible injury of others due to throwing objects including furniture dated 1/20/26. Interventions for this focus area include to involve the social services and activity departments as needed and psychiatric consult as needed both dated 1/20/26. R2's care plan documents other focus areas including delusional thinking and hallucinations at times dated 1/27/26; R2 has delirium and acute confusion episodes causing him to be easily distracted at times and disorganized thinking dated 1/27/26; and R2 uses psychotropic medications related to disease process of dementia with agitation and therefore could have potential risk for adverse effects dated 1/20/26. Interventions for this last focus area include to administer psychotropic medications as ordered by physician; monitor for effects and effectiveness every shift; consult with pharmacy and medical doctor to consider dosage reduction when clinically appropriate at least quarterly and educate the resident/family/caregivers about risks, benefits, and side effects and/or toxic symptoms related to the use of psychotropics all dated 1/20/26.R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a Brief Interview for Mental Status/BIMS score of 8, indicating R2 is not cognitively intact. R2's MDS documents resident has feelings including little interest or pleasure in doing things, feeling down depressed or hopeless, feeling bad about himself, trouble concentrating on things frequently in the 2 weeks prior to the assessment. R2's MDS documents R2 has behaviors including hitting, scratching self, pacing, rummaging, public sexual acts and disrobing in public. R2's MDS documents R2 is on 2 different high risk drug classes of medications including an antipsychotic and antidepressant.R2's February 2026 medication administration record (MAR) documents an order for Ativan oral tablet .5 MG as needed start date 1/20/26, discontinue date 2/12/26. R2's MAR documents R2 received Ativan on 2/1, 2/3, 2/4, 2/7 (two times), 2/8, and 2/10. R2 progress notes from 2/1/26 to 2/10/26 only contained 1 progress note related to administration of Ativan on 2/1. There were no progress notes on the other dates listed with the symptoms/reasons for administration of Ativan. R2's MAR documents an order for Ativan oral tablet .5MG as needed with a start date 2/19/26 and a discontinue date of 3/1/26. R2's MAR documents R2 received Ativan on 2/21 (two times), 2/24, and 2/26. R2 progress notes from 2/21/26 to 2/26/26 only contained 1 progress note on 2/21/26 that documented the reasons/symptoms for the administration of Ativan. On 3/17/26 at 1:07 PM, V27, (Power of Attorney/Family) stated she had requested on three separate occasions, beginning upon his admission to the facility on 1/19/26, to stop the medication Ativan because R2 was having an idiosyncratic (causing reverse reaction to what was expected) reaction to the medication. V27 stated it was finally discontinued for the last time on 3/11/26.On 3/17/26 at 3:39 PM, V27 stated she was not made aware on 2/12/26 when Ativan was discontinued or again on 2/19/26 when Ativan was reordered. V27 stated she had specifically spoke to the Administrator requesting to have Ativan discontinued on 3/4/26 and there was one conversation even before that one where she had voiced her concerns about R2 continuing the Ativan. V27 stated during both conversations she had made it clear the Ativan was to be stopped and not administered. V27 stated V1 (Administrator) admitted to her in one of the phone conversations the facility had made a mistake in relation to continuing the Ativan and he (V1) would check further into what caused the miscommunication/error.R2's Pharmacist medication record review form printed 2/23/26 documents: Please consider the following Psychotropic PRN medication(s): Ativan 0.5mg every 12 hours prn. Please choose from the following choices: Discontinue; add a stop date to PRN for short term use (MAX 14-Days CMS guidelines) and evaluate use: No change at this time- CURRENT ORDER CAN BE EXTENDED >14 DAYS, please provide duration (UP TO 180 DAYS) as part of medication order, indication for use, and document reason- risk/benefit to assist facility with regulatory compliance. None of those options were checked. Duration, indication for use and rationale are all left blank. The Physician/Prescriber Response section lists the choices as Agree, Disagree or Other. All are left blank. This document did not indicate the prescriber acknowledged or even read the above request from the pharmacist nor sign it at the bottom. On 3/19/26 at 8:24 AM, V26 (Licensed Practical Nurse/LPN) stated in relation to his progress note on R2 on 3/9/26, while he (V26) was off for back surgery, one of the (Name of Psychiatric Facility) psychiatric practitioners had evaluated R2 and reordered Ativan for a 3rd time. V26 stated he had remembered R2's Power of Attorney (V27) had stated the family no longer wanted R2 to be administered Ativan because it had an idiosyncratic reaction on him. V26 stated he then called V27 and confirmed with her she (V27) nor V28 (family member) still didn't want R2 administered Ativan, and V27 stated that was correct. V26 stated then he notified the facility's Nurse Practitioner (V30) for discontinuation orders and got it discontinued.On 3/19/26 at 10:20 AM, V7 (Registered Nurse/RN) stated in relation to use of Ativan with R2, every time R2 was administered Ativan R2 would become much more aggressive and violent. V7 stated it appeared that Ativan made him more agitated and unable to relax. V7 stated she also remembers V27 telling her R2 didn't do well on Ativan. V7 stated, I think I told my Director of Nurses/DON on the 21st of February about my concerns with (R2's) Ativan and the reaction he had.On 3/19/26 at 11:17 AM, V26 stated when R2 would be administered Ativan, he would turn into a whole different person becoming violent and aggressive. V26 went on to state V27 had mentioned it to him that was the same reason they stopped administering the Ativan at home as well.On 3/19/26 at 1:19 PM, V28 (family member) stated she doesn't remember giving verbal consent for use of Ativan upon admission of R2 to the facility. V28 stated, I know I didn't, in relation to giving verbal consent for use of Ativan. V28 went on to state even before R2 was admitted to the facility, the family had stopped administering the Ativan to R2 because it was having the opposite effect on R2. V28 stated she had witnessed a nurse administer Ativan once to R2, and at that time, had told them not to administer it anymore and the reason behind it. V28 was unable to provide a date, time, or person she spoke to in relation to that reported conversation.On 3/19/26 at 2:46 PM, V23 (RN/Assistant Director of Nurses/ADON) stated she doesn't remember R2's family requesting to have his Ativan stopped. V23 stated she does remember his family agreeing with stopping it though. In relation to why Ativan was started upon R2's admission, V23 stated R2's family brought all his medications from home, including Ativan, and that is why it was ordered initially. On 3/24/26 at 10:52 AM, V20 (RN) stated it was important to document in the progress notes when prn (as needed) medications were administered to monitor for effectiveness and to document what behaviors are being treated.On 3/24/26 at 11:34 AM, V2, (Director of Nursing/DON) stated R2 had admitted to the facility with a current order for Ativan. V2 stated the family brought all R2's medications from home including his Ativan. V2 stated she was not sure why R2 was getting the Ativan upon admission. V2 stated she doesn't remember V27 or V28 coming to her and requesting Ativan be discontinued. V2 stated she was not sure if V27 or V28 had spoken to any other staff member requesting R2's Ativan be discontinued. V2 stated she does remember after R2's Ativan was restarted the last time on 3/10/26, V27 asked her why Ativan was restarted. V2 stated she explained to V27 that psychiatry had come in and ordered Ativan without notifying the nursing staff. V2 stated Ativan had been started and R2 had been given one dose before the facility got it discontinued the last time. V2 stated nursing staff are now verifying psychiatric orders before they are put in the electronic health system to make sure everyone is notified, and consent is obtained before starting the medications. V2 was asked why there was no progress note documenting what behaviors or symptoms R2 was exhibiting prior to administration of Ativan on 9 of the 11 times it was administered. V2 stated she did not believe it was necessary to have a progress note each time a PRN medication is administered. V2 stated the reasoning or the diagnosis attached to the order should be enough documentation as to why the medication was administered. V2 was asked why she did not put in a corresponding progress note describing the symptoms/reasons for her administration of Ativan on 2/21/26. V2 stated she did not think it was necessary to put one in each time. V2 was asked if she administered R2 the Ativan related to comfort related to Alzheimer's disease; V2 stated she could not remember.On 3/24/26 at 2:01 PM, V1 (Administrator) stated he was not sure what the reasons were for R2 to have Ativan to be administered. V1 stated he does not work the floor and is not familiar with the residents' medications. When asked why Ativan was continued as a PRN medication past 14 days without a review by a prescriber, V1 stated it should have been reviewed and either reordered or discontinued. V1 stated he is not sure why it was missed to review R2's order for Ativan. V1 stated according to current standards of practice, PRN psychotropic medications are to be reviewed initially within 14 days after being ordered the first time in a facility. On 3/24/26 at 7:02 PM, V30 (Nurse Practitioner/NP) stated when R2 was first admitted to the facility, all his medication orders came from his family physician's office and what physical medications family brought from home. V30 stated that was the reason Ativan was ordered the first time on 1/20/26. V30 stated she does remember receiving a request from family to discontinue R2's order for Ativan. V30 stated it was discontinued the first time on 2/12/26. When asked why Ativan was reordered under her name as prescribing practitioner again on 2/19/26, V30 could not state why. V30 stated she reviewed the progress notes of R2's chart and her phone call records from that date and could not find a reason it would have been reordered at that time. V30 verified there were no progress notes linking a need for the reorder of Ativan. V0 stated the first order for Ativan on 1/19/26 was linked to diagnosis/reason of nausea related to depression. V30 stated she had seen Ativan be used in hospice for nausea but not related to depression. V30 stated the second time Ativan was reordered 2/19/26, the reason/diagnosis for administration was documented as comfort related to Alzheimer's. When asked about the reasons/diagnoses attached to the orders for Ativan, V30 stated neither was an appropriate reason/diagnosis for administration of Ativan.On 3/25/26 at 8:39 AM, V37 (LPN) stated she administered Ativan to R2 on 2/7/26 and 2/8/26. When asked why she (V37) did not document a progress note related to administration of the PRN Ativan to R2, she stated she believed the reason/diagnosis listed on the MAR was the only reasoning needed. When asked if R2 was experiencing nausea related to depression at those times she administered the Ativan to R2, she stated she did not remember what his symptoms were at that time because it had been so long.

Based on observation, interview, and record review, the facility failed to provide hot water for showers and personal care for 8 of 8 residents (R1, R2, R4, R5, R6, R11, R13, R14) reviewed for environment in a sample of 14. Findings Included:On 2/21/26 at 8:30 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/_ 2 degrees Fahrenheit. 1. On 2/21/26 at 9:30 AM, the North Hall Shower water temperature was taken at the shower head with a metal stemmed thermometer and the hot water measured 72 degrees Fahrenheit. The temperature of the hot water at the sink registered 95.3 degrees Fahrenheit 2. On 2/21/2026 at 9:35 AM, R6's and R13's bathroom sinks hot water temperature was taken with a metal stemmed thermometer and registered 95.5 degrees Fahrenheit. At that time where were both noted asleep in room. On 2/26/2026 at 11:20 AM, R6 was in her room alert and oriented and stated the water in her bathroom sink is too cold to wash her hands. 3. On 2/21/26 at 10:00 AM, R1's bathroom sinks hot water temperature was taken with a metal stemmed thermometer and never registered above 63.3 degrees Fahrenheit after it was let to run for 5 minutes. At that time, R1 was asleep in bed. 4. On 2/21/26 at 10:10 AM, R2's bathroom sinks hot water temperature was taken with a metal stemmed thermometer and never registered above 90.9 degrees Fahrenheit after it was let to run for 5 minutes. 5. On 2/21/26 at 10:15AM, R14's bathroom sinks hot water temperature was taken with a metal stemmed thermometer and never registered above 69.6 degrees Fahrenheit after it was let to run for 5 minutes. On 2/25/2026 at 9:58 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/_ 2 degrees Fahrenheit. 6. On 2/25/26 at 10:13 AM, V4 (Certified Nurse Assistant/CNA) was observed leaving the North Hall Shower room [ROOM NUMBER] with R11. At that time, V4 stated, The water is not warm enough, so we are going to a different shower room.7. On 2/25/2026 at 10:18 AM, the North Hall Shower room [ROOM NUMBER] water temperature was taken at the shower head with a metal stemmed thermometer and the hot water measured 84 degrees Fahrenheit. The water temp was allowed to run for several minutes and ranged from 82.9-85.3 degrees Fahrenheit. On 2/25/2026 at 10:21 AM, the North Hall Shower room [ROOM NUMBER] hot water temperature was taken with a metal stemmed thermometer at the sink that registered 84 degrees Fahrenheit.8. On 2/25/2026 at 10:20 AM, R4 and R5's bathroom sinks hot water temperature was taken with a metal stemmed thermometer and registered 92.3 degrees Fahrenheit. At that time, both R4 and R5 who were in the room alert and oriented stated sometimes the water is not warm in their sink to wash their hands. 9. On 2/25/2026 at 10:35 AM, North Shower room [ROOM NUMBER] water temperature was taken at the shower head with a metal stemmed thermometer and the hot water measured 66.0 degrees Fahrenheit. On 2/25/2026 at 10:43 AM, North Shower room [ROOM NUMBER] hot water temperature was taken with a metal stemmed thermometer at the sink that registered 78.4 degrees Fahrenheit. 10. On 2/25/2026 at 11:00 AM, R2 was sitting in her recliner in her room, alert and oriented. At that time, R2 stated the water in her bathroom sink never seems to be hot. On 2/25/2026 at 11:05 AM, R2's bathroom faucet water temperature reading 95.9 degrees Fahrenheit. On 2/26/2026 at 10:23 AM, V8 (Maintenance Director) stated he only checks the water temperatures in the faucets and not in the shower. V8 stated they are on a loop system and should all measure the same. V8 stated the water temperatures for the faucets and shower rooms should stay between 100 degrees Fahrenheit to 110 degrees Fahrenheit. V8 stated he has not had complaints of the water being cold, but he gets in at 7AM and all of the temps are fine because it is prior to shower being given. On 2/26/2026 at 11:49 AM, V1(Administrator) stated it is his expectation the water temperature in resident sinks, showers, and tubs stay between 100 - 110 degrees Fahrenheit per the facility policy. V1 stated his expectations are for resident sinks, showers, and tub water temperatures to be checked per protocol. The facility's Water Temperature Safety Guideline (undated) documented under Purpose-to help prevent resident burns and reduce the risk of bacteria growth by keeping water at safe temperatures. This same document under Safe Temperature Ranges-Ideal range: 100-110 degrees Fahrenheit.

