Every finding on record at The Pearl of Fox River Valley

Based on observation, interview, and record review, the facility failed to supervise 2 residents (R91,R94) during meal times, failed to transfer a resident (R60) with a gait belt, failed to ensure fall precautions were in place for a resident (R16). These failures apply to 4 of 9 residents reviewed for safety/supervision in the sample of 43.The findings include:1) R91's electronic face sheet printed on 9/4/25 showed R91 has diagnoses including but not limited to metabolic encephalopathy, chronic kidney disease stage 4, Alzheimer's disease, major depressive disorder, and congestive heart failure. R91's facility assessment dated [DATE] showed R91 has severe cognitive impairment and requires an altered diet. R91's physician's orders dated 5/7/25 showed, Regular diet, puree texture, nectar thick liquids consistency. R91's speech therapy Discharge summary dated [DATE] showed, diet: puree/nectar thick liquids, 1:1 supervision. On 9/3/25 at 12:33PM, R91 was sitting in his wheelchair in his room feeding himself a pureed diet. No staff were present in R91's room. On 9/4/25 at 10:33AM, V9 (Certified Nursing Assistant) stated, (R91) usually eats out in the activity/dining area so we can at least walk past him every now and again while we are passing trays. I don't think he needs constant supervision but it makes sense for someone on a pureed diet to need supervision. On 9/4/25a at 11:12AM, V12 (Speech Therapist) stated, (R91) is on a pureed diet with nectar thickened liquids. I only discharged him from therapy because he went on hospice. He does have difficulty swallowing and needs constant reminders and cueing. He is a 1:1 supervision at all meals. He cannot be eating alone in his room as he is confused and does not remember to sit upright and doesn't remember the small bites/sips concept. On 9/4/25 at 12:36PM, V2 (Director of Nursing) stated, If speech therapy recommends a resident to be 1:1 supervision, that would just go straight to nursing who would put it in as an order. I wasn't aware that (R91) was eating alone in his room. If speech therapy recommended 1:1 supervision there is obviously a safety concern with his swallowing so we need to be providing that supervision and cueing for (R91). 2) R60's electronic face sheet printed on 9/3/25 showed R60 has diagnoses including but not limited to unsteadiness on feet, lack of coordination, history of falls, anxiety disorder, and congestive heart failure. R60's facility assessment dated [DATE] showed R60 has no cognitive impairment and is a maximum assist for transfers. R60's care plan dated 4/28/25 showed, (R60) is at high risk for falls related to anxiety disorder. On 9/2/25 at 9:51AM, V11 (Certified Nursing Assistant) was providing hands on assistance to R60 to transfer from her bed to her wheelchair. R60 did not have a gait belt around her waist and V11 was holding underneath R60's arms to provide stability. R60 was shaky during transfer and let out a large sigh as she sat in her wheelchair. After the transfer, V11 stated, She seemed ok during the transfer and didn't need a gait belt. She is a 1 assist most of the time. It just depends on how she's feeling and how tired she is. On 9/3/25 at 9:14AM, R60 stated, They only put the belt around me when they take me to therapy, otherwise they don't ever use it. I'm not sure why they don't use it in my room but the use it in therapy. It doesn't make sense. On 9/3/25 at 12:58PM, V10 (Director of Rehab) stated, On a good day, (R60) is a minimal assist from the edge of the bed. We stand her up at the edge of the bed with a walker and go to the wheelchair. If she's sleepy or not having a good day she could be a maximum assist with 1 assist. Staff are to be using a gait belt at all times for safety with her-no exceptions. She is a high fall risk. and could become weak at any moment during a transfer. The facility's policy titled, Gait Belt revised 6/30/25 showed, The facility will use gait or transfer belts to assist residents needing limited to total assistance during transfers or walking. 3. R94's face sheet printed on 9/3/25 showed diagnoses including but not limited to dementia, right side hemiplegia/hemiparesis(paralysis) following cerebral infarction, traumatic brain injury, and chronic respiratory failure. R94's facility assessment dated [DATE] showed severe cognitive impairment and staff supervision or touching assistance for eating. R94's September 2025 order summary report showed an order start dated 7/9/25 for: Regular diet, pureed texture, nectar thick liquids consistency NO STRAWS. R94's care plan showed a focus area related to nutritional status and a hospitalization 7/1 to 7/9.hospice status. downgraded to puree texture with thickened liquids. R94's re-admission nutrition assessment dated [DATE] shows diagnoses including but not limited to dysphagia (difficulty swallowing) and the diet was downgraded to puree texture in the hospital (authored by V3, Registered Dietician). On 9/2/25 at 12:35 PM, R94 was in bed and eating her lunch alone in the room. R94's bed was furthest from the door and the privacy curtain was pulled around her bed. R94 was not visible from the hallway. R94 had a dietary ticket on her bedside table showing puree texture foods and nectar thick liquids were required. A large bright pink sign was on the bedside table stating, Thickened water only. R94 was eating a lunch of puree turkey, mashed potatoes, puree peas, and a thickened dairy beverage. R94 was pleasantly confused and unable to explain why she was receiving pureed meals. On 9/3/25 at 8:28 AM, R94 was in bed and eating her breakfast alone in the room. The privacy curtain was pulled around her bed. The meal was pureed and thickened juice. R94's call light was on and V18 (Registered Nurse) and V19 (Assistant Director of Nurses) entered the room, then exited shortly after. At 8:35 AM, this surveyor re-entered the room and the same foods were still on R94's bedside table while she continued to eat unsupervised. R94's privacy curtain was still drawn around her bed. On 9/4/25 at 9:25 AM, V3 (Registered Dietician) stated R94 was sent to the local hospital in July due to respiratory distress. She had a swallow evaluation done there and went on hospice. The hospital's speech pathologist determined the puree diet and thick liquids were needed. She has dysphagia and poor dentation. She needs softer food to reduce the risk of aspiration and swallow issues. She has a high risk of choking while eating and drinking. The facility speech pathologist will not re-evaluate her unless she is off hospice. Until then, we should be following all recommendations from the hospital evaluation. V3 was asked if it was appropriate for R94 to be eating alone and unsupervised in her room. V3 answered, No. Nursing staff should be observing her at all meals, especially considering her dementia and swallowing problems. On 9/4/25 at 9:36 AM, V2 (Director of Nurses) stated residents with dysphagia have difficulty swallowing and the potential to choke if eating unsupervised. V2 said R94 has not been re-evaluated by the speech department, and it is not safe for her to eat alone. She should be with an aide or nurse to supervise. That is not right for her to be alone in the room at meals. There is the risk of choking or aspiration. The facility's Dysphagia and Aspiration-Clinical Guidelines policy effective dated 7/17/21 states under the monitoring and follow-up section: 1. The staff and physician will monitor the progress of individuals with swallowing difficulties; for example, ease of eating, improvement of symptoms, and resolution of underlying causes. The facility's Clinical Guidelines (food intake) policy review dated 4/5/25 states: 4. Functional assistance with meals will be provided by the nursing personnel in accordance to the MDS and/or restorative nursing assessment. 4. On 9/2/25 at 12:06 PM, R16 was laying on her back in bed with a blanket covering her. R16 had a low bed with padded upper side rails. The door to her room was closed and the blind on the window facing the nurse's station was shut. The TV was on, and her video was not playing. There was a note on the wall next to her doorway that showed for the certified nursing assistants (CNA) to keep the blinds open, place two matts on the floor, check the DVD a lot, and nectar for nectar thick liquids. R16 was awake and when asked questions she would mumble something unintelligible. At 12:27 PM R16's door was shut, and the blinds closed. R16 was sitting up in bed; no one was in the room. At 12:39 PM V14 CNA took R16's food tray into her room to feed R16 lunch. V14 stated R16 was at risk for falls so they put two mattresses on the floor and keep her blind open. V14 stated they close the blind when care is provided and open them when they are done; before they leave the room. V14 stated R16 likes to see what is going on and staff keep them open so they can keep and eye on her. V14 stated R16 does try to crawl out of bed. On 9/3/2025 at 9:08 AM and 11:12 AM, the door to R16's room and blind on the window facing the nurse's station were closed. R16 was alone in her room; no care being provided. R16 was sitting up in bed. On 9/3/25 at 9:15 AM, V14 stated she forgot to open the blind on R16's window that was facing the nurse's station. V14 stated R16 has the mattresses on the floor for safety. The blind is to be kept open for safety and the resident sleeps better with the blind open. V14 stated the list posted next to R16's door is based on what she likes and is for her safety. On 9/4/25 at 8:36 AM, V2 Director of Nursing (DON) stated R16 is alert but unable to express herself. R16 is a fall risk, and it is the expectation that the blind on her window be left open when personal care is not being provided. V2 stated the blind should be open to monitor the resident. The Nurses Note dated 8/2/25 at 6:09 PM for R16 showed at about 3:15 PM R16 was observed lying prone on the floor mat next to her bed. R16 had a small laceration above her left eye with swelling and some bleeding present. R16 was evaluated in the local emergency room. The Face Sheet dated 9/4/25 for R16 showed diagnoses including traumatic brain injury, lack of coordination, abnormal posture, cognitive communication deficit, history of falling, major depressive disorder, ataxia, and generalized anxiety disorder. The Care Plan dated 7/11/25 for R16 showed she is at high risk for falls related to spastic movements due to traumatic brain injury. R16's fall on 8/2/25 was not listed on the care plan or that the care plan was reviewed and/or revised afterwards. The facility's Fall Prevention Program Guidelines policy (12/5/2021) showed safety interventions shall be initiated and implemented for each resident identified at risk for fall. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained.