Based on interview and record review, the facility failed to follow physician's orders and failed to assess and monitor a resident's declining condition for 1 of 3 residents (R1) reviewed for quality of care in a sample of 18. This failure resulted in R1's hospital admission for acute kidney injury and hyperkalemia requiring emergent dialysis and subsequent death.This failure resulted in Immediate jeopardy, which was identified to have begun on 12/28/25 when the facility failed to obtain physician ordered labs of CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and TSH (Thyroid-stimulating hormone) for R1. The facility failed to follow up on UA (Urinalysis) and Culture and Sensitivity lab results that was ordered for R1 on 12/28/25. The facility failed to notify the physician of a decline in R1's condition. This failure resulted in R1 not getting timely medical treatment, which resulted in R1 being sent out the hospital on [DATE] by V25 (Family Member) and requiring emergent dialysis and then transferred to palliative care, and R1 's death on 01/21/26. V1 (Administrator) was notified of the Immediate Jeopardy on 1/29/26 at 4:38PM. The immediacy was removed on 1/30/26, but non-compliance remained at a Level Two because additional time is needed to evaluate the implementation and effectiveness of In-service training.The Findings include:1.R1's admission Record documents an admission date of 12/26/25, with diagnoses of acute on chronic combined systolic (congestive) and diastolic heart failure, dysphagia, chronic obstructive pulmonary disease, pneumonitis due to inhalation of food and vomit, acute kidney failure, emphysema, type 2 diabetes mellitus, and secondary hyperparathyroidism.R1's Minimum Data Set (MDS), dated [DATE], documents in Section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15, which indicates R1 is cognitively intact. Section GG, Functional Abilities, documents toileting as substantial/maximal assistance. Section H, Bladder and Bowel, documents appliances as indwelling catheter.R1's Care Plan documents a focus area of R1 is at risk for alteration in psycho-social well-being d/t (due to) mood state, health decline and facility placement with a date initiated of 01/02/26. R1 has another focus area of R1 has noted delirium or an acute confusional episodes AEB (as evidenced by) him being easily distracted at times date initiated 01/02/26 with an intervention of report abnormal lab results to the MD (Medical Doctor). Another documented focus area is R1 has potential nutritional problem r/t (related to) dysphagia, therapeutic diet of NAS (No Added Salt)/LCS (Low Concentrated Sweets), mechanical soft per SLP (Speech Language Pathologist) diet restrictions with interventions of provide, serve diet as ordered, monitor intake and record every meal. There were no documented focus area on Diabetes Mellitus or Indwelling Catheter.R1's Progress Note, dated 12/28/25 at 2:00PM, documents Resident has not taken any food/nectar thick liquids this shift. Refuses to even with strong coaching from staff and family. Bladder palpated/firm. #16fr (French) foley [NAME] [sic] (Catheter) anchored with 450 mls. (milliliters) clear yellow urine received. Resident has not responded verbally this day. Squints eye closed. Did respond to insertion of Foley. (Medical Doctor) notified of resident condition and condition. Awaiting further orders at this time.R1's Progress Note, dated 12/28/25 at 2:37PM, documents, new orders rec'd (recorded) from (V27-Medical Doctor) start Megace Elixir 800mg once a day CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), TSH ( Thyroid-Stimulation Hormone), UA (urinalysis) and Urine Culture start protein supplement each meal TID (three times a day) have nutrition see patient have psychiatrist see patient.R1's Order Summary documents the following orders: Catheter- Record output from urinary catheter every shift order date of 01/07/26, with an order status of discontinued; Lasix 20mg by mouth one time a day related to acute on chronic combined systolic (Congestive) and diastolic (Congestive) heart failure, with an order date of 01/076/26, with an order status of discontinued; CMP (Complete Metabolic Panel), TSH (Thyroid-Stimulation Hormone), CBC (Complete Blood Count) one time only for per lab parameters until 12/29/25, with an order date of 12/28/25 and a start date of 12/29/25; UA (Urinalysis) with C &S (Culture and Sensitivity) only for prophylaxis until 12/29/25 with an order date of 12/28/25 and a start date of 12/29/25; Accucheck in the morning for DMII (Diabetic Mellitus type 2), with an order date of 12/26/25 and a start date of 12/27/25.R1's Order Summary does not document an order for an indwelling catheter or an order for instant glucose in December or January. R1's Progress Note, dated 01/11/26 at 5:55PM, documents, (V25-family member) coming to the nurses station saying her brothers blood sugar is low at 70 asking for orange soda, liquid glucose given. Now on [sic] hour later she states she is calling 911 because her brother cannot breathe and his glucose is low. Sats 92 on room air respers [sic] (respirations) even and unlabored. Resident has no pain, skin warm and dry. Pulse 74 glucose 117, bp (blood pressure) 112/64. Advised her that this is not an emergency situation.R1's Progress Note, dated 01/11/26 at 6:24PM, Resident leaving with EMS (Emergency Medical Services).R1's Progress Note, dated 1/12/2026 at 12:57 AM, documents, admitted [sic] to (name of out of state hospital) in (room number). Waiting on nephrologist to make rounds in the morning to decide any further medical decisions .dialysis.R1's Medication Administration Record for 01/01/26 to 01/31/26 documents accucheck in the morning for DMII (Diabetes Mellitus type 2) 5:00AM with a start date 12/27/25 and a D/C (discontinued) date of 01/13/26. On 01/04/26, 1/8/26, and 1/11/26 there is no accucheck documented.R1's Treatment Administration Record for 01/01/26 to 01/31/26 documents Catheter: record output from urinary catheter every shift start date of 01/07/26 and a discontinued date of 01/13/26. Recorded amounts documented: 01/07/26 night 200, 01/08/26 day 300cc (cubic centimeter) and night 400, 01/09/26 day 300 and night 450, 01/10/26 day none recorded and night 350, 01/11/26 day 200 and night none recorded.R1's ambulance Prehospital Care Report, dated 01/11/26 at 6:11PM, documents under narrative was dispatched to (the facility) for a [AGE] year old male with a possible UTI (Urinary Tract Infection) and low blood sugar. Upon our arrival, the patient was found in his room with his sister. The nurse had said she did not call 911 that it was the sister even though they could not find any reason to send him to the hospital. The sister informed us that she had given him glucose after the nurse had thrown it at her to do herself when she had refused. The nurse refused to come into the room and assist in moving the patient or talk to anyone once we entered the room. The sister said after she gave him the glucose the patient was a little more awake, she fed him fruit that also helped his sugar and made him feel a little more awake. The sister and patient wanted him to go (Local Hospital) due to the possibility of a UTI that has been getting worse over the past week and no one doing anything about it. He had a catheter in place and it was cloudy with specks of blood in it. He said it has been burning and lower abdomen sore feeling the need to urinate but cannot. He was placed on oxygen 3 L/Min (Liters per minute) by nasal cannula on scene and it helped bring his oxygen level up. Spo2 (Saturation of Peripheral oxygen) at 5:21PM was 89%.R1's Local hospital records, dated 01/11/26, documents under Medical Decision Making: [AGE] year-old Caucasian male who is brought in by EMS (Emergency Medical Services) after stating that he feels horrible in the nursing home he is there for rehab after having an illness which put him in the hospital. He states that he is not getting any better he feels weaker he has been hurting in his whole-body for last couple days he has a urinary catheter in because of urinary retention, but is not putting out urine and the while area is hurting. Discussion of management or test interpretation with external provider document called (outside hospital) transfer center for a bed for acute renal failure needing dialysis at 7:32PM. Clinical Impression: 1. Acute renal failure 2. Hyperkalemia.R1's hospital records from the out of state hospital, dated 01/11/26 ,documents under hospital course: This 66 yo (year old) male with PMHX (Past Medical History) significant for IDDMII (Insulin Dependent Diabetes Mellitus Type 2), COPD (Chronic Obstructive Pulmonary Disease), HTN (Hypertension), hyperlipidemia, hyperthyroidism, GERD (Gastroesophageal Reflux Disease), CKDIIIa (chronic kidney disease stage 3) and RA (Rheumatoid Arthritis). Patient transferred from SNF (Skilled Nursing Facility) to OSH (Outside hospital) ER (emergency room) with lethargy and decreased UOP (urinary output) from foley (catheter). He was transferred from OSH ER to (outside hospital) with BUN (Blood Urea Nitrogen) 90, creatinine >7, & K (potassium) 6.4 for higher level of care. Nephrology consulted, dialysis access was emergently placed and HD (hemodialysis) run after inadequate response to medical treatment for hyperkalemia. MWFT (Mid Way Feeding Tube) placed for medications and nutrition. Patient failed swallow and SLP (Speech Language Pathologist) noted results of recent MBSS (Modified Barium Swallow Study). SLP recommended PEG (Percutaneous Endoscopic Gastrostomy) placement. GI(Gastrointestinal) consulted for EGD (Esophagogastroduodenoscopy) to eval potential causes for severe dysphagia & consideration for PEG. Palliative care consultation requested to help further delineate goals of cares patient's wishes seemed to oscillate. While here, Rocephin and doxycycline continued to cover for possible CAP (Community-Acquired Pneumonia) Given constellation of Sx (Symptoms) and imaging, there was concern for nephrotic syndrome. Kidney bx (biopsy) recommended but not pursued due to Plavix use. Edema improved since HD initiated. Ultimately, patient elected to stop hemodialysis. He was evaluated for inpatient hospice and discharged there when bed became available. He was discharged to hospice on 01/21/26.On 01/20/26 at 12:22PM, V6 (Assistant Director of Nursing) said she was the nurse taking care of R1 on 01/11/26. V6 said she didn't take over R1's care until around 4:30PM on 01/11/26. V6 said the other nurse (V8, Registered Nurse/RN) didn't leave until around 5:00PM that day. V6 said V8 had been R1's nurse all day. V6 said she has maybe taken care of R1 one other time during the day shift and one night shift. V6 said V25 came out and was asking for an orange soda she didn't know who it was for, if it was for R1 or herself (V25). V6 saidV25 went and got change and came back to get the soda. V6 said V25 came out saying R1's sugar was running low. V6 said she didn't know how V25 knew R1's blood sugars were running low. V6 said V25 said his blood sugar was running in the 60's. V6 said she gave V25 a tube of instant glucose. V6 said she doesn't know why she gave it to V25 to give to R1. V6 said she doesn't know if V25 should have administered the instant glucose or not. V6 said V25 had a device to tell her what R1's blood sugars were. V6 said she didn't check R1's glucose at the time V25 said it was low. V6 said V25 said R1's blood sugars were running low all day. V6 said V25 had some kind of device in her hand waving it around. V6 said V25 was mad. V6 said V25 stated R1's blood sugars were 69 and 65. V6 said V25 was saying blood sugars were low but the dinner tray was coming in a few minutes. V6 said V25 gave the instant glucose to R1, and she told me she was going to call 911 because she felt that he was neglected. V6 said she went and got his vital signs after the sister told her that. V6 said she told V25 it wasn't an emergent situation and R1's vitals were normal. V6 said sometimes R1 wouldn't respond to staff. V6 said she tried to call V1 (Administrator) and V2 (DON) to let them know what was going on, but she was unable to get ahold of either of them and they didn't call her back. V6 said she wasn't able to print off any of R1's paperwork to be able to send to the hospital with R1 because the printer wasn't working. V6 stated she told V2 before the weekend that she wasn't able to print out papers. V6 said R1 didn't have any oxygen on and his oxygen saturation was 92% on room air. V6 said she doesn't think R1 had an order for oxygen. V6 said she thinks R1 did get breathing treatments earlier that day before R1 went to the hospital. V6 said R1 recently had gotten a catheter in as well at the facility.On 01/20/26 at 1:24PM, V8 (RN) said she remembers being told R1 went out to the hospital. V8 said she took care of R1 on 01/11/26 from 7AM to around 4:30PM-5:00PM. V8 said R1 wasn't complaining of any pain, shortness of breath, or low blood sugars. V8 said R1 had oxygen orders as needed. V8 said R1 wasn't on oxygen on 01/11/26. V8 said R1 only got oxygen to maintain his oxygen levels on room air. V8 said R1 had 4+ pitting edema to both of his lower extremities when he was admitted to the facility. V8 said R1 did have an indwelling catheter in, and she was the one who put the catheter in. V8 said a Certified Nurse Assistant had told her R1 hasn't urinated in several hours, so she put a catheter in and got back urine right away. V8 said V25 was concerned about R1's urine. V8 said R1 wasn't drinking a lot, and they were trying to encourage him to drink fluids often. V8 said R1 already had a history of kidney and bladder issues. V8 said she told R1 all the time that he needed to eat and drink. V8 said R1 didn't really complain of any pain or discomfort to the catheter area, the only thing R1 complained about was feeling sick.On 01/20/26 at 2:21PM, V16 (Certified Nurse Assistant/CNA) stated R1 wasn't really drinking very well while at the facility.On 01/21/26 at 11:02AM, V12 (Certified Nurse Assistant) stated she wasn't really taking care of R1 on 01/11/26. V12 said she did go in with V6 (RN) on 01/11/26 to take R1's blood sugar and vitals after V25 called 911. V12 said she was with V6 and R1's oxygen levels were within normal limits, but R1 was acting like he couldn't breathe. V12 said she was working on 12/28/25 when V8 was going to send R1 out to the hospital. V12 said V8 went in to check on R1, she said R1 wasn't responding to anyone then he was in the bathroom and took himself and was talking.On 01/21/26 at 11:20AM, V15 (CNA) stated he didn't really take care of R1; he only went over to take care of R1 when he went over to take the food trays or pick them up or to maybe check on him. V15 said he remembers R1 being out of it and he would try to wake him up. V15 said he emptied R1's urinary catheter bag a couple of times and R1 would have very little urine in his indwelling catheter bag. V15 saidthey tried to get R1 to drink; he said R1 liked tea and he would get R1 tea, but he really wouldn't drink much. V15 said R1 was a poor eater.On 01/21/26 at 11:26AM, V14 (Certified Nurse Assistant) stated on 1/11/26, V6 (Assistant Director of Nursing) told her V25 was calling 911 and said we weren't taking care of R1. V14 said she was the one to check R1's oxygen level. V14 said she had to go in and take the Spo2 monitor off of R1's finger.On 01/20/26 2:40PM, R1's lab results per orders documented on 12/28/25 were unable to be located in R1's chart. These lab results were requested from V2 (Director of Nursing) at this time.On 01/21/26 at 12:13PM, V2 (Director of Nursing/DON) stated R1 did have an order for CBC, CMP, TSH, and UA with culture and sensitivity. V2 stated the UA was completed and she did not have the results of the UA or the culture and sensitivity back yet. V2 said the CBC, CMP, and TSH were ordered on 12/28/25 but the nurse who put the order in put the order on the wrong flow sheet, which they don't use anymore. V2 said the orders did not populate to the EMAR (Electronic Medication Administration Record) for the nurse to obtain. V2 said the labs were never done because of this.On 01/21/26 at 2:30PM, R1's urinalysis culture and sensitivity report was provided and documented a collection date of 12/30/25 and printed date of 01/21/26 at 12:30PM. This report documented final: > 100,000 CFU/ML (Colony-forming units per milliliter) Pseudomonas fluorescens and >100,000 CFU/ML Enterococcus Faecalis.On 1/21/26 at 1:25PM, V8 (RN) stated, I went into (R1's) room on 12/28/25 and (R1's) eyes were closed and (R1) didn't look right. (R1) was breathing normal but wasn't responding. I rubbed (R1's) shoulder and took my fingers and tapped (R1) on the cheek. I looked at (R1's) eyes, but (R1) didn't respond so I did a sternal rub and called (V27, MD) and took (R1's) vitals. He has been in fluid retention and he did grunt when I put a catheter in (R1). V8 said she put a catheter in R1 because he wasn't urinating. V8 said she went to the nurse's station to get paperwork ready to send R1 out. After she called V27, R1 had got himself up to go to the bathroom. V8 said she notified V27 who didn't order anything new, just that we didn't have to send R1 out to the hospital now. V8 said R1 was having urinary retention, but it was because R1 wasn't drinking. V8 said she kept encouraging R1 to drink and he wouldn't. V8 said V27 gave an order for labs and urine. V8 said she didn't know if she got the urine sample when she put the catheter in R1 or not. V8 said she put all of this in the chart. V8 said she also put all of this on her report sheet for the next shift coming on. V8 said she put the indwelling catheter in when the CNA said R1 didn't have any output. V8 remembered she got around 450 ml of clear urine back. V8 said she put the indwelling catheter in when she did the assessment on R1 and then called the doctor, and he was ok with V8 putting in the indwelling catheter and gave V8 an order. V8 said she also reported the output to V27. V8 said V27 also put R1 on Megace to help with R1's appetite. V8 said sometimes R1 wouldn't respond or talk to staff.On 01/21/26 at 6:21PM, V18 (CNA) stated R1 was pretty sickly and R1 would hurt all the time when he moved. V18 said they put a catheter in R1 while he was at the facility. V18 said R1 would say that he had to pee all the time. V18 said R1 didn't have a lot of urine output. V18 said she would try to get R1 to drink.On 01/22/26 at 11:30AM, V22 (CNA) stated R1 did have some shortness of breath at times, but the nurse would check his oxygen level, and it would be good. V22 stated R1 wasn't really eating or drinking well.On 01/22/26 at 11:42AM, V2 (DON) stated they don't monitor fluid intake on a resident unless there is an order from the doctor, even if a resident has a catheter.On 01/22/26 at 12:47PM, V20 (CNA) stated R1 did have some shortness of breath at times. V20 said they would go get the nurse and she would check the oxygen levels and then go give R1 a breathing treatment.On 01/27/26 at 10:05AM, V25 (Family Member) stated R1 was admitted to the facility with a blood glucose sensor on so that way you can monitor his blood sugars with a phone. V25 said on 01/11/26 at 5:19PM, she went to see R1 and his blood sugars were low at 69 when she got to the facility. V25 said the monitor had shown her R1's blood sugars had been in the 60's all day on 01/11/26. V25 said when she got to the facility R1 was shaking and could hardly breathe. V25 said while R1 was at the facility, he never had oxygen on because he didn't have an order from the hospital for it when he was admitted . V25 said R1 had been on oxygen prior to him even going to the hospital prior to his admission to the facility. V25 said when she called 911 on 01/11/26, when the ambulance arrived, they said R1's oxygen level was 89% and they put oxygen on him right away to help get R1's oxygen level up, and they asked why R1 was not on oxygen. V25 said when she got to the facility, she told the nurse R1's blood sugars had been low all day and the nurse threw a tube of stuff at me and a spoon and told me to give it to (R1). V25 said she guessed it was something to help bring R1's blood sugars up. V25 said the nurse didn't give her any instructions on how to administer it or anything. V25 said she gave R1 the whole tube of medication. V25 said the nurse never came in to check what R1's blood sugars were. V25 said after the tube of medication was given, she was able to get R1's blood sugars up some and he was acting a little better. V25 said after a little bit, R1's blood sugars started dropping again, she could see it on the app on the phone. V25 said she went out and asked for an orange soda because R1 liked orange soda and the nurse told her they didn't have any soda; she would have to get it out of the vending machine. V25 said that she went out to get some change from her car for the vending machine. V25 said she gave R1 several things to help elevate R1's blood sugars. V25 said she asked the nurse about R1 going to the emergency room and she asked if they needed to call 911 or if she had to call 911. V25 said the nurse said it wasn't an emergent situation. V25 said the nurse didn't even come in and check R1's vitals until she called 911. V25 said after she called 911, the nurse then came in and checked R1's blood sugar and vitals. V25 said the nurse never came into R1's room until she called for an ambulance and then the nurse informed her that since it wasn't an emergent situation that she might have to bring R1 back by car or find another way to get him back to the facility. V25 said when the ambulance arrived, they asked about why R1 wasn't on oxygen and why there was no urine in R1's indwelling catheter bag. V25 said the only drainage that was in R1's bag was some sludgy stuff that was in the tube of the bag. That was the only output R1 had. V25 said R1 was so bad when they got to the hospital, they had to send him out to another hospital right away to do dialysis on him. V25 said R1 was so bad they ended up putting him on palliative care. V25 said R1 expired of renal failure. V25 said R1 was also not eating or drinking well while he was at the facility.On 01/27/26 at 10:35AM, V4 (Regional Nurse in training/Previous DON) stated he knows R1 didn't like his pureed diet and he doesn't know what they did without looking in the chart about his diet. V4 said residents who have congestive heart failure or who are on dialysis are some of the residents they usually do input and output on, but only if the doctor ordered it. V4 said every now and then we get a standing order to push fluids, it depends on the doctor if they want input and output. V4 said they should be documenting if a resident isn't eating or drinking. V4 said family would be ok to give instant glucose if the resident isn't taking the instant glucose for staff, but a nurse should be monitoring the blood sugar before and after administering the instant glucose. V4 said, If a resident appears short of breath, I would take the oxygen saturation and if that comes back ok, I wouldn't go off of just that,I would probably administer oxygen around 2 liters. A nurse can start the oxygen then let the doctor know. In a critical situation a nurse can insert an indwelling catheter and then notify the doctor.On 01/27/26 at 1:46PM, V27 (Medical Doctor/MD) said his parameters for blood sugars are anything below 70 he would want them to give him a call, but that is a judgement call. He saidthe nurses deal with it a lot so he wouldn't necessarily need the nurse to call him if they had the blood sugar back up with juice or food. V27 said he wasn't aware R1 was given instant glucose. V27 said he doesn't know if a nurse should use instant glucose with a blood sugar of 67; he said he would expect the nurse to use critical judgement. V27 said he would expect a nurse to check a residents blood sugar before administering instant glucose and about 20-30 minutes after administering it. V27 said he is not aware of R1 having any urinary retention and he wasn't aware of R1 having an indwelling catheter put in or of him giving any order for an indwelling catheter. V27 said if a resident isn't eating or drinking well, he would expect the nurse to use her judgement call on when to call him. V27 stated he does not remember ordering a CBC, CMP, TSH, and a urine with Culture and Sensitivity. V27 said if he did order labs, he would expect those labs to be done in a timely manner, and he would expect the nurses to notify him what the lab results were. V27 said if the CMP had been done, it would help show if R1 had renal issues; it would have been helpful. V27 said with the outputs R1 had, he didn't think R1 had oliguria (abnormally low urine output). He said, We look at the resident for all kinds of things not just the urine output. We look for dehydration and we also look at the physical appearance of the resident as well to see if there is something going on with them. We look for low blood pressure and high pulse. V27 said he would give an order to monitor output when a resident has an indwelling catheter if there is a reason for the indwelling catheter.On 01/27/26 at 2:10PM, V5 (Regional Operations) stated she would assume for the reason they didn't have output monitoring on the day R1 had his catheter inserted on 12/28/25, was because they switched V2 from the MDS (Minimum Data Set) position to the DON position and she did the admission audits with her MDS assessments, but with everything changing she didn't have a chance to get to the MDS yet for R1. When V2 did do R1's assessment, V2 got an order to monitor the output for R1. V5 said V2 usually would review the charts and make sure all the orders are in correctly and she will catch stuff the nurse missed like R1's output order. V5 said if they put an indwelling catheter in a resident, they should put an order in the physician orders for the indwelling catheter. V5 said the labs on R1 were missing because the person putting the order in put the order on the wrong flow sheet and not on the TAR (Treatment Administration Record) to let the staff know the labs needed to be done. V5 said this is something they didn't know until this happened to R1. V5 said with the new system, this didn't communicate over.On 01/28/26 at 10:16AM, V28 (Nephrologist) stated outputs of 700ml in 24 hours and 750ml in a 24-hour period aren't good outputs. V28 said those might be indicators of some renal problems or of poor fluid intake. V28 said there are several things that could cause a lower output. V28 also stated 350 ml and 200ml in a 12-hour period is not a good output as well. V28 said it could be indicators of renal failure or renal insufficiency. V28 said it would be hard to tell without looking at R1's lab results. V28 said if lab work was ordered that lab work should have been completed. V28 said it is a red flag as to why they weren't completed. V28 said if the labs would have been completed on the date that they were ordered it could have shown or indicated R1 was having renal insufficiency or renal failure. V28 said R1 already had renal problems prior to his admission to the hospital on [DATE]; he had an acute kidney injury. V28 said if you are putting a urinary catheter in for urine retention, you would most definitely monitor the output. V28 said that urinary retention, unresponsiveness, and confusion could all be indicators of renal problems such as insufficiency and failure, but without the labs being completed it is hard to say what was all going on at the time. V28 said if they had gotten the CBC and CMP it could have given the facility a better picture of what the resident had going on. V28 said if the labs had shown an elevated BUN and Creatine that it depends on how elevated it was, that could have been indicator of renal problems. V28 said if the levels were elevated, they should have notified the patient's doctor, and he would have decided if the resident needs to be sent to the hospital. V28 said, If the levels were high and he had the decreased output I would hope the primary physician would have sent the patient out to the hospital. V28 said she doesn't know if getting the labs completed on 12/28/25 would have changed the outcome of R1's death. V28 said it is hard to say 100% if the facility had completed the labs that R1 wouldn't have passed away. V28 said there are just too many ifs like did R1 have other things going on along with his renal problem. V28 said they could have maybe treated him sooner, but she doesn't know if the outcome would have been any different; it is so hard to say. V28 said by the time she treated R1 that his creatine was 7.7 and his BUN was 90. V28 said she needed to do a biopsy on his kidney, and they were unable to because R1 was on Plavix and they would have to hold it for several days and with everything going on he really didn't need the Plavix to be held. So, with the renal failure and everything else R1 had going on, the family and resident decided on palliative care. On 01/29/26 at 11:09AM, V1 (Administrator) stated even with a catheter unless a doctor orders for outputs to be recorded, they do not monitor outputs unless they have an order. V1 said that on 01/11/26 the nurse working called him and said R1's blood sugar was 70 and his oxygen level was 92% on room air and he doesn't remember the blood pressure and pulse, but they were within normal range. V1 said his outlook on 01/11/26 when R1 was sent out was the nurse told me when she called that R1's family was upset wanting R1 sent out because of R1's oxygen level at 92% on room air and R1's blood sugar being 70. V1 said he told the nurse at that time those readings are within normal limits and told the nurse to explain that to the family of R1 and if the family was adamant about sending R1 out, to send him out. V1 said ultimately R1 did get sent out because the family called 911. V1 said if a resident is more cooperative with the family, he could see a nurse giving the instant glucose to the family to give, especially if the resident is in the need for the medication. V1 said he thinks it would be ok if it was supervised by the nurse. V1 said they should have a physician order for the instant glucose along with an order for an indwelling catheter. V1 stated he does not know why they put an indwelling catheter in R1. V1 said he does not know why a UA with C&S, CBC, CMP and a TSH was ordered. V1 said the CBC, CMP, and TSH did not get done because the order was not generated in the MAR (Medication Administration Record). V1 said, Usually it would pop up in the MAR and then the nurse would draw the lab, but now we have an outside lab that will come weekly to do labs along with the nurses still drawing labs. The lab they sent the urinalysis to was supposed to deliver the results to the facility. Nurses should have followed up on it. V1 said he doesn't know the process V2 used to get the C and S on the urine finally. V1 said it should have been checked up previously. V1 said he would hope the doctor would send out any resident with a change in condition if it is not treatable in house. V1 said he was not aware of any problems they were having with the printer at the facility.The facility policy titled Nursing Care of the Resident with Diabetes Mellitus, with a revised date of April 2007, under Purpose documents the purpose of this guidelines are: create individualized plan for each resident with diabetes mellitus, to review the most common and serious conditions and complications associated with diabetes, to help the resident control his/her diabetes with diet, exercise, and insulin (as ordered), prevent recurrent hyperglycemia/hypoglycemia, recognize, manage, and document the treatment of complications commonly associated with diabetes; and, individualize teaching according to carefully assessed resident and family needs. Under condition associated with diabetes #3. Hypoglycemia (Blood sugar below reference ranges) signs and symptoms of hypoglycemia usually have a sudden onset and may include the following: a. weakness, dizziness, or faintness, b. restlessness and/or muscle twitching, c. tachycardia (increased heart rate), d. pale, cool, moist skin, e. excessive perspiration, f. irritability or bizarre changes in behaviors, g. blurred, or impaired vision, h. headaches, i. numbness of the tongue and lips/thick speech, j. (more serve) stupor, unconsciousness and/or convulsions; and, k. (more serv

Based on interview, observation, and record review, the facility failed to ensure sufficient staff were available to provide needed care in a timely manner. This failure has the potential to affect all 45 residents residing in the facility.The findings include:On 01/22/26 at 10:35AM, R2 who was alert to person, place, and time, stated she had to wait over 30 minutes last night for someone to come answer her call light. R2 said she is glad she really didn't need anything important. R2 had her call light on to see what all staff were working on 01/21/26 for the 6p to 6a shift. R2 stated, They must not have had a lot of staff because it took forever for them to answer my light and when someone did answer my light it was (V1, Administrator) who answered my call light. R2 said she has problems like this all the time, especially in the evening where it will take the staff 30 minutes to an hour to answer her call light, she said usually they might have just 1 certified nurse assistant on her hall and 1 certified nurse assistant on the other hall. On 01/28/26 at 1:29PM, R5, who was alert and oriented to person place and time, stated she has to wait over a half hour several nights for someone to answer her light on evening shift. R5 stated her bed was soaked, and she was freezing from laying in her urine one night recently. R5 said she gets mad about having to wait for staff to answer the call light, but she knows they don't have a lot of staff working so she tries to be patient. R5 said if she is still in her wheelchair, she will hit her call light and wheel out to the hall just to see if she can find a staff member to help her out.On 01/22/26 at 2:21PM, R6 who was alert to person, place, and time, stated last night she had her call light on several times, and she had to wait at least 30-45 minutes for a staff member to come answer her light. R6 said she rang her call light because she needed to be changed and she had to lay in urine the whole time she waited. R6 said this happens a lot on day and evening shift.On 01/22/26 at 10:42AM, R12 who was alert to person, place, and time, stated she was on her call light for over 30 minutes last night. R12 said she called the nurses' station to see if she could get someone to help her. R12 said she needed to be changed. R12 said she had an incontinent episode and was just lying there waiting on someone to come answer her light. R12 said finally V2 (Director of Nursing) came and answered her light. R12 she will have to just sit there and have to wait in the evening for someone to answer her light. R12 said she just waits for staff to answer the call light, and it may take 30-45 minutes, sometimes an hour, for them to answer the call lights.On 01/21/26 at 6:36PM, V2 (Director of Nursing) stated they only had V19 (Certified Nurse Assistant/CNA) and V18 (CNA) in the facility working the floor at this time. V2 said they had one call in and another staff member hadn't called at all or showed up. V2 said they had an agency nurse that was the nurse on duty working tonight who had never been at the facility before. V2 said she did have another CNA, V14, coming back into the facility to help out on the floor.On 01/21/26, the following observations were made:6:45PM: observed V19 (CNA) who was working on North Hall taking residents outside to go smoke. No other CNA working on North Hall.6:50PM: observed 4 call lights going off down North Hall in separate rooms.7:00PM: observed V19 (CNA) walk in from outside with the residents and she stated one of the residents wasn't feeling good. Call lights were still going off on North Hall in the 4 rooms previously noted.7:03PM: observed V2 asking V19 (CNA) to go down to room (#) and get the vital machine and take the resident who was sick vitals who was in the dining room. Call lights were still going off on North Hall in the 4 previous rooms.7:06PM: observed V19 (CNA) answered the phone she was very upset and said R12 had called and was wanting help. Call lights were still going off on North Hall in the 4 previous rooms.7:15PM: observed a resident's voice yelling from North Hall for help. Call lights were still going off on North Hall in the same rooms.7:21PM: observed V19 (CNA) going into room [ROOM NUMBER] to answer the call light. Call lights were still going off in 3 rooms.7:22PM: observed V1 (Administrator) going into a room to answer the call light.7:23PM: observed another room's call light was off.7:41PM: Observed V14 arriving at the facility to clock in.7:50PM: observed room [ROOM NUMBER] call light was off.On 01/29/26 at 11:09AM, V1 (Administrator) stated he feels like staff answer the call lights in a timely manner. V1 said it just depends on the CNA. V1 said he doesn't think if they have only 1 CNA down a hall, that the CNA should be taking the residents out to smoke and leaving no other staff down the hallway.On 01/21/26 at 6:21PM, V18 (CNA) stated she doesn't feel the facility has enough staff to care for all the residents adequately. V18 said it is not that they don't schedule enough help most of the time, but it's that they have call ins and they can't get it covered. V18 said they used to have agency to cover the CNA call ins, but now they don't have agency cover the empty CNA openings, only the nurse's spots.On 01/22/26 at 9:34AM, V16 (CNA) stated, The facility 100% needs more staff. There are days when we aren't able to get all the resident care needs done. We try to get all the care provided and most of the time we are able to get it done, but other days we cannot get it all done. V16 said there are days it will take them forever to answer a residents call light. V16 stated she had to come in at 1:40AM this morning because they only had 1 CNA and 1 Nurse. V16 said when she got to the facility this morning, it was V19 (CNA) in the building and 1 agency nurse.On 1/22/26 at 9:55AM, V23 (CNA) stated he does feel the facility has a problem with not having enough staff. V23 said they have times that some of the residents won't get all of their care needs provided to them because they don't enough staff. V23 said they try to get as much resident care done as they can when they are short of staff.On 01/22/26 at 10:46AM, V17 (CNA) stated sometimes they are short of staff, but it is on night shift. V17 said she doesn't know how many staff they usually have on night shift.On 01/22/26 at 11:30AM, V22 (CNA) stated the facility has a problem with not having enough staff. V22 said they schedule staff, but most of the time they will have call ins or staff don't show up and then they are short of staff and they don't get it covered so they work short. V22 said most of the time they can get all the residents' care done, but there are times when some of the resident care needs might not get done. V22 said it is harder to get all the work done on North Hall; she said it is a more demanding hall. V22 said on day shift from 6:00AM to 6:00PM, they have 3 CNA's on North Hall and 2 on the memory care unit along with 2 nurses until around 4:30PM, then it goes down to 1 nurse.On 01/22/26 at 12:47PM, V20 (CNA) stated she usually works from 6:00PM to 6:00AM. V20 said the facility does have a problem with not having enough staff. V20 said some nights she works it is only 1 CNA on North and 1 CNA on South or memory care and 1 nurse. V20 said the facility tries to get help when they have call offs or the schedule will change and they forgot to update it.On 01/22/26 at 3:02PM, V8 (Registered Nurse/RN) states she does not feel the facility has enough staff to be able to provide care adequately to all residents.On 01/28/26 at 9:59AM, V21 (CNA) stated, There are days I feel like we don't have enough staff to care for the residents adequately. I went from day shift to night shift. Usually we have 3 CNA's on North and usually 1 CNA on South and then 1 nurse. V21 said there have been times when they have 1 CNA on North and 1 CNA on South, especially when they have call offs or people don't show up. V21 said with the weather recently, they haven't had a lot of staff.On 01/29/26 at 9:12AM, V24 (Nursing Assistant) stated she has had to work with 1 CNA on multiple occasions and had to do all the CNA work, but she said that she does it with the other CNA. V24 said she works from 6:00AM to 6:00PM. V24 said they try to meet all the resident care needs but sometimes they might not get all the care needs done because they don't have enough staff. V24 said, Yes, we have a staffing problem; they are always having problems with staff calling in and it is hard to get all the work done when you don't have enough staff.On 01/29/26 at 11:09AM, V1 (Administrator) stated he feels the facility has enough staff to be able to provide adequate care. V1 said he was not aware of 1 CNA and 1 Nurse working from 6:00pm to 6:00AM. V1 said ideally on nights they have 2 CNA's on 1 hall and 1 on the other hall and 1 nurse.The employee time clock report titled Employee Punches and Hours by Day documents the following time clock records for 1/21/26 and 1/22/26: 01/21/26, V19 clocked in at 5:57PM and left on 1/22/26 at 6:05AM. 01/21/26, V18 (CNA) clock in at 5:57pm and clock out at 10:09PM. On 01/21/26 V14 (CNA) clock back in at 7:40PM clocked out at 11:59PM. On 01/22/26 V16 (CNA) clock in at 1:42AM and clock out at 6:12PM. Per employee punch records only 1 V19 (CNA) and 1 agency nurse in the facility from 1/21/26 at 11:59PM to 01/22/26 at 1:42AM.The facility daily census, dated 01/20/26, documents a total of 45 residents residing in the facility.The facility policy titled 'Staffing Policy undated documents under policy: It is the policy of this facility to provide an adequate number of staff to successfully implement resident functions to meet resident needs. Under standards #2. Adequate staffing ratios, by numbers and positions required to meet the needs of the residents will be maintained, including the scheduling of relief staff during all vacations, holidays and relief periods.