Based on observation, interview, and record review the facility failed to provide catheter care, ensure a drainage bag is not laying on the floor, and kept below the level of the bladder for 4 of 5 residents (R6, R13, R58, & R91) reviewed for catheters in the sample of 43.The findings include:1. On 9/2/25 at 10:01 AM, R13 was sitting up in her bed and her indwelling urinary drainage bag was on a hook on her nightstand. R13 was asked what kind of catheter care the facility staff provided and she stated they empty the drainage bag three times a day. They change her catheter for her. R13 stated she does not receive peri care and cleaning of her catheter tubing every day. R13 stated that it is done sometimes by the staff but not daily. R13 stated she does not clean her peri area daily and does not clean the catheter tubing. R13 stated she tries to clean her peri area twice a week when she has a shower. R13 stated she was willing to receive catheter care education. On 9/3/25 at 1:08 PM, V16 stated the catheter care that he provides for R13 is the emptying of her drainage bag and cleaning the bag off after it is emptied. V16 stated peri care and the cleaning of her catheter tubing is done by the resident herself. On 9/4/2025 at 8:36 AM, V2 Director of Nursing (DON) stated, catheter care is done once daily by staff. V2 stated it is done with activities of daily living. The catheter tubing is to be wiped down. V2 stated catheter care is done to prevent any infection. The Face Sheet dated 9/4/25 for R13 showed diagnoses including multiple sclerosis, obesity, chronic kidney disease, hypertension, hyperlipidemia, anxiety disorder, major depression, and neuromuscular dysfunction of the bladder. The Minimum Data Set, dated [DATE] showed no cognitive impairment; substantial/maximal assistance needed for toileting hygiene; and partial/moderate assistance needed for personal hygiene. The Care Plan dated 6/27/25 for R13 showed on 8/29/25 the care plan was updated because she was on antibiotic therapy for a urinary tract infection. The facility's Urinary Catheter Care policy (7/3/25) showed to wash the resident's genitalia and perineum thoroughly with soap and water; rinse the area well and towel dry. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately 4 inches outward. 2. On 9/2/25 at 10:35 AM, R58 had a mechanical lift sling behind him and was sitting in a recliner in his room. R58's catheter drainage bag was laying on the floor. On 9/3/25 at 11:07 AM, V15 Registered Nurse (RN) stated the catheter bag should not be on the floor for infection control reasons. On 9/4/25 at 8:36 AM, V2 Director of Nursing (DON) stated the drainage bag should not touch floor because of infection control. The Face Sheet dated 9/4/25 for R58 showed diagnoses including Parkinson's disease, Alzheimer's disease, and obstructive and reflux uropathy. The Care Plan dated 8/1/25 for R58 showed he has a potential for infection due to the urinary catheter. The facility's Urinary Catheter Care policy (7/3/25) showed, Infection control: Be sure the catheter tubing and drainage bag are kept off the floor. 3. R91's electronic face sheet printed on 9/4/25 showed R91 has diagnoses including but not limited to metabolic encephalopathy, chronic kidney disease stage 4, Alzheimer's disease, major depressive disorder, and congestive heart failure. R91's facility assessment dated [DATE] showed R91 has an indwelling catheter. R91's care plan dated 1/11/25 showed, (R91) has potential for infection related to (indwelling catheter) .initiate proper precautions per facility policy. On 9/3/25 at 9:33AM, V23 (Certified Nursing Assistant-CNA) and V24 (CNA Supervisor) transferred R91 using a full body mechanical lift. V24 hooked R91's urinary drainage bag on R91's mechanical lift sling above the level of R91's bladder. V23 then took R91's catheter drainage bag and placed it on his lap after he was seated in the wheelchair. V23 and V24 stated that urinary drainage bags should always be kept below the level of the bladder to prevent urine from backflowing into the tubing and back into a resident's bladder. On 9/4/25 at 9:43AM, V8 (CNA) was preparing to empty R91's catheter drainage bag when he held the drainage bag approximately 2 feet above R91's bladder to look into the bag to see how much urine was in it. Urine was observed backflowing in the tubing towards R91's catheter insertion site. V8 continued the remainder of R91's personal cares without ever removing R91's incontinence brief to provide catheter care. V8 stated he did not need to remove the brief because the other shift does cares. On 9/4/25 at 10:33AM, V14 (CNA) stated, When residents are receiving morning care they should get their brief changed even if they have a catheter because they may have had a bowel movement or their catheter could be leaking. This is also the time when we provide catheter care because it's provided at least once per shift. 4. R6's admission Record (Face Sheet) showed and admission date of 5/9/25 with diagnoses to include but not limited to central pain syndrome (pain due to nervous system damage), diabetes type 2, and left sided paralysis. R6's Care Plan showed she had an indwelling urinary catheter. On 9/03/2025 at 9:40 AM, V6 Wound Care Nurse and V7 Wound Care Technician provide wound care for R6. R6's catheter bag was attached to the right side of her bed frame. R6 was supine on her back at the start of the wound care. During wound care, R6 was repositioned to her left side. V7 assisted with the repositioning of R6 as well as the repositioning of R6's catheter bag. While moving R6's catheter bag, V7 held the bag a foot over the bladder, which cause the urine in the tubing to flow back towards R6. When R6 was repositioned to her back, V7 held R6's catheter bag above her bladder, which caused the urine in the catheter tubing to flow back towards R6. On 9/04/2025 at 8:36 AM, V2 Director of Nursing stated, catheter bags should always be kept below the level of the bladder to ensure proper drainage and prevent backflow of urine. V2 said, this is done to prevent potential infections or other effects of improper drainage of urine. The facility's Urinary Catheter Care policy (revised 7/3/25) showed, The purpose of this procedure is to prevent catheter-associated urinary tract infections.The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview and record review, the facility failed to ensure residents on a pureed diet received a pureed dinner roll during the lunch meal for 8 of 8 residents (R16, R18, R68, R69, R72, R79, R91, and R94) reviewed for pureed diets in the sample of 43.The findings include:On 9/2/2025 at 10:22 AM, an initial tour of the kitchen was conducted. V4 (Dietary Manager) said the residents lunch meal on that day included herbed turkey, California blend vegetables, mashed potatoes and gravy, cookies, and dinner rolls. At 11:27 AM, dietary staff were observed preparing the trays for the lunch meal service. No pureed dinner rolls were observed being provided to the residents on a pureed diet. At 12:55 PM, V22 (Cook) was not in the kitchen at the time. V4 was asked about the pureed dinner rolls not being served to the residents with pureed diets. V4 said she would ask V22 if he put it in with the pureed turkey. On 9/2/2025 at 1:53 PM, V3 (Registered Dietitian-RD) said the dinner rolls should have been served at lunch to the residents on a pureed diet to make sure they get enough carbohydrates. V3 said a larger portion would need to have been served if the pureed dinner rolls were added to the pureed turkey, to ensure residents are getting the correct amount of both bread and turkey. V3 said the dietary staff were going to serve the residents on pureed diets the pureed bread at the dinner meal. V3 was asked if it was not brought to their attention, did she think the residents would be getting the bread at the dinner meal? V3 said she would like to think the dietary staff would have noticed it and served it at the dinner meal. On 9/2/2025 at 1:58 PM, V4 (Dietary Manager) said the dietary staff forgot to make the pureed dinner rolls for the lunch meal. V4 was asked if it was not brought to her attention, would the residents be receiving the pureed bread at dinner? V4 stated, Well like I said, they forgot it. On 9/4/2025 at 12:54 PM, V3 (RD) said the menus are created by (a contracted food service company). V3 said it is important to make sure the menus are followed to support the residents' nutritional needs.The facility's Diet Type Report, printed on 9/2/2025, showed R16, R18, R68, R69, R72, R79, R91, and R94 were the residents in the facility receiving pureed diets.R16, R18, R68, R69, R72, R79, R91, and R94's Order Summary Reports, printed by the facility on 9/3/2025, showed all these residents had an order for pureed diets.The facility's Week at a Glance menu, printed on 9/2/2025, showed dinner roll was listed on the menu to be served on Tuesday 9/2/2025 during the lunch meal.The facility's policy and procedure titled Kitchen, with a revision date of 6/30/2025, showed all food items in the menu and recipe will be followed.

Based on observation, interview, and record review, the facility failed to implement pressure ulcer prevention measures for 2 of 6 residents (R10,R91) reviewed for pressure ulcers in the sample of 43.The findings include:1) R10's electronic face sheet printed on 9/4/25 showed R10 has diagnoses including but not limited to Parkinson's disease, dementia with behaviors, hypertension, hyperlipidemia, and osteoarthritis. R10's facility assessment dated [DATE] showed R10 has moderate cognitive impairment and is at risk for pressure ulcers. Fall risk evaluation 7/10/25 high risk R10's care plan dated 4/30/24 showed, (R10) has an actual impairment to skin integrity and is at risk for additional skin breakdown related to the following comorbidities but not limited to Parkinson's, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, hypertension, repeated falls .Interventions: off load heels . R10's skin risk assessment dated [DATE] showed R10 is a high risk for skin breakdown. On 9/3/25 at 8:52AM V23 (Certified Nursing Assistant-CNA) and V24 (Wound Care Nurse) assisted R10 to lay down in bed. R10's heels were resting on the bed and were not elevated off of the mattress. V23 and V24 stated R10's cares were completed and there was nothing else he needed. At 9:32AM, R10 was still lying in bed without his heels elevated. On 9/4/25 at 12:36PM, V2 (Director of Nursing) stated, The expectation is that pressure ulcer prevention will be done per physician's orders and the resident's care plan. If prevention is not done, residents are placed at increased risk for developing pressure ulcers. Someone on hospice is even more prone as they are declining already. The facility's policy titled, Wound Care Guidelines revised 01/24/2024 showed, .The goal of this care guideline is to achieve compliance to regulatory requirements and provide evidence-based recommendations for the prevention and treatment of pressure injuries that can be used by the health professionals in this facility. The purpose of the prevention recommendations is to guide evidence-based care to prevent development of pressure injuries .Procedures .4. Activity, Mobility, and Positioning .g. Resident may be properly positioned in bed using pillows or other supportive devices to help protect bony prominence areas susceptible to pressure .2) R91's electronic face sheet printed on 9/4/25 showed R91 has diagnoses including but not limited to metabolic encephalopathy, chronic kidney disease stage 4, Alzheimer's disease, major depressive disorder, and congestive heart failure. R91's facility assessment dated [DATE] showed R91 has severe cognitive impairment and is at risk for skin breakdown. R91's care plan dated 6/25/24 showed, (R91) has an actual impairment to skin integrity and is at risk for additional skin breakdown related to the following comorbidities but not limited to Alzheimer's, unsteadiness on feet, lack of coordination, history of falling, dementia, depressive disorder, hypertension, heart failure Interventions .off load heels R91's skin risk assessment dated [DATE] showed R91 is at high risk for skin breakdown. On 9/4/25 at 9:43AM, R91 was lying in his bed with his heels resting on the mattress. A pair of offloading boots were sitting in the chair in R91's room. V8 (Certified Nursing Assistant) stated, He needs them on later, not right now. He doesn't need them all the time I don't think. I believe he only needs them in the afternoon when he is taking a nap. On 9/4/25 at 10:18AM, V14 (Certified Nursing Assistant) stated, (R91) is to have his offloading boots on at all times or else we need to elevate his heels with a pillow. There is no reason why we would only offload a resident's heels when they are taking a nap and not overnight, it should be done anytime they are in bed to prevent pressure ulcers.

Based on observation, interview and record review, the facility failed to ensure the dignity of a resident was maintained for 1 of 2 residents (R109) reviewed for dignity in the sample of 43.The findings include:On 9/03/2025 at 10:11 AM, during the resident group meeting, R96 said his roommate (R109) had a mess in their bathroom a couple weeks ago. R96 said a housekeeper and a CNA (Certified Nursing Assistant) were going back and forth about whose job it was to clean it up. R96 said he thinks the housekeeper took pictures of the mess in the bathroom. R96 was not able to identify the housekeeper, or the CNA involved in the incident.On 9/3/2025 at 1:18 PM, V1 (Administrator) was asked about the incident regarding a housekeeper and CNA going back and forth in front of residents about whose responsibility it is to clean up a mess in a resident's bathroom. V1 said she was not aware of the incident. At 1:22 PM, V1 and this surveyor went to speak with V5 (Housekeeping Supervisor). V5 said she was told by one of the housekeepers that a CNA would not clean the stool up in a resident's bathroom. V5 said the housekeepers are not responsible for cleaning up feces. V1 (Administrator) said the CNAs are responsible for cleaning up stool, and the housekeepers disinfect the area after the CNAs clean the stool. V5 identified V20 as the housekeeper. V5 said she did not know who the CNA was. V5 said she thinks V20 sent her pictures of the mess. V5 looked through her phone and could not find the pictures, so she called V20. V5 said V20 was going to resend the pictures to her. V20 sent V5 six pictures. The first picture showed the toilet and surrounding area with non-formed, loose stool, on the lid, the seat, the bowl of the toilet, and a large puddle around the base of the toilet. The other pictures showed stool splatter on the wall and floor. V5 showed V1 the pictures V20 sent her. V1 told V5 under no circumstances is it okay for staff to take pictures of a resident or the resident's room. On 9/3/2025 at 2:28 PM, R96 said R109 was in the room when the CNA and housekeeper were going back and forth about whose job it was to clean stool. R96 said he felt bad for (R109). On 9/4/2025 at 8:38 AM, V20 (housekeeper) said she does not recall the exact day it happened, it was sometime near the end of August. V20 said there was a mess in R109's bathroom. Stool was on the toilet and the floor. The CNA came to me and said she needed my help. I asked her what she needed. We went to (R109 and R96's) room and I saw the stool on the floor and toilet. V20 said she told the CNA that the CNAs are responsible for cleaning stool, urine and blood up, then housekeeping will disinfect after it is cleaned. V20 said the CNA pushed back and said it was housekeeping's job to clean. V20 said she and V21 (unknown CNA) did go back and forth regarding who was responsible. V20 said she took pictures to send to her supervisor (V5), to ask who is responsible and to protect herself. V20 said she and V21 should not have had that conversation in front of the residents, and she should not have taken pictures of the residents' bathroom. V20 said It is a dignity issue. On 9/4/2025 at 8:43 AM, R109 said he was in the room when V20 and V21 were going back and forth about who was responsible for cleaning the mess in the bathroom. R109 said he felt down at the time. He was embarrassed because he could not help it. R109 said he got over it though. On 9/04/2025 at 1:21 PM, V1 (Administrator) said she had no idea the incident happened until this surveyor mentioned it. V1 said (V20 and V21) should not have had that conversation in the resident's room at all. they should have talked in a private area where no residents could hear. V1 said discussing that in front of the resident is a dignity issue. V1 said V20 has been written up and she is trying to find out who the CNA (V21) is so she can write them up too. V1 provided a copy of the Disciplinary Notice Form for V20. R109's admission Record, printed by the facility on 9/3/2025, showed he had diagnoses including, but not limited to, Parkinson's disease with dyskinesia (uncontrolled, involuntary muscle movement that can involve one body part, such as an arm or leg, or the entire body), unsteadiness on feet, lack of coordination, gout, depression, hallucinations, weakness, chronic obstructive pulmonary disease, and impingement syndrome of left shoulder (shoulder pain cause by connective tissue-tendon-rubbing on a shoulder blade. The pain may be consistent and increase with lifting or reaching movements).R109's 6/9/2025 facility assessment showed he was cognitively intact, had one-sided range of motion impairment to his upper extremity, required substantial to maximal assistance with toilet hygiene, was dependent on staff for toilet transfers, was frequently incontinent of urine and occasionally incontinent of bowel.The facility's policy and procedure titled Privacy and Dignity, with a revision date of 7/3/2025, showed It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. The policy and procedure showed 5. Residents will not be addressed in an undignified manner by staff at all times. 6. Residents' health information will not be shared to anyone who is not involved in resident's care and to anyone whom the alert and oriented resident does not wish to share his/her information with.

Based on observation, interview, and record review the facility failed to follow their policy for a resident to self-administer medications for 1 of 1 resident (R108) reviewed for self-administration in the sample of 43. The findings include:R108's face sheet printed on 9/3/25 showed diagnoses including but not limited to congestive heart failure, hypertension, diabetes mellitus, cardiomyopathy, and stage three kidney disease. R108's facility assessment dated [DATE] showed moderate cognitive impairment. R108's September 2025 order summary report showed an order start dated 4/23/25 for: Sildenafil citrate (Viagra) oral tablet 100 milligrams. Give 1 tablet by mouth as needed for erectile dysfunction, supervised self-administration daily on an empty stomach. On 9/2/25 at 10:05 AM, R108 was lying in bed and the bedside table had a pill vial with approximately 12 tablets in it. The label showed it was Viagra and to take one tablet one hour prior to intercourse. R108 stated he has been using it for the last two to three months. R108 said he keeps it on the bedside table. The nurses just leave it there for him to take as needed. At 10:13 AM, V17 (Registered Nurse) stated R108 cannot take medications on his own. We have to give all of them to him. On 9/3/25 at 9:05 AM, R108 was sitting in his room and the vial of prescription Viagra was still on the bedside table. R108's medical record had one assessment for the ability to self-administer medications which was dated 4/7/24 (well over one year ago). The assessment was related to the self-use of an inhaler. The same assessment showed a physician order and care plan were needed to self-administer a medication. R108's care plan and physician orders did not reflect any interventions or orders to self-administer the Viagra without supervision. There was no physician order to keep the medication at the bedside. On 9/4/25 at 9:05 AM, V2 (Director of Nurses) stated if a resident requests to self-administer any medication we reach out to the physician first to get approval. There needs to be a doctor's order stating the resident can do it and they can keep it at the bedside. They need to be care planned for it too. An assessment should be done to ensure the ability to do it safely. The assessment tells us the resident is mentally, physically, and visually able to take the medication alone. A return demonstration is needed. The assessment needs to be done before any self-administration and again every quarter. V2 confirmed R108 has had the Viagra since April 2025 and there was no assessment to self-administer. The facility's Self-Administration of Medication policy revision dated 7/3/25 states: 1. The IDT will assign a staff to evaluate resident's ability to safely administer medication. A Self-Administration Evaluation will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after the health teaching. 2. The resident may store the medication at bedside if there is a physician order to keep it at bedside. 5. The resident's ability to self-administer medication will be assessed regularly by the facility to coincide with MDS assessment or any notable change in status.

Based on observation, interview, and record review, the facility failed to apply compression stockings for 2 of 2 residents (R10,R91) reviewed for quality of care in the sample of 43.The findings include:1) R10's electronic face sheet printed on 9/4/25 showed R10 has diagnoses including but not limited to Parkinson's disease, dementia with behaviors, hypertension, hyperlipidemia, and osteoarthritis. R10's facility assessment dated [DATE] showed R10 has moderate cognitive impairment. R10's physician's orders dated 4/30/24 showed, Compression stockings to bilateral lower extremities. On 9/2/25 at 12:10PM, R10 was up in his wheelchair with no compression stockings on his feet. R10 was unable to recall if he wears them or not. On 9/3/25 at 8:52AM, V6 (Wound Care Nurse) and V13 (Certified Nursing Assistant-CNA) assisted R10 to lay down in bed. V6 removed R10's pants and R10 did not have compression stockings on. V13 stated she was not sure if R10 is supposed to have compressions stockings on or not. V6 stated she is also unaware if (R10) needs compression stockings on or not.R10's treatment administration record for September 2025 showed R10's compression stockings were applied on 9/2/25 and 9/3/25.On 9/4/25 at 12:36PM, V2 (Director of Nursing) stated, Physician's orders should be followed at all times. If a nurse is checking the box on the treatment administration record (TAR), then I would assume they are checking that the compression socks are on otherwise they would put them on and then check the box. They are not following physician's orders if the treatment is not in place.The facility's policy titled, Physician Orders revised 7/3/25 showed, It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Physician Order Sheet) .2) R91's electronic face sheet printed on 9/4/25 showed R91 has diagnoses including but not limited to metabolic encephalopathy, chronic kidney disease stage 4, Alzheimer's disease, major depressive disorder, and congestive heart failure.R91's facility assessment dated [DATE] showed R91 has severe cognitive impairment.R91's physician's orders dated 5/8/25 showed, Compression socks to bilateral lower extremities, apply every morning and remove at bedtime. On 9/2/25 at 12:33PM, R91 was sitting up in his wheelchair in his room with no compression stockings on. R91 stated he does wear tight socks on his legs, but they did not put them on today. On 9/3/25 at 9:33AM, V23 (CNA) and V24 (CNA Supervisor) assisted R91 out of bed. R91 did not have compression socks on. V22 and V23 were unsure if R91 is still using them. R91 had 2 signs in his room indicating he is to have compression stockings put on in the morning and removed in the evening. On 9/4/25 at 9:43AM, V8 (CNA) assisted R91 with morning cares and dressing assistance. V8 stated he is an agency CNA and is unsure if R91 is supposed to use compression stockings or not.On 9/4/25 at 10:18AM, V14 (CNA) stated, (R91) uses compression socks every day and will usually remind us if we forget so I'm surprised he didn't say anything. He has used them for a few months now.

Based on observation, interview, and record review the facility failed to ensure physician prescribed medications were administered as ordered for 1 of 1 resident (R3) reviewed for medication administration in the sample of 43. The findings include: R3's face sheet printed on 9/3/25 showed diagnoses including but not limited to cellulitis of right lower leg, cognitive communication deficit, chronic kidney disease, edema (swelling caused by excess fluid in tissues), and paranoid schizophrenia. R3's September 2025 order summary report showed an order start dated 7/10/25 for: Bumetanide (Bumex/diuretic) tablet 2 milligrams. Give one tablet by mouth in the morning for fluid retention. R3's September 2025 medication administration report (MAR) showed the Bumex medication scheduled to be given at 6 AM daily. The same report showed documentation it was given on 9/2/25 at the scheduled time. On 9/2/25 at 12:25 PM, R3 was seated in a chair in his room. R3 was alert and talkative. A plastic medication cup was on the bedside table next to R3. The cup held a white tablet that had been split in half. R3 stated that was his water pill. He only takes half of it at a time. R3 said if I take the whole thing I am peeing like crazy. I snap it in half and take the rest of it later, when I feel like it. On 9/4/25 at 10:45 AM, V6 (Wound Care Nurse) stated R3 has poor circulation and chronic venous ulcers on his lower legs. He has Bumex prescribed daily to help with the fluid retention. It is an ongoing problem. On 9/4/25 at 9:15 AM, V2 (Director of Nurses) stated nurses should verify medication orders then bring them directly to the resident. Nurses should remain with the resident until it is taken. They need to ensure it is swallowed. R3 should not be taking the Bumex in two separate doses. It should be taken as ordered. There is the potential of underdosage and not treating the condition it was ordered for. There is the potential for R3's fluid retention to worsen if he isn't getting the medicine as ordered. The facility's Medication Pass policy revision dated 7/2/25 states under the PO (by mouth) section: 7. PO meds -e. After medication is administered to each resident, sign MAR that it was given. The facility was unable to provide any other policy related to proper medication administration.

Based on observation, interview, and record review, the facility failed to wear personal protective equipment (PPE) during catheter care for a resident (R91) on Enhanced Barrier Precautions, failed to perform glove changes during resident care. This applies to 1 of 1 residents reviewed for infection control in the sample of 43.The findings include:R91's electronic face sheet printed on 9/4/25 showed R91 has diagnoses including but not limited to metabolic encephalopathy, chronic kidney disease stage 4, Alzheimer's disease, major depressive disorder, and congestive heart failure.R91's care plan dated 1/11/25 showed, (R91) is on enhanced barrier precautions .ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use for those with central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care for any skin opening requiring a dressing) that provide opportunities for transfer of MDROs (Multi-Drug Resistant Organisms) to staff hands and clothing. On 9/4/25 at 9:43AM, R91's doorway had a sign stating, STOP Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for high-contact resident care activities. Dressing, Bathing/Showering, Transferring, Changing Linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening that requires a dressing . V8 (Certified Nursing Assistant-CNA) entered R91's room to provide catheter care to R91. V8 wore gloves with no gown while emptying R91's catheter drainage bag. V8 then went and touched the shared bathroom door to empty R91's urinal with urine in it. V8 proceeded to touch the shared bathroom door handle, R91's bed remote, and R91's clean clothing with the same gloves on. V8 did not change his gloves throughout the entirety of R91's personal cares. V14 (CNA) called V8 out of R91's room to inform him he needed to put a gown on. V8 then applied a gown to transfer R91 out of bed. V8 stated he needs a gown because there is a sign outside R91's door. V14 stated, (V8) should have used gown and gloves with cares, especially with the catheter because that is why he is on EBP. On 9/4/25 at 12:36PM, V2 (Director of Nursing) stated, Residents on EBP include those with wounds, catheter, etc. All staff providing cares and high-contact activities are to wear a gown and gloves at all times to prevent the transmission of any bacteria from the resident to the staff. After catheter care if provided, gloves should be changed to prevent cross-contamination. These are basic CNA skills at this point. (V8) is an agency CNA but these procedures are across the board for CNA's, not just specific to our facility. The facility's policy titled, Enhanced Barrier Precaution revised 6/30/25 showed, The facility will use EBP to reduce transmission of multi-drug-resistant organisms in the nursing homes. EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDRO's as well as residents with wounds and/or indwelling medical devices .1. EBP will be used for any resident residing in the facility that has indwelling medical devices (E.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of XDRO (Extensively Drug-Resistant Organism) colonization status .3. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of XDRO's to staff hands and clothing .g) device care or use of central line, urinary catheter .