Based on interview, observation, and record review, the facility failed to maintain a resident's right to receive timely care and be treated with dignity for 4 of 18 residents (R2, R5, R6 and R12) reviewed for resident rights in a sample of 18. This failure has the potential to affect 26 residents residing on the North Hall.The findings include:1. R2's admission record, dated 02/02/26, documents an admission date of 11/23/2022 with diagnoses in part of chronic respiratory failure with hypoxia, type 2 diabetes mellitus, morbid obesity, lack of coordination, and hypertensive heart and chronic kidney disease with heart failure.R2's Care Plan documents a focus are with a date initiated of 08/27/25, of R2 is at risk for impaired skin integrity r/t (related to) history of vascular wounds, hx (history) of MASD (Moisture Associated Skin Damage): refusing to be turned and repositioned and prefers to lie in one position: dx (diagnosis) DMII (Diabetes Mellitus Type 2), chronic resp (respiratory) failure with hypoxia, COPD (Chronic Obstructive Pulmonary Disease), candidiasis, HTN (Hypertension), gout; renal disease; noncompliance with diabetic tx (treatment) regimen; takes SQ (subcutaneous) insulin; CHF (Congestive Heart Failure); has sensory impairment; skin is constantly moist r/t incontinence and perspiration; confined to bed; unable to make major changes in position without assistance requires max assist. Another focus area, with a date initiated of 10/20/25, R2 has ADL (Activities of daily living) self-care performance deficit r/t requiring extensive assistance with most ADL's r/t reduced mobility, lack of coordination, impaired mobility, weakness with an intervention of encourage resident to use call light when assistance is needed.R2's Minimum Data Set (MDS), dated [DATE], documents in Section C a Brief Interview for Mental Status (BIMS) score of 14, which indicates R2 is cognitively intact. Section GG documents R2 is dependent on staff for toileting and repositioning. Section H documents R2 has an indwelling catheter and is always incontinent of bowel.On 01/22/26 at 10:35AM, R2 stated she had to wait over 30 minutes last night for someone to come answer her call light. R2 said she is glad she really didn't need anything important. R2 had her call light on to see what all staff were working on 01/21/26 for the 6p to 6a shift. R2 stated, They must not have a lot of staff because it took forever for them to answer my light, and when someone did answer my light, it was (V1, Administrator) who answered my call light. R2 said that she has problems like this all the time, especially in the evening where it will take the staff 30 minutes to an hour to answer her call light. R2 said usually they have just 1 certified nurse assistant on her hall and 1 certified nurse assistant on the other hall. 2. R5's admission Record, dated 02/02/26, documents admission to the facility on [DATE], with diagnoses of Parkinson's disease, COPD, panic disorder, and fibromyalgia.R5's Care Plan, documents a focus area with a date initiated of 12/28/2021 R5 has self-care deficit as evidenced by: needs assistance with Adl's other lack of coordination, other abnormalities of gait and mobility, unsteadiness on feet, Parkinson's and another focus area of at risk for falls and injuries r/t medications: psychotropic meds/diuretic meds/cardiovascular meds/pain meds medical factors: pain with intervention on 09/23/23 of call don't fall sign in room and keep call light within reach.R5's MDS, dated [DATE], Documents in Section C a BIMS score of 10, which indicates R5 has moderately impaired cognition. Section GG documents R5 require set-up and clean up help with toileting hygiene and bed to chair and chair to bed transfers. Section H documents R5 is occasionally incontinent with bladder and bowel.On 01/28/26 at 1:29PM, R5 who was alert and oriented to person place and time stated she had to wait over an hour several nights ago for someone to answer her light on evening shift. R5 stated her bed was soaked, and she was freezing from laying in her urine. R5 said she gets mad about having to wait for staff to answer the call light, but she knows they don't have a lot of staff working, so she tries to be patient. R5 said if she is still in her wheelchair, she will hit her call light and wheel out to the hall just to see if she can find a staff member to help her out.3. R6's admission record, dated 02/02/26, documents R6 was admitted to the facility on [DATE], with diagnoses of permanent atrial fibrillation, chronic respiratory failure, type 2 diabetes mellitus, unsteadiness on feet, lack of coordination, and chronic pain.R6's Care Plan documents a focus area with a date initiated of 12/07/25 of the resident (R6) is (Specify high, moderate, low) risk for falls r/t with intervention of be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. R6's MDS, dated [DATE], Documents in Section C a BIMS score of 14, which indicates R6 is cognitively intact. Section GG documents R6 is dependent with toileting hygiene. Section H documents R6 is always incontinent of bladder and bowel.On 01/22/26 at 2:21PM, R6 stated last night, she had her call light on several times, and she had to wait at least 30-45 minutes for a staff member to come answer her light. R6 said she rang her call light because she needed to be changed and she had to lay in urine the whole time she waited. 4. R12's admission Record , dated 02/02/26, documents an admission date of 05/14/21 and diagnoses of hemiplegia and hemiparesis, type 2 diabetes mellitus, COPD, morbid obesity, personal history of transient ischemic attack diagnoses of acute respiratory disease, neurocognitive disorder with Lewy bodies, dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, stiffness right knee, pain, diarrhea, cellulitis of right toe, depression, osteoarthritis, obstructive sleep apnea, normal pressure hydrocephalus, hyperlipidemia and Parkinson's disease.R12's Care Plan documents a focus area ,with a date initiated of 10/31/25, of R12 has an ADL self-care performance deficit r/t dx (diagnosis): hemiplegia and hemiparesis following CVA (Cerebral Vascular Accident) affecting left, non-dominant side; diabetes with peripheral angiopathy; COPD; obesity; phlebitis; heart disease; a-fib (atrial fibrillation); mood disorder; anxiety; PVD (Peripheral Vascular Disease); vision impairment; Anemia; dorsalgia; depression. Another focus area with a date initiated of 02/10/2022 of R12 is at risk for falls, risk for injury from falls with an intervention of encourage use of call light.R12's MDS, dated [DATE], documents in Section C a BIMS score of 15, which indicates R12 is cognitively intact. Section GG documents R12 is dependent with toileting hygiene and transfers. Section H documents R12 is always incontinent of bladder and bowel.On 01/22/26 at 10:42AM, R12 stated she was on her call light for over 30 minutes last night. R12 said she called the nurses' station even to see if she could get some help. R12 said she needed to be changed because she had an incontinent episode and was just lying there waiting on someone to come answer her light. R12 said finally, V2 (Director of Nursing) finally came and answered her light. R12 stated it happens often in the evening time waiting on staff to answer the call lights andshe just has to sit there and wait it might take 30-45 minutes, sometimes an hour, for them to answer the call lights.On 01/21/26 at 6:36PM, V2 (Director of Nursing) stated they only had V19 (Certified Nurse Assistant/CNA) and V18 (CNA) in the facility working the floor at this time. V2 said they had one CNA call in and another CNA hadn't called at all or showed up. V2 said they had an agency nurse that was the nurse on duty working tonight who had never been at the facility before. V2 said she did have another CNA, V14, coming back into the facility to help out on the floor.On 01/21/26 at 6:45PM, V19 (CNA), who was working on North Hall, was observed taking residents outside to go smoke. There was no other CNA observed working on North Hall. On 01/21/26 at 6:50PM, observed 4 call lights going off down North Hall in 4 separate rooms.On 01/21/26 at 7:00PM, V19 (CNA) walked in from outside with the residents and she stated one of the residents wasn't feeling good. Call lights were still going off on North Hall in the rooms previously observed.On 01/21/26 at 7:03PM, V2 asked V19 (CNA) to go down to a room and get the vital machine and take the resident who was feeling sick vitals who was in the dining room. Call lights were still going off on North Hall in the rooms previously observed.On 01/21/26 at 7:06PM, V19 (CNA) answered the phone. V19 appeared very upset and said R12 had called and was wanting help. Call lights were still going off on North Hall in the 4 rooms previously observed.On 01/21/26 at 7:15PM, an unknown resident's voice was heard yelling from North Hall for help. Call lights were still going off on North Hall in the rooms previously observed.On 01/21/26 at 7:21PM, V19 (CNA) went into a room to answer the call light. Call lights were still going off in 3 of the 4 rooms previously observed.On 01/21/26 at 7:22PM, V1 (Administrator) went into a room to answer the light call.On 01/21/26 at 7:23PM, call light was off in room that had previously been activated.On 01/21/26 at 7:41PM, observed V14 (CNA) arriving at the facility to clock in.On 01/21/26 at 7:50PM, observed room [ROOM NUMBER] call light was off.On 01/29/26 at 11:09AM, V1 (Administrator) stated he feels like staff answer the call lights in a timely manner. V1 said it just depends on the CNA. V1 said he doesn't think if they have only 1 CNA down a hall that the CNA should be taking the residents out to smoke and leaving no staff on the hallway.The facility daily census, dated 01/20/26, documents a total of 26 residents reside on the North Hall. A review of facility policy titled Answering the Call light (revised 08/2008) documents under Purpose The purpose of this procedure is to respond to the residents requests and needs.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that includes post fall assessment and treatment, monitoring, reporting, and investigating for 1 of 3 residents (R1) reviewed for quality of care in the sample of 6. This failure resulted in R1 falling and sustaining a hip and femur fracture without timely assessment and treatment after the fall. A reasonable person would experience feelings of discomfort and distress due to not receiving timely after fall care. This past non-compliance occurred between 11/14/25 and 11/16/25.Findings include:R1's Transfer/Discharge report, dated 12/2/25, documents an admission date of 12/3/2021 and a discharge date of 11/20/2025.R1's diagnosis report, dated 12/3/25, documents the following diagnoses in part, fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing, muscle weakness (generalized), other abnormalities of gait and mobility, pain in right hip, unsteadiness on feet.R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 9, indicating R1 is moderately cognitively impaired. Section GG-Functional Abilities documents R1 is dependent on staff for all transfers.R1's Care Plan documents R1 is at risk for falls, risk for injury from falls with an initiation date of 2/28/22.R1's Fall Risk Assessment, dated 9/25/25, documents R1 is at high risk for falls.On 12/1/25 at 2:29pm, V12 (family member) stated V14 (family member) had visited R1 on 11/15/25 and said R1 was not wearing socks and she appeared to be in pain. V12 stated she went to visit R1 on 11/16/25 and noticed her leg did not look right and she was in pain. V12 stated one of the aides told her she had been in pain the day before and she had told the nurse about it. V12 stated she did not know the aide's name. V12 stated, Staff were using a mechanical lift with her and her leg was so messed up, it was rotated, and her foot was flat on the recliner. V12 stated she told V8 (Registered Nurse/RN) something was not right with R1's leg; she stated V8 tapped her leg and said it looked a little swollen. V12 stated the hospital diagnosed R1 with a right hip fracture and a left leg fracture. V12 stated V2 (Director of Nursing/DON) called her and said a nurse admitted R1 had fallen and she didn't do anything about it. V12 stated V2 told her some staff stated they had reported R1 was in pain and the same nurse didn't do anything about it; he told her they got rid of the nurse.On 12/1/25 at 12:56pm, V2 (DON) stated there is an event that should be triggered in a resident's medical record when they have a fall or incident. V2 stated it will show up in the progress notes. V2 confirmed this was not done for R1's fall on 11/16/25.On 12/1/25 at 2:54pm, V2 (Director of Nursing/DON) stated they realized there was an issue with R1 and quickly went into action to correct it.On 12/2/25 at 11:31am, V8 (RN) stated she was the nurse that sent R1 out on 11/16/25. V8 stated she had noticed R1 had some increased edema more so in her left leg than in the right. V8 stated, (R1) had edema, but it was a little more this day. She did not complain of pain; she did grimace a little when she touched it. (R1) was sent out because her daughter wanted her sent out. V8 stated she had pulses, and she had no complaint of pain prior to. V8 stated she had no knowledge of R1 falling until after she was sent to the hospital.On 12/2/25 at 1:27pm, V9 (Certified Nursing Assistant/CNA) stated she was not working on R1's hallway on Friday, the day she fell. V9 stated one of the other CNA's told her she had to help V11 (Licensed Practical Nurse/LPN) put R1 back into bed after finding her on the floor. V9 stated the only nurse they worked with that following weekend was V11, and she reported to her two different nights that R1 was in pain. V9 stated she was not there the day R1 was sent out.On 12/2/25 at 1:37pm, V10 (CNA) stated she was working the night that R1 fell. V10 stated she helped V11 (Licensed Practical Nurse/LPN) get R1 up after she fell; she stated she did not appear to be in pain. V10 stated V11 did not really assess R1, and she did not call her family or physician. V10 stated R1 did appear to be in pain later in the weekend, it was reported to V11, but to her knowledge V11 did not address it.On 12/2/25 at 11:08am and 12/3/25 at 9:37am; attempts to contact V11 (LPN) were made but unsuccessful. On 12/2/25 at 2:19pm, V2 (DON) stated they held a meeting on 11/16/25 with himself, V1; and V13 (RN, Minimum Data Set (MDS)/Care plan coordinator) to investigate and develop a plan of correction. V2 stated they interviewed all staff and residents and educated all the staff; and V11 (LPN) was terminated.On 12/2/25 at 2:40pm, V1 (Administrator) stated V2 (DON) jumped into action as soon as they found out that all the events that had taken place with R1. V1 stated as soon as he found out everything that went on with R1, he terminated V11 (LPN). V1 stated all staff and residents were interviewed, and staff were educated immediately.Facility document titled Fall Scene investigation for R1 documents the date of fall as 11/14/25. This documents states under Fall Summary R1 was found on the floor (unwitnessed). This document states under fall location the fall occurred in resident room. This document states that the resident was attempting to self-transfer.There is no documentation in R1's progress notes of a fall or post fall evaluation occurring on 11/14/25.R1's progress notes; dated 11/16/2025 at 2:15pm; documents . Residents daughter requests her mother to be transferred to (local emergency room) to have left hip evaluated. Resident has edema to ble (bilateral lower extremities) and has had bil (bilateral) knee replacements in the past, she is non-weight bearing. Resident does not c/o (complain of) pain or ask for medications, she will grimace when foot is pulled. non emergent EMS (Emergency Medical Services) notified to transport, report called to ER (emergency room) .R1's medical record from the local hospital documents in the emergency room Provider notes; dated 11/16/25 at 3:41pm, Patient is a [AGE] year-old female who presents to the ED (emergency Department) via EMS (Emergency Medical Services) from a local nursing facility complaining of left knee pain for the last 3 days. Patient has a history of dementia and does not recall any accident or injury to the knee. Per EMS, nursing faculty has no record of any injury to the knee.R1's medical record from the local hospital documents an x-ray result of R1's left knee, dated 11/16/25 at 4:55pm, showing a fracture of the distal femur.R1's medical record from the local hospital documents an x-ray result of R1's right hip, dated 11/16/25 at 4:57pm, to include: 1. sub capital fracture of the right femoral neck with proximal migration of the shaft, chronic in appearance however new since 2023. 