Based on interview and record review, the pharmacist's Medication Regimen Review (MRR) failed to identify the transcription omission of a resident's thyroid medication for her hypothyroidism diagnosis at the time of her readmission. This applies to 1 of 3 (R1) residents reviewed for pharmacy services. The finding includes: R1's EMR (Electronic Medical Record) showed R1 was discharged from the facility on 8/16/2024 and readmitted on [DATE] after she had an ER (emergency room ) visit. R1's Admission Record sheet showed R1 had an active diagnosis of hypothyroidism identified on 6/17/2024. On 11/15/2024 at 10:45 AM, R1 was interviewed regarding her medications. During the interview, R1 had difficulty expressing her thoughts and became frustrated at times. R1 said she felt confused, and tired and had trouble seeing close objects like her call light. R1 said she was worried because her community physician (V25) informed her she had not been receiving her thyroid medication and now her levels were too high. R1 said she was not sure why her thyroid medication had been missed because she had been taking it for a long time. R1's ER visit documents dated 8/19/2024 showed R1 was discharged back to the facility with the facility's Transfer/Discharge Report dated 8/16/2024. The report included R1's active medications, including Levothyroxine Sodium Tablet 150 MCG. Directions: Give 1 tablet by mouth in the morning for low thyroid hormone. R1's hospital documents were uploaded in her EMR on 8/19/2024. V25's (Physician) 11/8/2024 Physician Report showed R1's elevated TSH (thyroid-stimulating hormone) level of 120 was evaluated. The report said She is on half the dose that I had her listed on my medication list. She is feeling tired fatigue confused and is having some ocular issues and I think a lot of the symptoms could be related to her thyroid. The report showed V25 restarted R1's prior dose of Levothyroxine on 11/8/2024, 79 days later. On 11/19/2024 at 1:00 PM, V19 (Pharmacist Manager Consultant) said Pharmacists performed Medication Regimen Reviews (MRRs) for new admissions and readmissions, and then monthly to review the most recent hospital discharge medication lists and current electronic medical records. V19 said MRRs are done to try to catch medication errors and irregularities. V19 said he reviewed R1's MRRs dated 8/21/2024 when she readmitted , and then performed the following monthly MRRs dated 9/5/2024 and 9/22/2024, and R1's hospital discharge documents dated 8/19/2024. V19 confirmed R1's Levothyroxine medication was missed when she was readmitted on [DATE] and it was omitted from her medication list. V19 said it was unfortunate that R1's thyroid medication irregularity was also missed again during her MRR on 8/21/2024 and the following months. V19 said he was not sure if her hospital documents with her most recent medication list were reviewed by the pharamcists. R1's Pharmacist-Medication Regimen Review report dated 8/21/2024 said R1's Medication Review Results showed No irregularities. R1's Pharmacist-Medication Regimen Review report dated 9/5/2024 continued to show no irregularities were identified regarding R1's missing thyroid medication. R1's Pharmacist-Medication Regimen Review report dated 9/22/2024 said R1's Medication Review Results showed No irregularities. The facility's policy titled Medication Regimen Review dated 8/16/2024 said The Consultant Pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once a month for each resident residing in certified areas of a skilled long term care facility .Federally mandated standards of care as well as other applicable standards serve as the basis for review to ensure that resident's medications are promoting or maintain the resident's highest level of function in congruence with the resident's therapeutic goals and to identify clinically significant risks and/or adverse medication reactions .

Based on interview and record review the facility failed to transcribe a resident's medications as ordered, resulting in the original does of thyroid medication not being administered for 79 days. This applies to 1 of 5 (R1) residents reviewed for medications. The finding includes: R1's EMR (Electronic Medical Record) showed R1 was discharged from the facility on 8/16/2024 and readmitted on [DATE] after she had an ER (emergency room ) visit. R1's Admission Record sheet showed R1 had an active diagnosis of hypothyroidism identified on 6/17/2024. On 11/15/2024 at 10:45 AM, R1 was interviewed regarding her medications. During the interview, R1 had difficulty expressing her thoughts and became frustrated at times. R1 said she felt confused, and tired, and she was having trouble seeing close objects like her call light. R1 said she was worried because her Community Physician (V25) informed her she had not been receiving her thyroid medication and now her levels were too high. R1 said she was not sure why her thyroid medication had been missed because she had been taking it for a long time. R1's ER visit documents dated 8/19/2024 showed R1 was discharged back to the facility with the facility's original Transfer/Discharge Report from 8/16/2024. The report showed R1's active medications, including Levothyroxine Sodium Tablet 150 MCG. Directions: Give 1 tablet by mouth in the morning for low thyroid hormone. R1's hospital documents were uploaded in her EMR on 8/19/2024. R1's lab results dated 11/4/2024 showed R1's TSH (thyroid-stimulating hormone) level was 120.542 H (high). (TSH reference value range is 0.550-4.780 uIU/mL.) R1's physician visit report from V25 (Physician) dated 11/8/2024 showed R1's elevated TSH (thyroid-stimulating hormone) level of 120 was evaluated. The report said She is on half the dose that I had her listed on my medication list. She is feeling tired fatigue confused and is having some ocular issues and I think a lot of the symptoms could be related to her thyroid. The report showed V25 restarted R1's prior dose of Levothyroxine. On 11/15/2024 at 2:55 PM, V2 (Director of Nursing/DON) said R1's in-house Physician (V11) had ordered routine labs, including a TSH level, on 11/4/2024, and then started R1 on Levothyroxine medication for her thyroid because it was extremely elevated. V2 said then R1's daughter informed him that V25 (R1's Community Physician) reviewed her medications and informed them that R1's thyroid medication was omitted when she was readmitted , and that R1 was restarted at a lower dose. V2 said he expected nursing staff to review the most current medication list at the time of admission, and readmission, and to clarify any discrepencies with the Physician to ensure medication safety. R1 said he was unsure why R1's Levothyroxine was not reordered when she was readmitted and continued to be missed. R1's care plan had a focus problem for R1's diagnosis of hypothyroidism initiated on 9/19/2024. The care plan's goals included [R1's] Thyroid function tests will be within normal limits .will be compliant with thyroid replacement therapy . R1's EMAR (Electronic Medication Record) for August 2024 showed R1 last received Levothyroxine Sodium (thyroid hormone medication) 150 mcg (micrograms) on 8/16/2024, prior to her discharge. R1's EMAR did not show R1's Levothyroxine being restarted when she was readmitted on [DATE]. R1's EMAR for September 2024 showed R1's original Levothyroxine Sodium dosage was not restarted. R1's EMAR for October 2024 showed R1's Levothyroxine Sodium was still not restarted. R1's EMAR for November 2024 showed R1 was started on Levothyroxine Sodium 75 mcg on 11/6/2024 and then increased to 150 mcg on 11/9/2024. R1's lab results dated 11/11/2024 showed R1's TSH level was 104.958 H. The facility's policy titled Admission and Readmission Policy dated 7/12/2024 said, It is the policy of this facility to ensure that the facility complies with federal regulations in terms of admission and readmission of resident. Procedures: 2) Verify orders from the hospital with physician or on-call physician. 3) Obtain physician orders based on resident needs. 4) Carry out physician orders. The facility's policy titled Physician Orders dated 8/16/2024 said, The facility shall ensure to follow physician orders as it is written in the POS. 1. Upon admission and readmission, the facility will verify transfer orders from the hospital with the resident's attending physician or physician on call .The nurse may question and clarify physician orders that are not clear and are questionable .

Based on observation, interview and record review, the facility failed to ensure safe transport of resident to the shower room when a shower chair was utilized for the transfer in place of a wheelchair. This failure resulted in R24 falling from the chair and fracturing both of her legs. This applies to 1 of 4 residents (R24) reviewed for accidents in the sample of 26. The findings include: R24 is a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that include Multiple Sclerosis, Chronic pain, and Polyneuropathy. R24's MDS (Minimum Data Set) assessment dated [DATE], documents that resident requires substantial to maximal assistance with lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support. R24 was also assessed to be cognitively intact as evidenced by a BIMS (Brief Interview of Mental Status) score of 15/15. The Facility Reported Incident dated June 13, 2024, stated that at approximately 6:30 AM Certified Nursing Assistant (CNA) was transporting R24 to the shower room via shower chair. The report documents the chair suddenly stopped at the metal transition strip on the floor. This caused the chair to become unstable and the resident to lose balance and fall to the floor. Resident complained of pain to bilateral legs and knees. The resident was sent to the hospital and sustained a fracture of the right femur and fracture of the left tibia and fibula. On July 8, 2024, at 10:36 AM, R24, stated that on June 13, 2024, at about 6:20 AM, V10 (CNA) helped her into a Polyvinyl Chloride pipe (PVC) shower chair via a full body mechanical lift and wheeled her towards the shower room. R24 stated the shower chair was made of PVC pipe and had a footrest board. R24 stated the shower room closet to her room was occupied so he started to wheel her to the next closet shower room. R24 stated that when they got to the metal strip on the floor, the wheels locked, and the chair stopped abruptly, and she kept going and landed on her legs and knees. R24 stated when the staff is pushing you in the shower chairs the wheels lock and the shower chair jerk you forward then you see black marks on the floor behind you. R24 stated she has been complaining the shower chairs were not in good repair for 2.5 years. R24 stated she has told CNA's V18, V23, V24, and V26 that the shower chairs are in poor repair, stop abruptly, and the chairs jerks you forward. On July 9, 2024, at 9:02 AM, V9 (CNA) stated she has been working at the facility for 3 years. V9 stated the shower chairs are hard to move. They lock on their own while you are pushing them. V9 stated it is hard to get over the metal strips with the residents in the shower chairs. V9 stated when you go over the strips, with residents in the shower chair, the chairs tilt. V9 stated You have to push slowly so they don't tilt over. Observed 3 shower chairs 2 with PVC pipe and one gray metal one to be hard to push and pull with the locks on or off. They were very stiff with brown substance around the wheels. On July 9, 2024, at 2:12 PM, V10 (CNA) stated, the day of the incident, he lifted R24 into a shower chair with a whole-body mechanical lift, then proceeded to wheel R24 to the shower room. V10 stated when the chair reached the metal transition strip on the floor, the chair abruptly stopped and tipped forward. V10 stated he is not sure if it was the wheels that locked, the shower chair got caught on something, or her feet were dangling that caused the shower chair to stop and tip forward. V10 stated the transitions where higher at the time of the accident. V10 stated the chair he used to transport R24, is no longer in the facility. V10 stated, the shower chair was made of PVC pipe with a gray seat and a foot stand that was not movable but part of the chair. V10 stated some of the chairs stop abruptly and are hard to push. V9 stated there were no straps on the chair to hold the resident. On July 9, 2024, at 2:49 PM, V2 (Director of Nursing, DON) stated it could be multiple factors that caused R24 accident. V2 stated that it could have been that the resident's feet could have stopped the chair, the chair could have locked, and there may have been a problem with transition strip on the floor. V2 stated they ordered new chairs, pounded the metal strips down, and took the particular chair out of circulation and trashed it. V2 stated that the best practice for transporting residents to the shower room is to transfer them from bed to wheelchair, use the wheelchair to wheel the resident to the shower room, and then transfer the resident back to wheelchair before transporting the resident back to their room. On July 11, 2024, at 8:53 AM, V22 (Occupational Therapist) stated transporting residents in a shower chair would not be safe if the chair abruptly stopped or tilted while resident is in it. R24's Hospital imaging report dated June 13, 2024, showed fractures to her left tibia and fibula and her right femur. The facility's provided manufacture's owner's manual for the shower chairs and it shows the following: Do not use device if it appears wobbly or unstable, the casters are rusted or fail to move easily, the fabric appears torn or weak, cracks are observed in the fittings, or the device appears to be compromised in anyway. If you suspect a device is not functioning as intended, do not use device, and contact your distributor for assistance. Do not abruptly turn or stop the device. Do not abruptly turn or stop the device.

Based on observation, interview and record review, the facility failed to puree foods to a smooth consistency. This applies to 6 of 6 residents (R1, R56, R66, R68, R99 and R406) reviewed for pureed diets. The findings include: On July 8, 2024 at 12:30 PM, R66 was sitting in wheelchair and eating her lunch in her room. R66's meal ticket, dated 7/8/24, showed R66 was to receive a pureed diet including a serving of pureed beef top round roast beef. The pureed beef on R66's meal plate looked very lumpy with solid particles of beef visible in the serving. On July 8, 2024 at 12:34 PM in R66's room during lunch, V21 (Food Service Director) observed R66's pureed beef and stated it appeared to need more thickener. On July 8, 2024 at 12:38 PM in the kitchen after lunch service, V21 tasted the leftover pureed beef from the steam table line that was served to the pureed residents. V21 stated the pureed beef was not completely pureed and should be pureed further. The pureed beef tasted lumpy and had a large amount of small pieces of unpureed beef that required some chewing. On July 10, 2024 at 11:52 AM, V21 stated the pureed foods should be a smooth consistency with no solid particles. Facility Diet Census, dated July 8, 2024, shows R1, R56, R66, R68 and R99 and R406 all receive pureed diets at the facility. Facility policy Kitchen, reviewed June 6, 2024, shows, During pureed preparation, as the consistency of the pureed food changes with how the food is cooked the cook may add thickener to the food items being pureed, until the right consistency (pudding or mashed potato consistency) is reached. Meal Tray ticket, dated July 8, 2024, shows R66 was served pureed beef top round roast beef.

Based on interview and record review, the facility failed to document and promptly resolve resident's stated concerns. This applies to 5 of 5 residents (R29, R43, R85, R38 and R24) reviewed for grievances in the sample of 26. The findings include: 1.During the resident meeting on July 9, 2024, at 1:00 PM, V11 (Ombudsman) asked the resident group if residents' prior concerns had been resolved. R29 (RCP-Resident Council President) stated the previous concern raised regarding R1(confused peer) wandering into other resident's rooms had not been resolved. R43 (resident who regularly attends resident council) stated R1 continues to wander into other resident's rooms after his visitors leave. R43 stated R1 will cuss at other residents if residents tell R1 to leave their room and some residents will cuss at R1 when he tries to enter their rooms. R85 and R38 (residents who regularly attend resident council meetings) also agreed R1 continues to wander into other resident's rooms remains a concern that has not changed since initially brought up in the May 20, 2024, Resident Council Meeting. The Resident Council Meeting Minutes dated May 20, 2024, showed under New Business, showed Resident requesting another resident does not go into their room and staff asked Ombudsman questions on how to respond if a resident is swearing at staff, other residents in the hallway, and discussed swearing at staff and residents. The scribe listed on the meeting minutes was staff member, V12 (Activity Director). On July 10, 2024, at 9:21 AM, V12 stated she does attend the Resident Council Meeting and takes the meeting minutes and stated the resident who wanders into other residents' room was identified as R1. V12 stated she did not create a concern form for the resident's concern regarding R1. On July 10, 2024, at 9:41 AM, V1 (Administrator) stated she was aware of the resident's concerns regarding R1 wandering into other resident's rooms. V1 stated the expectation for staff is to complete the grievance form when a resident raises a concern or a grievance. V1 stated that R1 was placed on 1:1 monitoring on July 9, 2024, in the afternoon after the surveyor made the facility aware of the continued concerns regarding R1, from the resident meeting. 2.On July 8, 2024, at 10:36 AM, R24 stated she had been complaining about the condition of the shower chairs for the last two and one-half years. R24 stated she had complained about the poor condition of the shower chairs, that they stop abruptly, and the chair jerks forward. R24 stated she reported the shower chair concerns to V18 (CNA- Certified Nursing Assistant), V23 (CNA), V24, (CNA) and V26 (CNA). A review of the facility concern/response/compliment forms, provided by the facility, from January 1, 2024, through July 4, 2024, showed there were no concern forms generated on behalf of R1 and R24 during that time frame. The facility's grievance policy revised June 6, 2024, showed 3. The notification will include the name, address, and phone number, of the grievance official, a reasonable time frame to investigate the grievance, and the resident's right to obtain a written copy of the grievance investigation if requested .5. During the investigation the facility will put in place immediate action to prevent potential violation of resident's rights .7. All written grievance decisions will include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance and the date the written decision was issued.

Based on interview and record review, the facility failed to obtain resident weights in accordance with physician orders. This applies to 5 of 5 residents (R21, R60, R14, R37, R61) reviewed for weight documentation in the sample of 26. The findings include: 1.R21 was admitted to the facility on [DATE], with multiple diagnoses including, heart failure unspecified, atrial fibrillation, chronic kidney disease stage 3, and type 2 diabetes according to R21's face sheet. R21's physician order summary showed an order initiated on May 28, 2024, to obtain daily weights (on the same scale)-record weight and scale if weight differences is 2 pounds from prior day, reweigh and document every day shift. R21's weight record showed R21 was weighed on May 29, 2024, June 10, 2024, June 18, 2024, and June 26, 2024, and July 6, 2024. There were no daily weights documented. The record showed the weights as follows: May 29, 2024, 262 lbs.(pounds) (Mechanical Lift) June 10, 2024, 255.2 lbs. (Mechanical Lift) June 18, 2024, 258 lbs. (Mechanical Lift June 26, 2024, 254.2 lbs. (Mechanical Lift) July 06, 2024, 260.2 lbs. (Mechanical Lift) R21's care plan for fluid retention/overload initiated on May 16, 2024, intervention included weight will be obtained as ordered by the MD and Monitor/record/report to MD PRN (as needed) situations leading to increased food consumption, reasons for weight gain, significant wt changes. 2.R60 was admitted to the facility on [DATE], with multiple diagnoses including chronic venous hypertension with ulcer of bilateral lower extremity, lymphedema, type 2 diabetes, and chronic diastolic congestive heart failure according to R60's face sheet. R60's physician order summary showed an order for daily weight initiated on June 13, 2024. R60's weight and vital record showed weights were documented on June 15, 2024, June 18, 2024, July 5, 2024, July 9, 2024, and July 10, 2024. R60's weights were not documented daily as ordered. R60's care plan for CHF (Congestive Heart Failure), lymphedema, and diuretic use dated June 23, 2023, interventions showed weight will be obtained as ordered by MD. 45303 3. R14's EMR (Electronic Medical Record) showed R14 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, dysphagia, dementia, and clostridium difficile. R14's nutrition care plan dated May 13, 2024, showed, [R14] is at risk for alteration in nutritional status related to Parkinson's, Urinary Tract Infection, clostridium difficile, atrial fibrillation, hypothyroidism, ulcerative pancolitis, altered mental status, dementia, anxiety, depression, type 2 diabetes mellitus, hyperlipidemia, and hypertension. The care plan continued to show multiple interventions dated May 13, 2024, including Obtain weight as ordered. R14's Order Listing Report dated July 10, 2024, showed an order dated May 8, 2024, for Weight Daily, every day shift for monitoring. R14's May MAR (Medication Administration Record) showed R14 was not weighed or refused to be weighed on seven days. R14's June MAR showed R14 was not weighed or refused to be weighed on 12 days. R14's July MAR showed R14 was not weighed on three days. 4. R37's EMR showed R37 was admitted to the facility on [DATE], with multiple diagnoses including spinal fracture, dysphagia, hypertension, and chronic obstructive pulmonary disease. R37's nutrition care plan dated June 7, 2024, showed, [R37] is at risk for alteration in nutritional status related to: depression, hypertension, type 2 diabetes mellitus, arthritis, chronic obstructive pulmonary disease, recent surgical procedure, recent decrease in appetite, obesity. The care plan continued to show multiple interventions dated June 7, 2024, including Obtain weight as ordered. R37's Order Listing Report dated July 10, 2024, showed, an order dated June 6, 2024, for Weight upon admission/readmission, weekly times four, then monthly, every day shift every seven days for 28 days weekly times four. R37's June 2024 Monitoring Record showed R37 was not weighed or refused to be weighed weekly on June 13, June 20, and June 27, 2024. 5. R61's EMR showed R61 was admitted to the facility on [DATE], with multiple diagnoses including stroke, pneumonia, hypertension, and congestive heart failure. R61's nutrition care plan dated July 1, 2024, showed [R6] is at risk for alteration in nutritional status related to type 2 diabetes mellitus, traumatic brain injury, history of craniectomy, hemiplegia, history of dysphagia, vitamin D deficiency, congestive heart failure, hyperlipidemia, hypertension, anxiety. The care plan continued to show multiple interventions dated October 18, 2023, including Obtain weight as ordered. R61's Order Listing Report dated July 10, 2024, showed an order dated June 27, 2024, for Daily weights, every day shift for congestive heart failure. R61's June 2024 MAR showed R61 was not weighed or refused to be weighed on June 27, June 28, and June 29, 2024. R61's July 2024 MAR showed R61 was not weighed or refused to be weighed on July 2, July 3, and July 6, 2024. On July 10, 2024, at 11:55 AM, V2 (DON/Director of Nursing) said resident weights should be obtained as ordered by the physician. V2 continued to say it is the expectation of facility staff to follow the physician's order and document in the medical record if a resident refused to be weighed. The facility's policy titled Weights revised on June 6, 2024, showed Policy Statement: It is the facility's policy to obtain resident's monthly weight unless otherwise ordered differently by the physician. For a resident who is on dialysis, the resident's dry weight will be also obtained monthly .

Based on interview and record review, the facility failed to obtain treatment orders for a newly admitted resident with pressure ulcers. This applies to 1 of 3 residents (R256) reviewed for pressure ulcers in the sample of 26. The findings include: R256's EMR (Electronic Medical Record) showed R256 was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy, pressure ulcer of right buttock, pressure ulcer of left buttock, pressure ulcer of right heel, chronic kidney disease, and urinary tract infection. R256's MDS (Minimum Data Set) dated July 4, 2024, showed R256 had moderate cognitive impairment. The MDS continued to show R256 had two stage three pressure ulcers, two unstageable pressure ulcers, and one deep tissue pressure injury present on admission to the facility. On July 8, 2024, at 10:33 AM, R256 said she has wounds on her buttocks. On July 10, 2024, at 9:44 AM, V28 (Wound Care Nurse) said R256 was admitted to the facility on [DATE], with multiple pressure ulcers. V28 continued to say she saw R256 on July 1, 2024, and assessed R256's pressure ulcers and received treatment orders for R256's pressure ulcers. V28 said before July 1, 2024, R256 did not have any orders for treatment for her pressure ulcers and V28 does not see documentation of R256 receiving pressure ulcer treatment from facility staff. V28 said upon admission to the facility, the admitting nurse should notify the physician if the resident has pressure ulcers to receive treatment orders. On July 10, 2024, at 11:08 AM, V2 (DON/Director of Nursing) said when a resident is admitted to the facility, the nurse should assess the residents, specifically for wounds. V2 continued to say as soon as the nurse identifies a pressure ulcer, the nurse should notify the physician for treatment orders and enter the orders into the medical record. V2 said R256's admitting nurse should have entered treatment orders for R256's pressure ulcers. V2 said facility staff are expected to document pressure ulcer treatments. On July 10, 2024, at 11:14 AM, V16 (Regional Nurse Consultant) said the nurse should enter treatment orders for pressure ulcers on admission. V16 continued to say if the treatment order is to leave the wound open to air, the nurse should enter that as an order in the medical record. R256's Order Summary Report dated July 11, 2024, showed the first treatment orders for R256's pressure ulcers was ordered on July 1, 2024. The facility does not have documentation to show R256 received pressure ulcer treatment on June 28, June 29, and June 30, 2024. The facility's policy titled Wound Care Guidelines revised on January 24, 2024, showed, .10. Pressure Injuries Treatment: a. Initiate wound care treatment upon identification of the wound with physician's order .