2. Age-indeterminate fractures of the superior and inferior right pubic ramus.Facility Policy titled Fall Guideline, with a revision date of 8/2024, documents under the section titled Post fall, Staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Documentation of falls should include information to assist in determining the cause of the fall .For an individual who has fallen, staff will attempt to define probable causes within 24 hours of the fall .Prior to the survey date, the facility took the following actions to correct the deficient practice:A QAPI (Quality Assurance and Performance Improvement) meeting was held on 11/16/25. In attendance - V1 (Administrator), V2 (DON) and V13 (MDS/Care plan coordinator). The QAPI ad hoc form notes the following: 1. Immediate corrective action: Resident received medical attention. MD (Medical Doctor) notified, DON (Director of Nursing) and POA (Power of Attorney) notified. 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents residing in the facility have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: All residents and staff interviewed to identify unreported falls.4. Plan to monitor performance to ensure solutions are sustained: DON or designee will interview three residents and three staff members weekly for any unreported falls. Administrator will report quarterly findings to the QA (quality assurance) committee.An in-service was completed with all employees regarding documenting and reporting falls.

Based on interview and record review, the facility failed to ensure that a resident was properly assessed for injury and pain and to address resident complaints of pain post fall for 1 of 3 (R1) residents reviewed for pain in a sample of 6. R1 fell and sustained a hip and femur fracture without proper assessment of injury/pain. A reasonable person would experience feelings severe pain and discomfort due to not receiving pain relief medication. Findings include:R1's Transfer/Discharge report dated 12/2/25 documents an admission date of 12/3/2021 and a discharge date of 11/20/2025.R1's diagnosis report, dated 12/3/25, documents the following diagnoses fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing, muscle weakness (generalized), other abnormalities of gait and mobility, pain in right hip, unsteadiness on feet.R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 9, indicating R1 is moderately cognitively impaired. Section GG-Functional Abilities documents that R1 is dependent on staff for all transfers.R1's Care Plan documents R1 is at risk for falls, risk for injury from falls with an initiation date of 2/28/22.R1's Order Recap Report, printed 12/2/25, documents R1 had an order for Ibuprofen Oral Tablet 600 milligrams (mg) give 600 mg by mouth every 8 hours as needed for pain started 8/24/23 and an order for Tylenol Extra Strength Tablet 500 mg give 2 tablets by mouth every 4 hours as needed for mild pain, take 1-2 tablets every 4-6 hours as needed for mild pain with a start state of 12/26/21. On 12/1/25 at 2:29pm, V12 (family member) stated V14 (family member) had visited R1 on 11/15/25 and said R1 was not wearing socks and she appeared to be in pain. V12 stated she went to visit R1 on 11/16/25 and noticed her leg did not look right and she was in pain. V12 stated one of the aides told her she had been in pain the day before and she had told the nurse about it. V12 stated she did not know the aide's name. V12 stated, Staff were using a mechanical lift with her and her leg was so messed up, it was rotated, and her foot was flat on the recliner. V12 stated she told V8 (Registered Nurse/RN) something was not right with R1's leg; she stated V8 tapped her leg and said it looked a little swollen. V12 stated the hospital diagnosed R1 with a right hip fracture and a left leg fracture. V12 stated V2 (Director of Nursing/DON) called her and said a nurse admitted R1 had fallen and she didn't do anything about it. V12 stated V2 told her some staff stated they had reported R1 was in pain, and the same nurse didn't do anything about it; he told her they got rid of the nurse.On 12/2/25 at 11:31am, V8 (RN) stated she was the nurse that sent R1 out on 11/16/25. V8 stated she had noticed R1 had some increased edema more so in her left leg than in the right. V8 stated R1 had edema, but it was a little more this day. V8 stated she did not complain of pain; she did grimace a little when she touched it.On 12/2/25 at 1:27pm, V9 (Certified Nursing Assistant/CNA) stated she was not working on R1's hallway on Friday, the day she fell. V9 stated one of the other CNA's told her she had to help V11 (Licensed Practical Nurse/LPN) put R1 back into bed after finding her on the floor. V9 stated the only nurse they worked with that following weekend was V11, and she reported to her two different nights that R1 was in pain.On 12/2/25 at 1:37pm, V10 (CNA) stated she was working the night R1 fell. V10 stated she helped V11 (Licensed Practical Nurse/LPN) get R1 up after she fell; she stated she did not appear to be in pain. V10 stated V11 (LPN) did not really assess R1, and she did not call her family or physician. V10 stated R1 did appear to be in pain later in the weekend, it was reported to V11, but to her knowledge V11 did not address it.On 12/2/25 at 11:08am and 12/3/25 at 9:37am, attempts to contact V11 (LPN) were made but unsuccessful. R1's progress notes, dated 11/16/2025 at 2:15pm, documents, Residents daughter requests her mother to be transferred to (local emergency room) to have left hip evaluated. Resident has edema to ble (bilateral lower extremities) and has had bil (bilateral) knee replacements in the past, she is non-weight bearing. Resident does not c/o (complain of) pain or ask for medications, she will grimace when foot is pulled. non emergent EMS (Emergency Medical Services) notified to transport, report called to ER (emergency room) .R1's Medication Administration Record for November of 2025 documents R1 did not receive the as needed Tylenol Extra Strength 500 mg tablet or the as need Ibuprofen Oral Tablet 600 mg pain medications between the dates of 11/14-11/16/25. R1's MAR documents R1 had pain assessments done day and night shift on 11/14/25 and 11/15/25 with a pain level of 0. On 11/16/25 during the morning shift, R1's pain level was documented as a 2 on a 1-10 scale. R1's Progress Notes from 11/14/25-11/15/25 did not document any reference to R1 being in pain. R1's medical record from the local hospital documents in the emergency room Triage notes, dated 11/16/25 at 3:28pm, Patient presents from a local nursing home with complaints of left knee pain. Patient states she has had pain for a long time. Her daughter states that staff noticed she was complaining about it since Thursday.R1's medical record from the local hospital documents in the emergency room Provider notes, dated 11/16/25 at 3:41pm, Patient is a [AGE] year-old female who presents to the ED (emergency Department) via EMS (Emergency Medical Services) from a local nursing facility complaining of left knee pain for the last 3 days. Patient has a history of dementia and does not recall any accident or injury to the knee. Per EMS, nursing faculty has no record of any injury to the knee.R1's medical record from the local hospital documents an x-ray result of R1's left knee, dated 11/16/25 at 4:55pm, showing a fracture of the distal femur. R1's medical record from the local hospital documents an x-ray result of R1's right hip, dated 11/16/25 at 4:57pm, to include: 1. sub capital fracture of the right femoral neck with proximal migration of the shaft, chronic in appearance however new since 2023. 2. Age-indeterminate fractures of the superior and inferior right pubic ramus.Facility Policy titled Fall Guideline, with a revision date of 8/2024, documents under the section titled Purpose To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately.

Based on interview and record review, the facility failed to safely transfer a resident for 1 of 3 residents (R1) reviewed for accidents in a sample of 5. This failure resulted in R1 falling from the lifting machine, hitting her head and receiving three staples to repair a 1.2 cm (centimeter) laceration to the back of her scalp.This past non-compliance occurred between 9/14/2025 and 9/15/25.Findings included:R1's admission Record documented R1 was admitted to this facility on 2/25/2025, with diagnoses of type 2 diabetes mellitus, essential hypertension, opioid dependency, chronic pain and spinal stenosis among others.R1's MDS (Minimum Data Set) assessment, dated 8/4/2025, documented R1 with a BIMS (Brief interview for Mental Status) score of 12 out of 15, which indicated R1 is cognitively intact. This same MDS under section GG (Functional Ability) documented R1 has impairment to both lower extremities and is dependent on staff for all transfers and toileting.On 9/29/2025 at 10:00am, R1 said on 9/14/2025 right after lunch, she needed to use the commode and put her call light on. R1 said the staff use a lifting machine that lifts her to a standing position and then will lower her onto the commode and back to her chair again. R1 said V4 (Certified Nursing Assistant/CNA) answered her call light. R1 said, by himself, V4 placed the lifting straps around her and tightened them, but when V4 used the lifting machine to lift her up, she slipped out of the straps and fell to the floor, hit her head and caused a laceration. R1 said she was sent to the local emergency room and received 3 staples in her scalp to close the laceration.On 9/29/2025 at 2:00pm, V4 said he was the staff providing care for R1 on 9/14/2025. V4 said about 1:00pm, he answered R1's call light, and R1 said she needed to use the bedside commode. V4 said he knows two staff are to be present when using the patient lift machines, but this time he did not wait for more staff to come and transferred R1 by himself and used the lift machine. V4 said he strapped R1 into the lifting machine and began to lift her up. V4 said during mid transfer, R1 slipped out of the straps and fell backwards. V4 said he tried to grab R1 but could not. V4 said when R1 fell from the lifting machine, she hit her head and caused a laceration.R1's emergency room records, dated 9/14/2025, documented the following in part: (R1) states the staff was getting her up to go to the bathroom using a stand assist device when (R1) passed out and fell off. (R1) has a small 1.2cm laceration to the right posterior scalp where 3 staples were used to repair the wound.The facility's Final Report and Conclusion of Incident form under the section titled Summary of Investigative findings is documented: A comprehensive investigation was completed and found on September 14, 2025. (R1) was noted to have sustained a witnessed fall in her room attempting to use sit to stand lift with CNA (Certified Nursing Assistant). Upon initial assessment the resident was noted to have a laceration to her scalp. POA (Power of Attorney) and MD (Medical Doctor) were notified with an order obtained to send to ER (Emergency Room) for eval (evaluation) and treat. (R1) returned to facility with three staples for closer [SIC] of laceration. The facility has completed a root cause analysis and concluded that the root cause was improper use of (mechanical lifting device).On 9/29/25 at 9:00am, V1 (Administrator) said it was the facility's policy for a minimum of two nursing assistants to transfer a resident using a mechanical lift. V1 said V4 should not have been transferring R1 with the sit-to-stand lift machine by himself and should have waited for the other staff before starting.The facility policy titled Using a Mechanical Level II (revision date of 11/01/23) documented the following: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. Under the section titled General Guidelines is documented in part: 1.) At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2.) Mechanical lifts may be used for tasks (such as): toileting or bathing and 3.) Types of lifts that may be available in the facility are: Floor based full body sling lifts, overhead full body sling lifts and Sit-to-stand lifts. Prior to the survey date, the facility took the following actions to correct the non-compliance:A Quality Assurance and Performance Improvement meeting was held on 9/15/25.On 9/29/2025, V1 (Administrator) provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form outlining the actions taken by the facility prior to the survey date to correct the noncompliance.Immediate corrective action taken for those affected by the deficient practice: Care plan review completed on all residents on 9/15/25 and Residents reviewed for need for mechanical lift. Measures put into place to ensure the deficient practice does not recur: Nursing staff educated on mechanical lift policy on 9/15/25 and all residents reviewed for lift orders.Plan to monitor performance to ensure solutions are sustained: DON/designee will randomly review use of (mechanical lift) and/or sit-to-stand lift weekly for four weeks.

Based on interview and record review, the facility failed to administer prescribed medications at the prescribed time. This failure has the potential to affect all 49 residents residing in the facility. Findings include:1. R3's Face Sheet documents an admission date of 11/23/22, with diagnoses including chronic kidney disease, chronic obstructive pulmonary disease, chronic venous hypertension, chronic congestive heart failure, and type 2 diabetes mellitus.R3's Minimum Data Set (MDS), dated [DATE] in section C, documents R3 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact. Section N of same MDS documents R3 is ordered the following classes of medications: diuretic, opioid, antiplatelet, and hypoglycemic (insulin).R3's Care Plan, dated 7/17/25, documents a focus area that R3 is on diuretic therapy related to edema. Interventions for this focus area include administering diuretic medications as ordered by physician with an initiation date of 4/10/23. Another focus area documents that R3 has a mood problem. Documented interventions for this focus area include administer medication as ordered with an initiation date of 1/6/23.R3's July 2025 Medication Administration Records (MAR) documents R3 has medications scheduled to be administered at the following times: 7:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 5:00 PM, and 8:00 PM. R3's MAR provided did not document the actual time the medication was administered.A Resident Grievance form filed by R3, dated 6/19/25, states R3 voiced concerns with timeliness of medication pass at night.On 8/13/25 at 9:54 AM, R3 stated she frequently doesn't get her 8:00 PM medications until midnight. R3 stated in one instance, she did not get her scheduled 8:00 AM medications until 2:00 PM in the afternoon. 2. R4's Face Sheet documents an admission date 2/25/25, with diagnoses including, but are not limited to, depression, hypertension, hypothyroidism, and osteoarthritis.R4's MDS, dated [DATE], documents in section C that R4 has a BIMS score of 13, indicating R4 is cognitively intact. Section N of same MDS documents R4 is on the current class of medications: antidepressant, diuretic, opioid, antiplatelet, and hypoglycemic.R4's Care Plan, dated 8/4/25, documents a focus area of R4 takes a psychotropic medication. A related intervention to the previous focus area includes administering medications as indicated by physician orders, with an initiation date of 8/1/25. Another focus area documents R4 has hypertension. A related intervention is to give antihypertensive medications as ordered, with an initiation date of 5/22/25. Another focus area on the R4's Care Plan documents R4 has diabetes mellitus. A related intervention for this focus area is to administer diabetes medication as ordered by doctor, with an initiation date of 5/22/25. Another focus area listed on R4's CP is she has chronic pain related to other chronic pain, osteoarthritis, carpal tunnel syndrome and depression. A related intervention includes to administer analgesia as per orders, with an initiation date of 2/25/25.R4's July 2025 Medication Administration Records (MAR) documents R4 has medications scheduled to be administered at the following times: 5:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 5:00 PM, and 8:00 PM. R4's MAR provided did not document the actual time the medication was administered.On 8/13/25 at 9:37 AM, R4 stated she often doesn't get her scheduled 8:00 PM medications until 10:30 PM or 11:00 PM. R4 stated one time she didn't get her 8:00 PM medications until 12:30 AM.On 8/18/25 at 11:34 AM, V7, Licensed Practical Nurse (LPN) stated she is often over the ordered time range of two hours for medication administration, by up to one and a half hours. V7 gave the example of the 8:00 PM medication pass should be completed by 9:00 PM, but she is frequently not finished until 10:30 PM. V7 stated the 8:00 PM medication pass is a large one, and it needs two nurses to get it completed in the ordered time range.On 8/18/25 at 3:20 PM, upon this surveyor asking for July MAR's for R3 and R4 with documented and timestamped medication administration times from V2, Director of Nursing/DON, he stated he was instructed by his superior, V24, Chief Operating Officer, not to turn the time stamped MAR's over to this surveyor because the facility had started an internal Quality Assurance investigation, and those documents were now considered confidential. V2 stated he had been instructed by his superior to not allow this surveyor to even visualize the time stamped MAR's in the Electronic Health Record on V2's computer. V2 stated the internal investigation was started approximately 2-3 weeks ago. V2 stated the internal investigation was started when R3 and R4 had brought it to administration's attention that medications were being administered past the ordered time ranges. V2 stated he has had complaints from floor nurses the medication passes are too large to be completed in the ordered time range of two hours. V2 stated presently, at times, R3 and R4 are continuing to complain medications are being administered past the ordered time range.On 8/13/25 at 1:47 PM, V8, Certified Nurse's Aide (CNA), stated R3 has specifically mentioned to him she had not gotten her medications on time specifically when V4, Registered Nurse (RN), was working.On 8/13/25 at 2:14 PM, V11, CNA, stated she has had complaints from residents about getting their medications late, past the ordered time range, but she was unable to recall any names.On 8/13/25 at 2:32 PM, V13, CNA, stated she has had multiple residents complain that they did not get their medications administered at the correct time. V13 stated in the past, she also has had R3 and R4 complain about their medications being administered late past the ordered time range. V13 also stated she had residents complain to her (couldn't remember who) V4, RN, had left for two hours one evening when she was supposed to have been administering medications.On 8/14/25 at 8:15 AM, V14, CNA, stated she has had multiple complaints from residents about not getting their medications administered at the ordered time frame especially when V4, RN, was working. The residents who mentioned this to her were specifically complaining they were not getting their 5:00 PM or 8:00 PM medications at all.V4, RN, no longer works at the facility and was unable to be reached for an interview.On 8/14/25 at 10:01 AM, V15, CNA, stated she had many residents complain to her they were not getting their medications until past the ordered time range, especially on the midnight shift from 6:00 PM-6:00 AM.On 8/14/25 at 12:44 PM, V2, Director of Nurses (DON), stated there are some nurses, especially on midnight shift, struggling to get medications administered within the ordered time range. On 8/14/25 at 3:00 PM, V23, RN, stated on occasion, she is 1-2 hours out of the ordered time range for administering the medications ordered to the residents.On 8/14/25 at 3:31 PM, V21, RN, stated when she worked the floor, she would be past the ordered time range to administer medications one out of every three shifts on average every week. V21 stated she was up to 30 minutes to one hour past the ordered time range.On 8/18/25 at 10:01 AM, V17, RN, stated she frequently goes over the ordered time range for medication administration by approximately thirty minutes.On 8/18/25 at 10:26 AM, V5, RN, stated she is usually 10-15 minutes up to thirty minutes over the ordered time range for administering medications.The Resident Council meeting minutes, dated 7/17/25 at 2:00 PM, documents residents voiced concerns about not being administered their pain medications on time.The facility's Medication Administration Policy, with a revised date of 9/17/22, states, Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe.The facility's Daily Census sheet, dated 8/13/25, documents there are 49 residents residing in the facility.

Based on interview and record review, the facility failed to provide medical records requested to aide in the survey process for 2 of 2 residents (R3 and R4) reviewed for medication administration in a sample of 19.Findings includeOn 8/14/25, this surveyor reviewed the July 2025 Medication Administration Records (MAR's) for R3 and R4 in their Electronic Health Records. The MAR's for R3 and R4 did not document the actual time the medication was administered.On 8/14/25 at 3:30 PM, this surveyor requested R3 and R4's July 2025 MAR's with documented and timestamped medication administration times from V2, Director of Nurses (DON).On 8/18/25 at 8:00 AM, V2, DON, stated he had been instructed by V24, Chief Operating Officer, not to provide the copies of R3 and R4's MAR's with documentation of the times the medications were administered or allow this surveyor to visualize them in the Electronic Health Record.On 8/18/25 at 3:20 PM, V2, DON, he stated he was instructed by V24 not to turn the time stamped MAR's R3 and R4 over to this surveyor because the facility had started an internal Quality Assurance investigation, and those documents were now considered confidential. V2 stated the internal investigation was started approximately 2-3 weeks ago. V2 stated the internal investigation was started when R3 and R4 had brought it to administration's attention that medications were being administered past the ordered time ranges.

Based on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure resident care needs are met. This failure has the potential to affect all 47 residents living in the facility. The findings include: 1. R1's admission Record, dated 06/17/25, documents an admission date of 11/23/2022, with diagnoses in part of type 2 diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, chronic kidney diseases, and chronic diastolic (congestive) heart failure. R1's Minimum Data Set (MDS), dated [DATE], documents in Section C a Brief Interview for Mental Status (BIMS) score of 15 which indicates R1 is cognitively intact. Section GG documents eating as setup and clean-up assistance, and toileting, personal hygiene, and showering as dependent. R1's Care Plan, with a revision date of 04/07/23, documents a focus area of R1's requires extensive assistance with ADL's (Activities Daily Living) r/t (related to) reduced mobility, lack of coordination, impaired mobility and weakness. On 06/16/25 at 10:47AM, R1 stated she believes the facility is short of staff. R1 stated everyone at the facility keeps quitting. R1 said at nighttime, all they have is one helper a lot of times, and she needs two staff to assist her at times with positioning. R1 said sometimes it takes over an hour for staff to answer the call light, but other times only 15 minutes. R1 said the longer wait time is usually in the evening and on the weekend. 2. R3's admission Record, dated 06/17/25, documents an admission date of 04/29/25, with diagnoses in part of traumatic subdural hemorrhage, chronic obstructive pulmonary disease, type 2 diabetes, history of falling, and other intervertebral disc degeneration. R3's MDS, dated [DATE], documents in Section C a BIMS score of 13 which indicates R3 is cognitively intact. Section GG documents R3 is independent with most ADL functions. R3's Care Plan, with a revision date initiated of 04/29/25, documents a focus area of needs assistance with ADL'S related to [SIC]. On 06/16/25 at 11:10AM, R3 stated the facility does not have enough staff in the evening and on the weekends. R3 stated he doesn't require much assistance from staff, but he can tell they don't have hardly any workers in the evening or on the weekend most of the time. 3. R4's admission Record, dated 06/17/25, documents an admission date of 02/25/25, with diagnoses in part of type 2 diabetes mellitus, hypertension, diverticulosis, other chronic pain, and unspecified osteoarthritis. R4's MDS, dated [DATE], documents in Section C a BIMS score of 14, which indicates R4 is cognitively intact. Section GG documents R4 is dependent with toileting, showers, dressing, and personal hygiene. R4's Care Plan, with a revision date of 03/27/25, documents a focus area of R4 needs assistance with ADL's related to unsteadiness on feet, other abnormalities of gait and mobility, other lack of coordination, ataxia. On 06/16/25 at 10:33AM, R4 stated the facility is short of staff. R4 said sometimes the facility only has maybe one or two CNA's (Certified Nurse Assistants) show up to work. R4 said they have even had some staff walk out. R4 said sometimes you have to wait for an hour for someone to answer your call light to get changed. R4 said weekends and midnight and evening shift is when she has to wait the longest. 4. R5's admission Record, dated 06/17/25, documents an admission date of 04/28/25, with diagnoses in part of type 2 diabetes mellitus, chronic respiratory failure, other lack of coordination, neuromuscular dysfunction of bladder, other chronic pain, other kyphosis, and unspecified urinary incontinence. R5's MDS, dated [DATE], documents in Section C a BIMS score of 14, which indicates R5 is cognitively intact. Section GG documents R5 is Set-up and clean up assist with eating, dependent with toileting, and substantial/maximal assistance with showering. R5's Care Plan, with a revision date of 06/04/25, documents a focus area of needs assistance with ADL's related to displacement of internal fixation device of vertebrae, major depressive disorder, kyphosis cervicothoracic region. On 06/16/25 at 10:40AM, R5 stated it takes the staff sometimes two hours to answer the call light. R5 said on averag,e it doesn't take them that long to answer the call light, but sometimes she can be left for quite some time. R5 said the facility has a problem with keeping good staff. 5. R6's admission Record, dated 06/17/25, documents an admission date of 05/19/22, with diagnoses in part of type 2 diabetes mellitus, fibromyalgia, morbid obesity, unspecified dementia, and chronic pain syndrome. R6's MDS, dated [DATE], documents in Section C a BIMS score of 14, which indicates R6 is cognitively intact. Section GG documents R6 requires set-up and clean-up assistance with eating, toileting, dressing, and personal hygiene, and requires substantial/maximal assistance with showering. R6's Care Plan, with a revision date of 03/27/25, documents a focus area of R6 has Self-Care deficit as evidenced by needs assistance with ADL's, dementia, contusion, psychological needs. On 06/16/25 at 11:08AM, R6 stated it takes staff sometimes 30-45mins to answer a call light. R6 said night shift is the worst for being short of staff. 6. R10's admission Record, dated 06/17/25, documents an admission date of 12/06/21, with diagnoses in part of inflammatory polyarthropathy, other chronic pain, morbid obesity, chronic kidney disease, urinary incontinence, and vitreous degeneration. R10's MDS, dated [DATE], documents in Section C a BIMS score of 14, which indicates R10 is cognitively intact. Section GG documents R10 requires setup and clean-up assistance with eating, is dependent with toileting, lower body dressing, and personal hygiene, and requires substantial/maximal assistance with showering. R10's Care Plan, with a revision date of 12/20/21, documents a focus area of Self-care deficit evidenced by: needs assistance with ADL's related to chronic pain, COPD (Chronic Obstructive Pulmonary disease) and gait imbalance. On 06/16/25 at 10:18AM, R10 stated evening shift is short of staff, and she said it takes a long time for staff to answer the call lights. 7. R11's admission Record, dated 06/17/25, documents an admission date of 06/24/21, with diagnoses in part of atherosclerosis, hypertension, osteoarthritis, and hypothyroidism. R11's MDS, dated [DATE], documents in Section C a BIMS score of 10, which indicates R11 has moderately impaired cognition. Section GG documents R11 requires set-up and clean-up assistance with eating, supervision and touching assistance with toileting, and partial/moderate assistance with showering. R11's Care Plan, with a revision date of 03/27/25, with a focus area of R11 has a self-care deficit that may vary throughout the day and requires staff assistance with ADL' S related to weakness, unspecified abnormalities of gait and mobility, unsteadiness on feet. On 06/16/25 at 10:25AM, R11 stated the facility is short of staff in the evening and on the weekends. 8. R12's admission Record, dated 06/17/25, documents an admission date of 05/20/25, with diagnoses in part of cerebral palsy, narcolepsy, myotonic muscular dystrophy, and left bundle branch block. R12's MDS, dated [DATE], documents in Section C a BIMS score of 15, which indicates R12 is cognitively intact. Section GG documents R12 requires set-up and clean-up assistance with eating and partial/moderate assistance with toileting, showering, dressing, and personal hygiene. R12's Care Plan, with a revision date of 05/22/25, documents a focus area of needs assistance with ADL's related to cerebral palsy, unspecified myotonic muscular dystrophy. On 06/16/25 at 10:00AM, R12 stated the facility could use more help, especially on evening and midnights. On 06/16/25 at 1:31PM, V3 (Certified Nurse Assistant/CNA) stated she believes the facility is short of staff as far as CNA's. V3 stated it is hard to do rounds every 2 hours. V3 stated she doesn't feel that they give the best care to the resident because they are short of staff. V3 said the staff is much shorter on night shift. V3 said they are supposed to have one CNA on the locked unit, and three CNA's on the regular hall for every shift. On 06/16/25 at 1:50PM, V4 (CNA) stated she does believe that facility is short of staff in relation to CNA's. V4 said the facility does not have enough staff to care for the resident properly. V4 said that sometimes they have enough staff, but not all the time, most of the time they are short of staff. V4 said that only maybe two days a week they are fully staffed. On 06/16/25 at 2:09PM, V14 (CNA) stated the facility is short of staff most shifts, but it is worse on evening shift and sometimes on the weekend. V14 said he always tries to get all the resident care done to the best of his ability. V14 said sometimes he can't get all the showers done that he is supposed to have completed. On 06/17/25 at 8:42AM, V8 (CNA) stated the facility is short of staff. V8 said that today was her day off and they asked her to come in because they needed help for several days in a row, because you guys (Surveyors) are here. V8 said the weekends are where they are the shortest of staff, especially Sundays. V8 stated showers don't get done, because they don't have enough staff. V8 said they don't have enough staff to be able to provide appropriate care to the residents. V8 said they should have at least 3 CNA's on the regular hall every day, and most of the time they don't. On 06/17/25 at 11:04AM, V10 (Licensed Practical Nurse/LPN) stated short staffing is causing the resident to have to wait longer to receive care that they need. On 06/17/25 at 12:55PM, V1 (Administrator) stated the facility does not have any staffing problems. V1 stated the facility does use agency to pick up shifts if needed. V1 stated she has been trying to lean away from using agency as much. V1 said she believes the facility has enough staff to cover care needs. V1 stated the CNA's work 12-hour shifts, and they have four CNA's on day shift, along with 2 nurses and a activity aid that works the dementia unit. V1 said there are two nurses on day shift until 5:00PM, then there is one nurse until 7:00AM. V1 said on evening into night shift they have 3 CNA's and one nurse. V1 said there has been evening into night shift on a couple of days they only had one nurse and two CNA's for the entire facility. V1 said she thinks that the residents would still be able to get proper care if the right staff are working. V1 stated the facility does not have a policy on staffing. On 06/17/25 at 2:11PM, V17 (LPN) stated she feels the facility is short of staff at times. V17 said times when they only have two aides in the building on nights that they try to give the resident the care they need, but it's very hard to get done. On 06/17/25 at 2:17PM, V2 (Director of Nursing/DON) stated he believes the facility has enough staff to be able to care for the residents on a day-to-day basis. V2 said he believes when they have two CNA's and one nurse on nights they are able to care for the residents properly. V2 said it is difficult, but doable. V2 said they are always working on trying to improve on staffing. The Facility Assessment, dated 04/01/2,5 documents under total number needed of FTE (Full Time Employees) on average or range documents Licensed Nurse providing direct care as 2.67 (FTE) per day, Nurse Aides as 8 (FTE) per day. The daily assignment for 06/02/25 documents from 6PM to 6AM 1 nurse and 2 CNA's. The daily assignment for 05/27/25 documents from 6PM to 6AM 1 nurse and 2 CNA's. The facility Midnight Census Report, dated 6/16/25, documents there are 47 residents residing in the facility.