Based on observation, interview, and record review the facility failed to provide indwelling catheter care in a manner that would prevent infection. The facility also failed to ensure indwelling urinary catheter is kept secured to prevent from pulling and tugging and prevent catheter related skin trauma. This applies to 3 of 5 residents (R1, R70 and R86) reviewed for indwelling catheter care in the sample of 26. The Findings include: 1. R1, a [AGE] year-old with diagnoses of hemiplegia and hemiparesis; lack of coordination; flexion deformity, UTI (urinary tract infection), presence of urogenital implant and epilepsy. R1 was admitted to the facility on [DATE]. On July 08, 2024, at 10:00 A.M, R1 was sitting in his wheelchair by the hallway next to the shower room R1 was with V18 (CNA-Certified Nursing Assistant). V18 was observed placing R1's indwelling catheter tubing and drainage bag to the other side of R1's wheelchair arm rest. R1 was indwelling catheter tubing was cloudy with yellowish sediments and the tubing and drainage bag was discolored with bluish color. On July 08, 2024 at 2:24 P.M. R1 was sitting in his wheelchair by the 300 nurse's station. R1's still with same condition regarding his indwelling catheter with urine being cloudy and with yellow sediments. On July 09, 2024, at 1:30 P.M., R1 was sitting in his wheelchair by the lounge area. R1's indwelling catheter still with cloudy sediments in the tubing. On July 10,2024 at 9:35 A.M., R1 was sitting in his wheelchair in his room. V15 (CNA) was providing a 1:1 supervision to R1. V15 was repositioning R1. The indwelling catheter was still with cloudy urine and with sediments in the tubing. The care plan dated June 6,2024 showed interventions for the indwelling catheter to prevent infection and catheter-related skin trauma. The intervention included but not limited to catheter care every shift and as needed, change indwelling catheter drainage bag as needed, change the indwelling catheter per facility's protocol or physician order. 2. R70, a [AGE] year-old with diagnoses of Parkinson's' disease, urine retention, UTI, obstructive and reflux uropathy. R70 was admitted to the facility on [DATE]. On July 8, 2024, at 11:53 A.M., R70 was lying in bed. R70 was observed with an indwelling catheter. The urine in the indwelling catheter tubing was cloudy and noted with yellowish sediments. On July 9,2024 at 12:45 P.M., R70 was lying in bed. R70 noted with same condition of the indwelling catheter that had the cloudy urine with sediments. On July 10, 2024 at 9:23 A.M, R70, was in bed. R70's cloudy urine with sediments was pointed to V14 (RN/Registered Nurse). V14 said that she would have to call the physician to either change the entire catheter or just change the tubing or irrigate the tubing first, but something needs to be done due to the cloudiness of the urine and clumps of sediments. The care plan dated July 2,2024 showed interventions for R70's indwelling catheter that included but not limited to R70's potential for infection related to indwelling catheter and that assessment for signs and symptoms of infection and catheter care every shift and as needed were to be implemented. 3. R86, an [AGE] year-old with diagnoses that included ventricular tachycardia, protein-calorie malnutrition, dementia, obstructive and reflux neuropathy, diabetes mellitus type 2, chronic kidney disease, and benign prostatic hyperplasia. On July 8, 2024, at 2:08 P.M., R86 was lying in bed. R86 was noted with an indwelling catheter. The urine in the catheter tubing was cloudy and full of sediments. On July 10,2024 at 9:25 A.M., together with V14 (RN/Registered Nurse), R86's indwelling catheter was checked. R86 was noted to try playing/pulling the catheter tubing. There was no device to secure the tubing in place. V14 said she will apply an anchor device to ensure that indwelling catheter will be secured and not be pulled or tugged and prevent catheter related trauma. R86 was also noted with cloudy urine full of sediments. V14 said that she will call the physician and the catheter need to be irrigated or change the indwelling catheter. The care plan October 18,2023 showed interventions for R86's indwelling catheter that included but not limited to R86's potential for infection related to indwelling catheter and that assessment for signs and symptoms of infection and catheter care every shift and as needed were to be implemented. On July 10, 2024 at 11:30 A.M., V2 (DON/Director of Nursing) said that if the indwelling catheter tubing was cloudy with sediments, then an irrigation of the tubing was indicated and calling the physician for further interventions. V2 also said that irrigation was indicated to ensure patency of urine flow and prevent UTI. V2 said that the indwelling catheter tubing should be secured with an anchor device to prevent the indwelling catheter from being pulled or tugged and prevent catheter related trauma. On July 10, 2024, at 11:50 A.M., V16 (Nurse Consultant) said that she will discuss with corporate to revise policy to ensure there was a secured device for the indwelling catheter to prevent pulling and tugging. The facility's policy and procedure dated June 6, 2024, and titled Urinary Catheter Care showed Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction.Secure catheter . The facility's policy for indwelling catheter dated January 5, 2026 showed an indwelling catheter maybe changed as needed.

Based on interview and record review the facility failed to ensure incontinence care was provided per a resident's request for 1 of 4 residents (R10) reviewed for incontinence care in the sample of 10. The findings include: R10's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include radiculopathy of the sacral and sacrococcygeal region, rash and other nonspecific skin eruption, atherosclerotic heart disease, morbid obesity, major depressive disorder, chronic pain, and candidiasis. R10's facility assessment dated [DATE] showed she has no cognitive impairment. R10's care plan initiated 10/9/19 showed, [R10] displays frequent bladder incontinence related to medication side effects . [R10] will remain free from skin breakdown due to incontinence and brief use through next review . Incontinence: I would like the staff to check me for incontinence episode every two hours and as needed. I would also need assistance to wash, rinse, and dry my perineum . R10's care plan initiated 12/10/19 showed, [R10] requires assistance with ADLs (activities of daily living) (bed mobility, transfers, dressing . personal hygiene .toileting . [R10] will be assisted with ADL's as needed . R10's care plan initiated 11/29/20 showed, [R10] has potential for impairment to skin integrity related to . braden (skin breakdown risk assessment) score of 13 (high risk) . [R10] will be free from any redness, blisters, or discoloration to skin through next review date . [R10] is assisted by staff to keep skin clean and dry . R10's 12/12/23 NP (Nurse Practitioner) visit note showed, . Still has groin/pannus (lower abdominal above the pubis area) rash that is improving but itches at times . Urinary Incontinence: Continue meticulous hygiene . On 12/16/23 at 1:28 PM, V10 was sitting in her wheelchair in her room. R10 said she has difficulty when some of the agency staff are working. R10 said on 12/15/23 she put her call light on due to being incontinent and needing her brief changed. R10 said her call light was not answered until about 10:15 PM when the next shift came in. R10 said she has been having problems with being sore, itchy, and needing creams for her skin due to being in wet incontinence briefs for extended periods of time. On 12/16/23 at 2:15 PM, V6 RN (Registered Nurse) said incontinence briefs should be changed as needed to prevent the resident from experiencing moisture and burning. On 12/16/23 at 3:36 PM, V7 RN (Registered Nurse) said incontinence care should be provided at least every two hours and as needed to prevent skin breakdown and urinary tract infections. The facility's policy and procedure titled Incontinent and Perineal Care showed, . Policy Statement: It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition .

Based on observation, interview and record review, the facility failed to ensure that R10 was free from physical, mental, and emotional abuse from an agency staff, V15 (CNA/Certified Nurse Assistant). The facility also failed to implement its policy to keep R10 free from further abuse. This failure resulted in Immediate Jeopardy on 11/5/2023 at 9:00 A.M., when R10 had sustained physical, emotional harm and mental distress from abusive care provided by V15. The facility also failed to implement their abuse policy by not reporting and investigating V15's inappropriate behavior such as yanking resident's bed rail, abrupt with care, ignoring call lights, that had occurred on 11/1/2023, and this had led to physical abuse on 11/5/2023 when V15 jerked R10's arm. The facility also failed to protect other residents from potential abuse when V15 was not suspended from work after the incident with R10. V1 (Administrator), V2 (Director of Nursing) and V28 (Vice President of Operations) were notified of the immediate jeopardy on 11/27/2023 12:15 P.M. The surveyor confirmed by observation, interview, and record review that immediate jeopardy was removed on 11/29/2023 at 12:40 P.M., but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. This applies to one of three residents (R10) reviewed for injuries of unknown origin and abuse. The findings include: The EMR (Electronic Medical Record) showed that R10, an [AGE] year-old, was admitted to the facility on [DATE]. R10's diagnoses included but not limited to atrial fibrillation, thrombocytopenia, S/P (status post) CABG (coronary artery bypass graft), history of DVT (deep vein thrombosis), iron deficiency anemia, myocardial infarction, obsessive-compulsive disorder, CAD (coronary artery disease), anxiety and depression. The MDS (Minimum Data Set) dated 9/21/2023 showed that R10 was moderately impaired in cognition with BIMS (Brief Interview Mental Status) and score of 12/15. R10's functional status showed she required one-person physical assistance with ADLs (Activities of Daily Living). The MDS showed that R10 was not delusional, no psychosis, no negative behavior and was not rejecting care. The care plan dated 9/21/2023 showed that R10 had no negative behavior such as being hostile, aggressive and or combative. The progress notes dated 11/7/2023 at 6:00 P.M. documents Bruising noted to left inner forearm from base of wrist to elbow and on left bicep area. Head to toe assessment done .Family member made aware (R1's MD) made aware. Order given to obtain x-ray to left arm and PT/INR in morning 11/8/23. Review further of the progress notes showed that last documentation of the progress notes before 11/7/2023 was 11/2/2023. The documentation for 11/2/2023 was related to medication order. The EMR/progress notes showed that there was no documentation regarding the bruise not until 11/7/2023. The facility's incident report dated 11/7/2023 at 4:57 P.M. showed there was an allegation of resident abuse that occurred 11/5/2023. The resident referred to was R10 and V15 (CNA/Certified Nurse Assistant) as the perpetuator. The incident report showed that on a 11/7/2023 at around 4:00 P.M., V25 (Transportation Coordinator/Unit Clerk) reported that R10 had stated that (V15) was rough during patient care. On 11/8/2023 at 10:30 A.M., together with V2 (Director of Nursing), R10 was observed and interviewed. R10 was alert and oriented and had responded to questions coherently. R10 was aware of time, name and place and current events. R10 showed her left arm. R10's left forearm was observed with a bruise that extended from her wrist to the elbow, the bruise was irregular in shape, the color was dark purple/blue. There was no other visible bruise noted on R10's extremities. R10 said this bruise was caused by rough handling from (V15, CNA from staffing agency), I was pulled from my left arm by (V15) with force on 11/5/2023 around 9:00 A.M. I thought (V15) was not to take care of me because of an incident that occurred on 11/1/2023 when (V15) took care of me during the evening shift. (V15) had a nasty attitude, very abrupt when she talked, no respect, and she broke and yanked my bed rail. R10 pointed her bed's left upper rail that was tied with a rope. R10 said I told everyone (staff) I don't remember each of their names but told (V19/nurse) since he runs the ship regarding (V15) not to return to facility anymore because she had handled me roughly, with nasty attitude, and (V15) even said she doesn't care, she can be assigned anywhere because she is from staffing agency. R10 continued to state that on 11/5/2023, (V15) came in early morning, with nasty attitude like she does not want to be at work, verbally abrupt when questions were asked, or she does not answer at all, and will not listen to my request that I wear a blue color brief and not yellow and (V15) insisted on putting the yellow brief. I am scared of her (V15) and I do not want her to take care of me. R10 said she called V20 (Receptionist on Duty) in the morning of 11/5/2023 that V15 should not be assigned to her because V15 was rough handling her and R10 might get hurt. However, R10 said that she was told by V20 that she will inform V21 (RN/MOD/Manager of the Day) when she comes in that day. R10 continued to state that (V15) pulled my left arm with force when she was getting me out of bed, I felt the pain, then few hours later, I saw this big bruise on my left forearm. (V21) came in around 9:30 A.M. and she acted like she was a MEDIATOR and advised me to say PLEASE when asking for care. (V15) continued to give me care, and other residents (R4, R6, R14) and they saw me how upset I was because they also complained how (V15) treated them. I know (V15) did hurt me intentionally because she jerked my arm. On 11/8/2023 at 2:00 P.M., R10 was sitting in the activity department and was interviewed again about the incident involving V15. R10 repeated the same account of events as stated during the earlier interview. During this time of interview, V23 (Police Officer) came in and said he had to ask R10 for few more questions. R10 had agreed. V23 said he saw R10 the day before (11/7/2023) for initial investigation of physical abuse by V15. V23 and R10 gave permission for the surveyor to stay during V23's interview. R10 was consistent with her statement stating that V15 had rough handled her during care in the morning of 11/5/2023. After the interview, R10 was assisted back by a staff to the activity department and R10 was seen sobbing, tears flowing down her cheeks, was shaking, and said, I am scared of (V15) she might come back again, and I do not want other residents to go through what I have been through with her (V15). During this time R10 was noted to be shaken and other residents came to comfort her. R12 was holding R10's hands continuously consoling her, R8, R13 and R14 also tried to console R10. V2 then removed R10 from activity room and once again, R10 stated, I want to make sure (V15) she will not take care of me again. R10 was noted to keep asking V2 who would take care of her and that she did not want V15 to provide care since she was afraid of V15. The following residents were assigned to V15 on 11/5/2023 during the day shift. They were interviewed on 11/8/2023 from 11:00 A.M. to 2:30 P.M. at an intermittent time: R14 said I filed a grievance on 11/5/2023 regarding (V15's) that she has bad attitude causing us mental and emotional distress, but up to now, I have not heard from the management. (V15) told me on 11/5/2023 I am not your CNA, I cannot take care of you, you are so fat. R14 also said that she needs help with transfers and uses a mechanical transfer lift device. R14 also said that she was incontinent of bladder function and that V15 refused to change her incontinence brief and that R14 wore the soaked brief at least 5-6 hours. R4 said she requested V15 to pick up condiments that was dropped off from her lunch tray on 11/5/2023. R4 said that V15 responded I am not your C.N.A. R4 said (V15) then left the room and does not care at all. On 11/8/2023 at 4:52 P.M., V20 (Receptionist) said that on 11/5/2023 at around 9:00 A.M., R10 called her via phone and informed that V15 was rough handling her. V20 also said that she that she could tell from R10's voice that R10 was upset. V20 added that R10 was crying and stating that V15 was rough with her and had a nasty attitude. V20 said she told R10 that she will inform V21 as soon as she arrives at the facility since V21 was the assigned MOD (manager on duty) for the day. On 11/8/2023 at 4:30 P.M., V21 (RN/Registered Nurse) said that when she arrived at the facility on 11/5/2023 at around 9:30 A.M., she was informed by V20 that R10 was upset due to V15 being rough with care and with a bad attitude. V21 said she went to R10's room around 9:45 A.M. V20 said she saw R10 lying in bed, and V15 pulling up R10's pants. V21 said I can tell that there was an argument between the two, I saw R10 crying and visibly upset. I helped (V15) get (R10) up and stayed with (R10) for a while since she was crying. Surveyor asked V21 what the argument was, and the reason of R10 being upset and crying. Surveyor also asked if it makes sense for V15 to pull up R10's pants if V15 can do it while R10 was standing up. V21 had no explanation or answer what the argument was and why R10 was upset. V21 said she did not remove V15 from work and V15 continued to work until the end of the shift (10:00PM). V21 also said she did not report this incident to the administrator, nor had she initiated an investigation for potential abuse. On 11/8/2023 at 3:45 P.M., V19 (Nurse) said R10 had informed him regarding V15 that she has a nasty attitude and that V15 broke R10's bed rail on 11/1/2023. V19 added that he saw the bed rail on the floor and was detached from R10's bed on 11/1/2023 evening shift. V19 also said that he also worked on 11/5/2023 and that V15 had ignored residents' call lights and will not answer for 35 minutes. V19 showed to surveyor a monitor screen that showed V15 had not responded to residents' call light for 35 minutes. V19 said that V15 had bad attitude, abrupt, not motivated to work. V19 added that she had texted V16 (staffing scheduler) on 11/5/2023 for V15 not to return to facility since V15 was from staffing agency. On 11/11/2023 at 8:30 A.M., V16 (staffing scheduler) had validated that V15 had worked double shift (6:00 A.M. through 10:00 P.M.) on 11/5/2023. V16 also confirmed that V15 took care of R10 on 11/1/2023 for the evening shift and morning shift on 11/5/2023. On 11/8/2023, at 3:00 P.M., V1 (Administrator) said she was only informed regarding alleged physical abuse by V15 towards R10 by V25 (Transportation Coordinator) on 11/7/2023 at 4:00 P.M. On 11/27/2023 at 10:30 A.M., V20 was asked again regarding the phone call that she had received from R10 on 11/5/2023 in the morning. V20 had verbalized the same statement when first interviewed on 11/8/2023. V20 said R10 called around 9:00 A.M. on 11/5/2023, and that R10 said she does not want V15 to take care of her because V15 was rude, and rough when handling R10. V15 also said that R10 was crying and upset. V20 said she told R10 that she will inform V21 as soon as she arrives at the facility. V20 said that she had reported this to V21 as soon as V21 arrived at the facility around 9:30 A.M. V20 added that she had not received abuse training provided by the facility when asked on 11/28/2023. On 11/27/2023 at 2:35 P.M., V21 was again interviewed. V21 had said that V15 has bad attitude/loud talking to residents and that she had reported this to V2 on 11/8/2023. When asked to verify the date, since facility had in initiated the abuse allegation investigation on 11/7/2023 due to a report made by V25 to V1, V21 responded oh, I must have reported on 11/5/2023 to (V2). On 11/27/2023 at 3:00 P.M., V1 and V2 were asked about V21's statement that she had reported to V2 regarding V15's bad attitude/loud talking to residents. V1 answered that (V2) would have reported to me immediately if (V21) had reported this to him (V2). V2 said that V21 had never mentioned anything regarding V15's inappropriate behavior, bad attitude /loud talking to residents. V2 added that he would have reported this to V1 immediately if V21 had informed him. V1 said she only found out the abuse allegation by R10 towards V15 when V25 had reported to her on 11/7/2023. On 11/27/2023 at 11:30 A.M., V25 (Unit Secretary/Transportation Clerk) said that on 11/7/2023 around 4:00 P.M., R10 had informed her that on 11/5/2023 during the morning care, V15 had roughly handled her, grabbed her left arm with force that had caused a huge bruise from the wrist all around the elbow. V25 said she immediately informed nurse supervisor and they both informed V1 on 11/7/2023 at around 4:00 P.M. regarding the allegation of physical abuse by V15 towards R10. On 11/27/2023 from 4:30 P.M. to 5:30 P.M., at an intermittent time, the following residents were interviewed again. V2 was present during the interview except with R8: R14, lying in bed in her room. R14 said I remember you; you are the investigator from the state. I tell you, other staff here are nice, but no way in H*LL that (V15) should come back here nor work in a facility where residents are subjected to abuse. (V15's) licensed to work in a nursing home should be removed, she has a nasty behavior, does not provide care, ignore our needs, have to wait 5-6 hours before our brief be changed, told me to find another nurse or CNA to care for me because I am F*T. (V15) gave me so much aggravation that she is a bully to us, she does whatever she wants and does not listen to our needs. I don't want her here and I hope she goes to jail. R4, sitting in her chair in her room. R4 said that V15 ignored their needs, she waited prolong hours for her meal and when it was given to her, the food was cold. R4 also said that (V15) does her own thing, and she does not care to attend to our needs because she said she works from agency, and she can go anywhere. R8, requested that V2 not present during the interview. R8 said that (V15) was no good, bad attitude, and intimidating. I am a big man, but she was also a big woman, and with her bad attitude she was a bully. The way she (V15) talks to us, and her approach was bad. The staff knows how she was (V15), but she came back and had worked again here. R10, sitting in her wheelchair in her room. R10 said she remember the surveyor. R10 said so many people were asking me about this abuse, I am already overwhelmed with questions. The main issue here was that (V15) had jerked my arm, grabbed me roughly (pointed her left arm), and she should have not come back here when she did this to me Sunday (11/5/2023). (V15) was here before that (Wednesday) and broke by bed rail. I told the staff, showed to (V19/Nurse) that my bed rail on the floor because (V15) broke it. I was seen by a shrink because of this but was not seen by the social worker. On 11/29/2023 at 10:30 A.M., R10 was in her room. R10 was sitting in her wheelchair. R10 said her left arm was still sore from being jerked and grabbed by (V15). She should be in jail; I would like to pursue criminal charges against her (V15). Review of the police report dated 11/7/2023 showed that V15 was charged for aggravated battery and warrant of detention was processed. The facility's abuse policy dated 7/14/2023 showed It is the facility's policy to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and through investigations of allegations Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm maybe considered abuse. Types of abuse: 1. Physical 2. Verbal 3. Mental 9. Injury of unknown origin Prevention of abuse: Identify, correct, and intervene in situations in which abuse, neglect .is more likely to occur .Establish a safe environment Supervision of staff to identify inappropriate behaviors, such as derogatory language, rough handling, ignoring residents while giving care .Employee accused must be suspended pending investigation . Reporting . must be reported to the administrator immediately . The Immediate Jeopardy that began on 11/5/2023 at 9:00 A.M. was removed on 11/29/2023 at 12:40 P.M. when the facility took the following actions to remove the immediacy: 1) R10 remains in the facility in stable condition. 2) R10 was seen by a psychotherapist on 11/9/23, and wellness checks by the social services department have been ongoing from 11/9/23 and will continue 3x/week for 30 days. 3) V15 agency CNA was removed and placed on the do not return list on 11/7/23 and has not returned to the facility since. 4) On 11/27/23, Administrator notified [NAME] Agency that V15 was asked not to return due to an abuse allegation that IDPH has substantiated. 5) V15's background check was obtained from [NAME] agency and is clear. 6) On 11/27/23, the facility re-opened the abuse allegation related to R10 due to new information available. This investigation is ongoing and will be concluded in five business days. 7) All new agency staff will be provided onboarding training (facilities policies and procedures including Abuse) prior to the start of their shift by the DON or designee. Any new agency staff scheduled to start on off hours (weekend or night shift), the nurse in charge at the time will provide the onboarding training. Compliance will be audited 3x/week for the first month and reviewed weekly for compliance and a plan will be reviewed and discussed until compliance. 8) The facility has contracts with agencies, and it is the agency's responsibility to conduct background checks in accordance with the Illinois regulations. The facility will make every effort to obtain a copy of the background checks for agency employees prior to the start of their shift, if the facility is unable to obtain the background check prior to the start of the shift, then the facility will obtain the background check at its earliest possible time. 9) Staff were re-educated on the facility Abuse and Neglect policy by the Administrator and/or designee on 11/15/23. This re-education will continue and be completed by 11/28/23. Return demonstration of understanding provided by way conducting an audit questionnaire. Re-education emphasis on identifying staff behaviors such as being rude & rough during care AND reporting abuse immediately to the Administrator. if any resident would present signs of crying, anxiety and any form of mental distress, to provide comfort and re-assurance and to immediately report it to Abuse coordinator. Staff will be re-educated prior to their next shift. Agency staff will be re-educated prior to start of their shifts also by the DON (Director of Nursing) or designee. Compliance will be audited 3x/week for the first month and reviewed weekly for compliance and a plan will be reviewed and discussed until compliance. 10) Facility will request abuse training proof showing that agency staff have been educated on the facility's abuse policy and procedure. The facility abuse education materials will be sent to the contracted agencies. This will start on 11/28/23 and anticipated completion is 11/28/23. 11) Residents who are alert and oriented were also re-educated on the facility's abuse policy and procedures and provided reassurance of their safety, and comfort to be able to verbalize any abuse related concerns to staff immediately on 11/27/23, this is ongoing and will be completed by 11/27/23. 12) All residents that V15 took care from 11-1-23 to 11-7-23, an audit will be conducted to ensure abuse did not occur with anyone else. This was completed on 11/27/23 and there were no reports of abuse. 13) Quality assurance audit will be conducted daily by the Administrator and/or designee to ensure staff are identifying any abuse and reporting it timely. This will start on 11/27/23 and continue for the first month. All identified trends will be reviewed by the monthly QAPI committee, and a plan will be discussed and implemented until resolution. 14) The incident and abatement plan will be discussed and reviewed with the facility medical director on 11/28/23 at 3pm. 15) Emergency QAPI meeting was conducted on 11/27/23 at 4:45pm.