Based on interview and record review, the facility failed to change an indwelling urinary catheter per physician's orders for 1 of 3 residents (R1) reviewed for urinary catheters in a sample of 16. Findings include: R1's admission Record documents an admission date of 11/23/22, with diagnoses including chronic kidney disease, benign lipomatous neoplasm of kidney, and neuromuscular dysfunction of the bladder. R1's Minimum Data Set, dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. Section H, Bladder and Bowel, documents R1 was indwelling urinary catheter. R1's Care Plan documents a Focus area with an initiation date of 6/8/23 of: High Risk for Urinary Tract Infection due to: Indwelling Catheter. Documented interventions include Change catheter and drainage bag per MD orders with an initiation date of 6/8/23. R1's Order Summary Report, with a print date of 6/17/25, documents an order of, Catheter: 18 FR (french) Coude catheter with 10cc (cubic centimeter) balloon Dx (diagnosis) Neuromuscular Dysfunction of Bladder; change once monthly and PRN (as needed) one time a day every 28 day(s) for infection prevention, with an order date of 6/16/25. R1's Treatment Administration Record (TAR) for April, May, and June 2025 documents an order, dated 3/28/25, to change catheter once monthly and PRN. There is no documentation on the April, May, and June 2025 TAR's indicating R1's catheter was changed. R1's Progress Note's in the Electronic Health Record (EHR), dated 3/28/25, documents, Nurse received N.O. (new order) to insert an 18 Fr 10ml (milliliter) coude catheter d/t (due to) res. (resident) catheter coming out c (with) balloon intact. Nurse inserted c no resistance felt and no c/o (complaints of) pain or discomfort at this time. Catheter patent and drng (draining). There was no documentation in R1's EHR documenting R1's catheter was changed since 3/28/25. On 6/16/25 at 10:47 AM, R1 stated she had not had her indwelling urinary catheter changed since 3/28/25. On 6/17/25 at 10:55 AM, V13 (Medical Doctor/MD) stated his expectations for the facility would be to change R1's indwelling urinary catheter as ordered. V13 stated that means he would expect the indwelling urinary catheter to be changed monthly from March 28th. On 6/16/25 at 2:38 PM, V2 (Director of Nurses/DON) stated indwelling urinary catheters should be changed as ordered by the medical doctor. V2 stated R1's doctor's orders are for R1's indwelling urinary catheter be changed every month. On 6/17/25 at 12:55 PM, V1 (Administrator) stated if the medical doctor's order states the indwelling urinary catheter should be changed every thirty days, then it should be changed every thirty days. V1 stated, As the old saying goes, if it wasn't documented it wasn't done, but facility administration would call all the nurses to check and make sure if it was done and just forgotten to document it. On 6/17/25 at 2:17pm, V2 stated he had called all the nursing staff, and was unable to find a nurse that had changed R1's indwelling urinary catheter in the past two months. V2 stated R1's indwelling urinary catheter was changed on the evening of 6/16/25 by V12 (Registered Nurse/RN), and the doctor was notified it was the first time R1's indwelling urinary catheter had been changed in over two months. On 6/17/25 at 12:04 PM, V12 stated she changed R1's indwelling urinary catheter on the evening of June 16th at request of V2. On 6/17/25 at 12:03 PM, V11 (RN) stated she has been on leave since April 13th, but before that, she doesn't remember changing an indwelling urinary catheter on R1. On 6/17/25 at 2:11PM, V17 (Licensed Practical Nurse/LPN) stated indwelling urinary catheters should be changed as ordered by the physician. V17 stated she had never changed R1's indwelling urinary catheter. V17 stated she doesn't know the last time R1's indwelling urinary catheter was changed. On 6/17/25 at 11:00 AM, V7 (RN) stated she doesn't remember changing an indwelling urinary catheter on R1 in the past two months. On 6/17/25 at 11:04 AM, V10 (LPN) stated she doesn't remember changing an indwelling urinary catheter on R1 in the past two months.

Based on observation, interview, and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment was accurately coded for 1 (R9) of 1 resident reviewed for accuracy of assessments in the sample of 28. Findings Include: R9's Admission Record documented R9 as a 71 -year -old, with an admitted [DATE] to the facility. Diagnoses listed are unspecified atrial fibrillation, type 2 diabetes mellitus, edema, primary osteoarthritis of left knee, obesity, venous insufficiency, poly osteoarthritis, pain in leg, and unspecified osteoarthritis. R9's Illinois PASRR (Preadmission Screening and Resident Review) Summary of Findings, dated 03/22/2024, documented, Level II Outcome- Approved No SS (Specialized Services). R9's MDS with an Assessment Reference Date of 07/02/2024 documented this MDS as being an annual assessment. Section A1500. Preadmission Screening and Resident Review (PASRR) asks Is this resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The answer was documented as a 0 for No. The same MDS section I Active Diagnoses has a checkmark under Psychiatric/Mood Disorder has an X marked next to I5900 Bipolar Disorder, I5950 Psychotic Disorder, and I6000 Schizophrenia indicating these are all active diagnoses for R9. On 05/15/2025 at 11:10 AM, V7 (Licensed Practical Nurse/ MDS) stated he was not the person who completed the July MDS for R9. V7 stated he was not employed at this facility at that time. V7 stated the section A1500 of R9's MDS from 07/02/2024 was not documented appropriately. V7 stated R9 has an annual MDS that he is working on, and will make sure that section is documented appropriately. On 05/15/2025 at 11:54 AM, V1 (Administrator) stated the company does not have a policy for accurately completing MDS assessments. V1 stated the company follows the RAI (Resident Assessment Instrument) Manual for guidance on how to complete the MDS. V1 stated it is her expectation the MDS be coded accurately.

Based on interview and record review the facility failed to prevent incidents of abuse resulting in bruising, involuntary seclusion, and/or mental anguish for 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for abuse in the sample of 7. These failures resulted in psychosocial harm for R2, in that, a reasonable person would react to such physical and mental abuse with such feelings as agitation, anxiety, frustration, fearfulness, humiliation and punishment. Findings Include: 1. R2's Face Sheet documents the [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], documents that R2's Brief Interview for Mental Status, Section C Cognitive Pattern, is 3 of 15 indicating resident's cognitive ability is severely impaired. Section E, Behavior, documents that R2 has Delusions and Wandering Behaviors that places resident at significant risk of getting into dangerous places and intruding on the privacy or activities of others. R2's Universal Progress Record and Consultants Report, dated 4/18/17 1:00PM, documents bruising to R'2s arms and hands, scattered, dark purple in color, bruising noted of unknown origin. The Wound Flow Sheet, undated, documents bruising on 4/18/17 to the Bilateral Upper Extremities. The bruising is documented as scattered and purple. The entry on this same report dated 5/1/17 documents the scattered bruising to the Bilateral Upper Extremities as fading. The Abuse, Neglect, and/or Theft Incident Reporting Form documents that 2 CNAs (E4 and E3, Certified Nurse Aides) witnessed a nurse (E5) and CNA (E6) walk a resident, R2, to her room with excessive force. The report further documents new bruises noted to R2's bilateral wrist and forearms. There is no documentation of the date or time that this incident occurred. The form indicates that E2 (Director of Nursing) was not notified until 5:45AM on 4/18/17 by E4 (CNA/Certified Nurse Aide). On 5/2/17 at 8:30 AM, E2 (Director of Nurses) stated she was notified on 4/18/17 at 5:30 AM when she arrived at the facility. E2 stated she notified E1 (Administrator) at 5:45AM on 4-18-17. E2 stated the incident occurred on 4/17/17 between 10:00PM and 10:30PM. E5 and E6 were called on 4/18/17 in the afternoon and both employees resigned. On 5/1/17 at 8:10AM, E1 (Administrator) stated that there is no charting regarding the 4-17-17 incident in R2's records and no documentation of behaviors during that shift on 4/17/17-4/18/17. He went on to say that we recently put an extra CNA on nights to catch E5's bad behavior, for possibly yelling at residents. On 5-1-17 at 12:05PM, E1 stated that when they did the investigation regarding abuse, the residents questioned were not specifically asked about E6 and E5 being abusive, the residents were only questioned about staff in general. E1 went on to say this is the way he has always performed an abuse investigation. During this same interview, E1 stated after reviewing the file once IDPH entered on this complaint, that he then reported E5 to the State Board of Nursing and E6 to the Health Care Registry and Department of Public Health, Region 5. E1 further stated that law enforcement was not notified of the incident either. E3's (CNA) written statement dated 4/20/17 documents that on 4/17/17 she was sitting with R2, and R2 was looking at a picture book. Sometime after that R2 got up and walked over to a little table where E5 was sitting. R2 was going to say something or ask something and didn't get a chance because E5 got up quickly and 'took a hold' of one side of R2 and E6 (CNA) the other side and took R2 to her room. I asked E5 maybe there was a better way to handle R2 and why didn't they just let her talk. E5 told her it was handled this way because R2 won't do what you need her to do, and you just have to tell her what to do or to do it, that this is the only thing R2 understands. After awhile R2 got up, and came out of her resident room and came back out to the day room and they told her to go and they both took her back to her room. On 5/2/17 at 2:20PM, E3 (CNA) stated that the incident happened on 4/17/17 about 10:00 to 10:30PM. She went on to say that E5 was annoyed, got up very fast and took hold of R2's arm and another CNA took the other arm and they walked R2 to her room. E3 stated R2 was not happy and didn't want to go with them. E3 stated she was very alarmed because she felt R2 could have been handled differently or talked to more calmly. On 5/1/17 at 3:10 PM E4 (Certified Nurse Aide) stated, that she was sitting in the Day Room on 4-17-17 at approximately 10:00 pm, when R2 walked up to where E5 (Licensed Practical Nurse) and E6 (Certified Nurse Aide) were sitting when E5 stated we are not having that tonight. E4 stated that E5 and E6 both grabbed R2's wrist and dragged her to her room. Soon R2 came out of her room and E5 grabbed R2's wrist and E6 grabbed R2's elbow, forcing her back into her resident room. About 5 minutes later E5 and E6 were in R2's room and R2 fell into bed with force. E4 stated due to darkness she was unable to see how or why that occurred. E4 stated she checked R2's wrist and forearm and noted 'hand mark bruising' to her wrist and forearm. She stated she reported it to E2 (Director of Nurses) about 5:30AM on 4/18/17 and to E1 later in the morning on 4/18/17. On 5-2-17 at 10:00 am, an interview was attempted with R2, due to R2's cognitive loss, R2 could not express how she felt to be physically abused and secluded in her room on 4-17-17. A reasonable person would react to such physical abuse and seclusion with such feelings as agitation, anxiety, frustration, fearfulness, humiliation and punishment. 2. On 5/1/17 at 11:00AM, R1 stated that E5 would take his 2 water pitchers away from him when she came in to work in the evenings and gave me a small glass of water. I begged her not to because I have 3 kidneys and I have to have the extra water, if not my urine turns brown. She also told me and R5 that she was not going to take any crap from me, that she was in a bad mood. R1 stated I was afraid she would not help me if I reported her, so I did not report anything R1's Brief Interview for Mental Status (BIMS) dated 4-14-17, scores R1 as 15 out of 15, meaning R1 is cognitively intact. 3. On 5/1/17 at 10:05 AM, R6 stated that E5 was very rude and cross if you needed something. E5 had a mean voice and gruff, and the residents are glad she is gone. E5 would say things that made you feel bad. R6 stated If E5 was having a bad day she made sure everyone was having a bad day too. R6, when asked if it had been reported, would not answer. R6's Brief Interview for Mental Status (BIMS) dated 4-7-17, scores R6 as 12 out of 15, meaning R6 has moderate impaired cognition. 4. On 5/1/17 at 10:20AM, R4 stated that E5 was very rude when I asked for a beer stating Do I look like a bartender also if I asked for a pain pill she would ask me Do I look like a pharmacy. R4 went on to say that E5 would yell up and down the halls in the evenings. R4 also stated that E5 would target R5 with nasty comments like I know you pissed in your chair so you could go out to smoke. R4 stated she really got tired of E5's bad mouth and attitude. R4's physician's orders [REDACTED]. The Physician order [REDACTED]. R4 states the incidents were not reported and did not provide a reason why they were not reported. R4's Brief Interview for Mental Status (BIMS) dated 2-23-17, scores R4 as 15 out of 15, meaning R4 is cognitively intact. 5. On 5/1/17 and 5/2/17 R5 stated, that E5 was mean to a lot of people and she would say mean stuff to me but I'm tough and I ignored her. R5 did not report the incidents and did not provide a reason why they weren't reported. R5's Brief Interview for Mental Status (BIMS) dated 4-3-17, scores R5 as 15 out of 15, meaning R5 is cognitively intact. 6. On 5/1/17 at 9:15AM,R3 stated that E5 is gone and I am glad. R3 also stated she was taking a Blood Pressure Medication that caused her to have bad dreams and crawl on the floor. E5 would tell me that I was doing it to get attention. E5 was a hell cat and hell on wheels. She frequently told me no one liked me and that I was acting like a queen. R3 then showed the surveyor a page from her journal dated April 2016 and read it to me. R3's journal documented that E5 told her 1. No one liked her (night crew and day crew), The staff regards me as someone who thinks they are a Queen and expects everyone else to wait on them, and 3. They are considering putting R3 in another room because she is lonely and that is why she was having these spells at night because she wants attention. R3 also stated E5 really made me think I was a bad person. R3 stated that the incidents were not reported because E5 made me feel bad enough. R3's Brief Interview for Mental Status (BIMS) dated 4-13-17, scores R3 as 15 out of 15, meaning R3 is cognitively intact. The Resident Abuse or Neglect policy, dated 3/1/17, documents the following: It is the policy of this facility to protect the residents from verbal and physical abuse. This shall be achieved by appropriate screening and training employees who participate in resident care. Appropriate intervention, identification, investigation, protection and reporting will be utilized. If there is reasonable suspicion that the injury is a result of a crime, then law enforcement shall be notified as well. If the events that cause reasonable suspicion of a crime, but do not result in a serious bodily injury to the resident, the facility shall report the suspicion not later than 24 hours after forming the suspicion to the Illinois Department of Public Health and law enforcement. The facility shall report to the State Nurse Aide Registry or Professional Regulation any knowledge it has of any actions by a court of law which would indicate an employee unfit for service. Based on interview and record review the facility failed to prevent incidents of abuse resulting in bruising, involuntary seclusion, and/or mental anguish for 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for abuse in the sample of 7. These failures resulted in psychosocial harm for R2, in that, a reasonable person would react to such physical and mental abuse with such feelings as agitation, anxiety, frustration, fearfulness, humiliation and punishment. Findings Include: 1. R2's Face Sheet documents the [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], documents that R2's Brief Interview for Mental Status, Section C Cognitive Pattern, is 3 of 15 indicating resident's cognitive ability is severely impaired. Section E, Behavior, documents that R2 has Delusions and Wandering Behaviors that places resident at significant risk of getting into dangerous places and intruding on the privacy or activities of others. R2's Universal Progress Record and Consultants Report, dated 4/18/17 1:00PM, documents bruising to R'2s arms and hands, scattered, dark purple in color, bruising noted of unknown origin. The Wound Flow Sheet, undated, documents bruising on 4/18/17 to the Bilateral Upper Extremities. The bruising is documented as scattered and purple. The entry on this same report dated 5/1/17 documents the scattered bruising to the Bilateral Upper Extremities as fading. The Abuse, Neglect, and/or Theft Incident Reporting Form documents that 2 CNAs (E4 and E3, Certified Nurse Aides) witnessed a nurse (E5) and CNA (E6) walk a resident, R2, to her room with excessive force. The report further documents new bruises noted to R2's bilateral wrist and forearms. There is no documentation of the date or time that this incident occurred. The form indicates that E2 (Director of Nursing) was not notified until 5:45AM on 4/18/17 by E4 (CNA/Certified Nurse Aide). On 5/2/17 at 8:30 AM, E2 (Director of Nurses) stated she was notified on 4/18/17 at 5:30 AM when she arrived at the facility. E2 stated she notified E1 (Administrator) at 5:45AM on 4-18-17. E2 stated the incident occurred on 4/17/17 between 10:00PM and 10:30PM. E5 and E6 were called on 4/18/17 in the afternoon and both employees resigned. On 5/1/17 at 8:10AM, E1 (Administrator) stated that there is no charting regarding the 4-17-17 incident in R2's records and no documentation of behaviors during that shift on 4/17/17-4/18/17. He went on to say that we recently put an extra CNA on nights to catch E5's bad behavior, for possibly yelling at residents. On 5-1-17 at 12:05PM, E1 stated that when they did the investigation regarding abuse, the residents questioned were not specifically asked about E6 and E5 being abusive, the residents were only questioned about staff in general. E1 went on to say this is the way he has always performed an abuse investigation. During this same interview, E1 stated after reviewing the file once IDPH entered on this complaint, that he then reported E5 to the State Board of Nursing and E6 to the Health Care Registry and Department of Public Health, Region 5. E1 further stated that law enforcement was not notified of the incident either. E3's (CNA) written statement dated 4/20/17 documents that on 4/17/17 she was sitting with R2, and R2 was looking at a picture book. Sometime after that R2 got up and walked over to a little table where E5 was sitting. R2 was going to say something or ask something and didn't get a chance because E5 got up quickly and 'took a hold' of one side of R2 and E6 (CNA) the other side and took R2 to her room. I asked E5 maybe there was a better way to handle R2 and why didn't they just let her talk. E5 told her it was handled this way because R2 won't do what you need her to do, and you just have to tell her what to do or to do it, that this is the only thing R2 understands. After awhile R2 got up, and came out of her resident room and came back out to the day room and they told her to go and they both took her back to her room. On 5/2/17 at 2:20PM, E3 (CNA) stated that the incident happened on 4/17/17 about 10:00 to 10:30PM. She went on to say that E5 was annoyed, got up very fast and took hold of R2's arm and another CNA took the other arm and they walked R2 to her room. E3 stated R2 was not happy and didn't want to go with them. E3 stated she was very alarmed because she felt R2 could have been handled differently or talked to more calmly. On 5/1/17 at 3:10 PM E4 (Certified Nurse Aide) stated, that she was sitting in the Day Room on 4-17-17 at approximately 10:00 pm, when R2 walked up to where E5 (Licensed Practical Nurse) and E6 (Certified Nurse Aide) were sitting when E5 stated we are not having that tonight. E4 stated that E5 and E6 both grabbed R2's wrist and dragged her to her room. Soon R2 came out of her room and E5 grabbed R2's wrist and E6 grabbed R2's elbow, forcing her back into her resident room. About 5 minutes later E5 and E6 were in R2's room and R2 fell into bed with force. E4 stated due to darkness she was unable to see how or why that occurred. E4 stated she checked R2's wrist and forearm and noted 'hand mark bruising' to her wrist and forearm. She stated she reported it to E2 (Director of Nurses) about 5:30AM on 4/18/17 and to E1 later in the morning on 4/18/17. On 5-2-17 at 10:00 am, an interview was attempted with R2, due to R2's cognitive loss, R2 could not express how she felt to be physically abused and secluded in her room on 4-17-17. A reasonable person would react to such physical abuse and seclusion with such feelings as agitation, anxiety, frustration, fearfulness, humiliation and punishment. 2. On 5/1/17 at 11:00AM, R1 stated that E5 would take his 2 water pitchers away from him when she came in to work in the evenings and gave me a small glass of water. I begged her not to because I have 3 kidneys and I have to have the extra water, if not my urine turns brown. She also told me and R5 that she was not going to take any crap from me, that she was in a bad mood. R1 stated I was afraid she would not help me if I reported her, so I did not report anything R1's Brief Interview for Mental Status (BIMS) dated 4-14-17, scores R1 as 15 out of 15, meaning R1 is cognitively intact. 3. On 5/1/17 at 10:05 AM, R6 stated that E5 was very rude and cross if you needed something. E5 had a mean voice and gruff, and the residents are glad she is gone. E5 would say things that made you feel bad. R6 stated If E5 was having a bad day she made sure everyone was having a bad day too. R6, when asked if it had been reported, would not answer. R6's Brief Interview for Mental Status (BIMS) dated 4-7-17, scores R6 as 12 out of 15, meaning R6 has moderate impaired cognition. 4. On 5/1/17 at 10:20AM, R4 stated that E5 was very rude when I asked for a beer stating Do I look like a bartender also if I asked for a pain pill she would ask me Do I look like a pharmacy. R4 went on to say that E5 would yell up and down the halls in the evenings. R4 also stated that E5 would target R5 with nasty comments like I know you pissed in your chair so you could go out to smoke. R4 stated she really got tired of E5's bad mouth and attitude. R4's physician's orders [REDACTED]. The Physician order [REDACTED]. R4 states the incidents were not reported and did not provide a reason why they were not reported. R4's Brief Interview for Mental Status (BIMS) dated 2-23-17, scores R4 as 15 out of 15, meaning R4 is cognitively intact. 5. On 5/1/17 and 5/2/17 R5 stated, that E5 was mean to a lot of people and she would say mean stuff to me but I'm tough and I ignored her. R5 did not report the incidents and did not provide a reason why they weren't reported. R5's Brief Interview for Mental Status (BIMS) dated 4-3-17, scores R5 as 15 out of 15, meaning R5 is cognitively intact. 6. On 5/1/17 at 9:15AM,R3 stated that E5 is gone and I am glad. R3 also stated she was taking a Blood Pressure Medication that caused her to have bad dreams and crawl on the floor. E5 would tell me that I was doing it to get attention. E5 was a hell cat and hell on wheels. She frequently told me no one liked me and that I was acting like a queen. R3 then showed the surveyor a page from her journal dated April 2016 and read it to me. R3's journal documented that E5 told her 1. No one liked her (night crew and day crew), The staff regards me as someone who thinks they are a Queen and expects everyone else to wait on them, and 3. They are considering putting R3 in another room because she is lonely and that is why she was having these spells at night because she wants attention. R3 also stated E5 really made me think I was a bad person. R3 stated that the incidents were not reported because E5 made me feel bad enough. R3's Brief Interview for Mental Status (BIMS) dated 4-13-17, scores R3 as 15 out of 15, meaning R3 is cognitively intact. The Resident Abuse or Neglect policy, dated 3/1/17, documents the following: It is the policy of this facility to protect the residents from verbal and physical abuse. This shall be achieved by appropriate screening and training employees who participate in resident care. Appropriate intervention, identification, investigation, protection and reporting will be utilized. If there is reasonable suspicion that the injury is a result of a crime, then law enforcement shall be notified as well. If the events that cause reasonable suspicion of a crime, but do not result in a serious bodily injury to the resident, the facility shall report the suspicion not later than 24 hours after forming the suspicion to the Illinois Department of Public Health and law enforcement. The facility shall report to the State Nurse Aide Registry or Professional Regulation any knowledge it has of any actions by a court of law which would indicate an employee unfit for service.

Based on observation, interview and record review the facility failed to assess, identify causative factors, implement interventions based on identified hazards, and monitor and modify those interventions when falls reoccurred for 4 residents (R13, R6, R2, R9) of 9 reviewed for falls in the sample of 13. This failure resulted in R13 fracturing her left clavicle, right hip, and left hip. Findings include: 1. R13 a [AGE] year old woman resided in this facility from 3/24/2011 until 2/7/2012, according to facility admission records of this date. R13's Physician order [REDACTED]. A review on 3/14/2012 of R13's record notes documentation of R13 falling on 5/7/2011, 5/21/2011, 5/27/2011, 10/3/2011, 10/4/2011, 11/ 1, 12/27/2011, and 2/7/2012. A review on 3/14/2012 of the facility's Incident Log notes R13 fell on [DATE] and sustained a hematoma to her forehead. R13 fell on [DATE] sustaining a laceration and hematoma and was sent to the local hospital for treatment. On 5/27/2011 R13 fell again and sustained a fractured left clavicle. The Incident Log notes R13 fell again on 10/3/2011, and 10/4 2011. On 10/4/2011 R13 sustained a fractured right hip from that fall and received treatment at the local hospital. R13 fell on [DATE] again injuring her right hip, bruising, and a received a hematoma to her right eye. On 2/7/2012 R13 fell and sustained a fracture to her left hip. A review on 3/14/2012 of the facility's Incident Reports notes recommended steps to prevent recurrence of the fall of 5/7/2011 is "possibly increasing the number of accuchecks, encourage the resident to ask for help." The Incident Report for the fall of 5/27/2011 fails to note recommended steps to prevent recurrences. The Incident Report of the fall of 10/3/2011 lists as recommended steps to prevent recurrence as "1:1 with resident reminded to ask for assist." There are no noted recommendations for the fall of 10/4/2011. The Incident Report of 11/10/2011 notes as recommendation to prevent recurrence "resident did not use call light." The Incident Report of the fall of 2/7/2012 notes recommended steps to prevent recurrence as "we might need to use personal alarm to alert staff resident getting out of bed, check more frequently." No Incident Reports were submitted for review for incidents of 5/21/2011, or 12/27/2011. Review of an x-ray report dated 6/21/2011 notes a non displaced fracture of the left distal clavicle. The Discharge Summary from the local hospital dated 10/5/2011 notes fall with Right Hip Fracture. Review of an x-ray report dated 2/7/2012 notes left hip fracture. The Minimum Data Set/MDS dated [DATE] Section J - Health Condition fails to identify any falls since admission or prior assessment. This review of 3/14/2012 fails to note a Care Plan, Fall Risk Assessment, Assessment of Cognitive Status, or any other documentation to address causes of falls and appropriate interventions to prevent recurrences of falls. 2. R6 is a [AGE] year old woman residing in this facility since 6/5/09 according to facility admission records of this date. R6's physician's orders [REDACTED]. A review on 3/12/2012 of R6's record notes 17 falls occurring on 4/20/2011, 5/5/2011, 6/8/2011, 6/21/2011, 7/4/2011, 7/9/2011, 8/27/2011, 8/31/2011, 9/4/2011, 9/6/2011, 9/8/2011, 9/12/2011, 9/24/2011, 9/29/2011, 10/1/2011, 10/3/2011, and 12/7/2011. These 17 falls are also identified on the facility's Incident Log. A review of the facility's Incident Reports notes observation of occurrence and recommended steps to prevent recurrences for the 4/40/2011 fall "resident found sitting on floor on buttock, chair alarm". Recommendations for the fall of 5/5/2011 " resident observed on mat beside bed, CNA needs to stay with resident while in bathroom, she also needed to put alarm on wheelchair". 5/13/2011 " bed alarm went off resident observed sitting on floor, continue with alarm use." 6/8/2011 " resident observed on the floor, resident will not use call light gets up to go to bathroom by self, alarm in use at this time, resident temp 100.4, Tylenol Extra Strength two tabs was given, this may help with sleep". 6/21/2011 " bed alarm sounded resident found on floor, frequent checks on resident, and take to bathroom as needed." 7/4/2011 "got up unassisted and fell , remind resident not to rise unassisted." 7/9/2011 " resident stood up from wheelchair, stumbled and fell , lap belt for resident". 8/27/2011 "alarm sounded resident climbed out of bed and lost her balance, more frequent checks." 8/31/2011 " resident bumped her head on headboard of bed, monitor bed alarm report incidents right away." 9/4/2011 "resident hit head on 1/2 side rail on left side of bed, more frequent checks, resident trying to get up self numerous times during the night, staff alerted to check more often than every 2 hours." 9/6/2011 "got up from wheelchair tried to walk and fell , continue to use chair alarm, remind resident to not be up without assist." 9/8/2011 "found sitting on floor, promptly react to alarm when sounded, lap belt to be used if needed." 9/12/2011 "attempting to get into another resident's bed, lap belt for safety, assessment for restraint to be completed." 9/24/2011 " observed on floor, I was unable to find alarm in room for bed pad, we are also working short staffed, 2 CNAs." 9/29/2011 "resident sitting on mat on floor, resident has bed alarm, was not on, make sure alarm on." 10/06/2011 " resident observed on floor, bed alarm missing battery, replace battery." 12/7/2011 "observed on floor urine on floor, neuro check within normal limit, range of motion within normal limit, monitor." Fall Risk assessment dated [DATE] indicates with a score of 15 that R6 is high risk for falls. Care Plan dated 5/30/2011 identifies problems with falls but does not address the use of lap belt or bed alarm. Observation of R6 on 3/14/2012 at 1:45 am in the facility beauty shop noted R6 sitting in her wheelchair, no chair alarm was noted, R6 was wearing a non self releasing seat belt. The seat belt was across R6's lap and was tied around and fastened behind and at the bottom of the wheelchair. Observation of R6's bedroom on 3/14/2012 at 2:00 pm noted a body alarm device attached to the head of the bed. Observation on 3/15/2012 at 11:00 am of R6 noted her self propelling in wheelchair in front lobby area of the facility no chair alarm was noted. During an interview at this time 3/15/2012 11:00 am with E10 (Certified Nurse Aide/CNA), E10 stated the chair alarm was discontinued 6-7 months ago and was replaced with the electronic monitoring bractlet. 3. The Incident and Accident log and Incident Reports dated 05/09/11 , 06/13/11, and 07/09/11 note R-2 was found in the floor near his bed on the evening and night shifts. The only intervention attempted was a personal alarm.. The Incident Report dated 09/07/11 at 2:30 AM notes R-2 fell from bed and would be in a low bed with a personal alarm. During an observation on 03/12/12 at 2:15 PM , R-2 was in bed. It was not in the lowest position.. At 10 :00 AM on 03/13/12, R-2 was in bed. It was not in the lowest position and both side rails were up.