Based on observation, interview and record review, the facility failed to implement their abuse policy regarding immediate reporting and investigation of an alleged abuse. The delay in reporting and investigating meant that V15(CNA/Certified Nursing Assistant) staff continued to work after R10 made allegation of inappropriate behavior, yanking R10's bed rail and was abrupt with care. This failure resulted in R10 sustaining bruises, emotional harm and mental distress from abusive care provided by V15. This applies to one of three residents (R10) reviewed for injuries of unknown origin and abuse. The findings include: The EMR (Electronic Medical Record) showed that R10, an [AGE] year-old, was admitted to the facility on [DATE]. R10's diagnoses included but not limited to atrial fibrillation, thrombocytopenia, S/P (status post) CABG (coronary artery bypass graft), history of DVT (deep vein thrombosis), iron deficiency anemia, myocardial infarction, obsessive-compulsive disorder, CAD (coronary artery disease), anxiety and depression. The MDS (Minimum Data Set) dated 9/21/2023 showed that R10 was moderately impaired in cognition with BIMS (Brief Interview Mental Status) and score of 12/15. R10's functional status showed she required one-person physical assistance with ADLs (Activities of Daily Living). The MDS showed that R10 was not delusional, no psychosis, no negative behavior and was not rejecting care. The care plan dated 9/21/2023 showed that R10 had no negative behavior such as being hostile, aggressive and or combative. The progress notes dated 11/7/2023 at 6:00 P.M. documents Bruising noted to left inner forearm from base of wrist to elbow and on left bicep area. Head to toe assessment done .Family member made aware (R1's MD) made aware. Order given to obtain x-ray to left arm and PT/INR in morning 11/8/23. Review further of the progress notes showed that last documentation of the progress notes before 11/7/2023 was 11/2/2023. The documentation for 11/2/2023 was related to medication order. The EMR/progress notes showed that there was no documentation regarding the bruise not until 11/7/2023. The facility's incident report dated 11/7/2023 at 4:57 P.M. showed there was an allegation of resident abuse that occurred 11/5/2023. The resident referred to was R10 and V15 (CNA/Certified Nurse Assistant) as the perpetuator. The incident report showed that on a 11/7/2023 at around 4:00 P.M., V25 (Transportation Coordinator/Unit Clerk) reported that R10 had stated that (V15) was rough during patient care. On 11/8/2023 at 10:30 A.M., together with V2 (Director of Nursing), R10 was observed and interviewed. R10 was alert and oriented and had responded to questions coherently. R10 was aware of time, name and place and current events. R10 showed her left arm. R10's left forearm was observed with a bruise that extended from her wrist to the elbow, the bruise was irregular in shape, the color was dark purple/blue. There was no other visible bruise noted on R10's extremities. R10 said this bruise was caused by rough handling from (V15, CNA from staffing agency), I was pulled from my left arm by (V15) with force on 11/5/2023 around 9:00 A.M. I thought (V15) was not to take care of me because of an incident that occurred on 11/1/2023 when (V15) took care of me during the evening shift. (V15) had a nasty attitude, very abrupt when she talked, no respect, and she broke and yanked my bed rail. R10 pointed her bed's left upper rail that was tied with a rope. R10 said I told everyone (staff) I don't remember each of their names but told (V19/nurse) since he runs the ship regarding (V15) not to return to facility anymore because she had handled me roughly, with nasty attitude, and (V15) even said she doesn't care, she can be assigned anywhere because she is from staffing agency. R10 continued to state that on 11/5/2023, (V15) came in early morning, with nasty attitude like she does not want to be at work, verbally abrupt when questions were asked, or she does not answer at all, and will not listen to my request that I wear a blue color brief and not yellow and (V15) insisted on putting the yellow brief. I am scared of her (V15) and I do not want her to take care of me. R10 said she called V20 (Receptionist on Duty) in the morning of 11/5/2023 that V15 should not be assigned to her because V15 was rough handling her and R10 might get hurt. However, R10 said that she was told by V20 that she will inform V21 (RN/MOD/Manager of the Day) when she comes in that day. R10 continued to state that (V15) pulled my left arm with force when she was getting me out of bed, I felt the pain, then few hours later, I saw this big bruise on my left forearm. (V21) came in around 9:30 A.M. and she acted like she was a MEDIATOR and advised me to say PLEASE when asking for care. (V15) continued to give me care, and other residents (R4, R6, R14) and they saw me how upset I was because they also complained how (V15) treated them. I know (V15) did hurt me intentionally because she jerked my arm. On 11/8/2023 at 2:00 P.M., R10 was sitting in the activity department and was interviewed again about the incident involving V15. R10 repeated the same account of events as stated during the earlier interview. During this time of interview, V23 (Police Officer) came in and said he had to ask R10 for few more questions. R10 had agreed. V23 said he saw R10 the day before (11/7/2023) for initial investigation of physical abuse by V15. V23 and R10 gave permission for the surveyor to stay during V23's interview. R10 was consistent with her statement stating that V15 had rough handled her during care in the morning of 11/5/2023. After the interview, R10 was assisted back by a staff to the activity department and R10 was seen sobbing, tears flowing down her cheeks, was shaking, and said, I am scared of (V15) she might come back again, and I do not want other residents to go through what I have been through with her (V15). During this time R10 was noted to be shaken and other residents came to comfort her. R12 was holding R10's hands continuously consoling her, R8, R13 and R14 also tried to console R10. V2 then removed R10 from activity room and once again, R10 stated, I want to make sure (V15) she will not take care of me again. R10 was noted to keep asking V2 who would take care of her and that she did not want V15 to provide care since she was afraid of V15. The following residents were assigned to V15 on 11/5/2023 during the day shift. They were interviewed on 11/8/2023 from 11:00 A.M. to 2:30 P.M. at an intermittent time: -R14 said I filed a grievance on 11/5/2023 regarding (V15's) that she has bad attitude causing us mental and emotional distress, but up to now, I have not heard from the management. (V15) told me on 11/5/2023 I am not your CNA, I cannot take care of you, you are so fat. R14 also said that she needs help with transfers and uses a mechanical transfer lift device. R14 also said that she was incontinent of bladder function and that V15 refused to change her incontinence brief and that R14 wore the soaked brief at least 5-6 hours. -R4 said she requested V15 to pick up condiments that was dropped off from her lunch tray on 11/5/2023. R4 said that V15 responded I am not your CAN. R4 said (V15) then left the room and does not care at all. On 11/8/2023 at 4:52 P.M., V20 (Receptionist) said that on 11/5/2023 at around 9:00 A.M., R10 called her via phone and informed that V15 was rough handling her. V20 also said that she that she could tell from R10's voice that R10 was upset. V20 added that R10 was crying and stating that V15 was rough with her and had a nasty attitude. V20 said she told R10 that she will inform V21 as soon as she arrives at the facility since V21 was the assigned MOD for the day. On 11/8/2023 at 4:30 P.M., V21 (RN/Registered Nurse) said that when she arrived at the facility on 11/5/2023 at around 9:30 A.M., she was informed by V20 that R10 was upset due to V15 being rough with care and with a bad attitude. V21 said she went to R10's room around 9:45 A.M. V20 said she saw R10 lying in bed, and V15 pulling up R10's pants. V21 said I can tell that there was an argument between the two, I saw R10 crying and visibly upset. I helped (V15) got (R10) up and stayed with (R10) for a while since she was crying. Surveyor asked V21 what the argument was, and the reason of R10 being upset and crying. Surveyor also asked if it makes sense for V15 to pull up R10's pants if V15 can do it while R10 was standing up. V21 had no explanation or answer what the argument was and why R10 was upset. V21 said she did not remove V15 from work and V15 continued to work until the end of the shift (10:00PM). V21 also said she did not report this incident to the administrator, nor had she initiated an investigation for potential abuse. On 11/8/2023 at 3:45 P.M., V19 (Nurse) said R10 had informed him regarding V15 that she has a nasty attitude and that V15 broke R10's bed rail on 11/1/2023. V19 added that he saw the bed rail on the floor and was detached from R10's bed on 11/1/2023 evening shift. V19 also said that he also worked on 11/5/2023 and that V15 had ignored residents' call lights and will not answer for 35 minutes. V19 showed to surveyor a monitor screen that showed V15 had not responded to residents' call light for 35 minutes. V19 said that V15 had bad attitude, abrupt, not motivated to work. V19 added that she had texted V16 (staffing scheduler) on 11/5/2023 for V15 not to return to facility since V15 was from staffing agency. On 11/11/2023 at 8:30 A.M., V16 (staffing scheduler) had validated that V15 had worked double shift (6:00 A.M. through 10:00 P.M.) on 11/5/2023. V16 also confirmed that V15 took care of R10 on 11/1/2023 for the evening shift and morning shift on 11/5/2023. On 11/8/2023, at 3:00 P.M., V1 (Administrator) said she was only informed regarding alleged physical abuse by V15 towards R10 by V25(Transportation Coordinator) on 11/7/2023 at 4:00 P.M. On 11/27/2023 at 11:30 A.M., V25 (Unit Secretary/Transportation Clerk) said that on 11/7/2023 around 4:00 P.M., R10 had informed her that on 11/5/2023 during the morning care, V15 had roughly handled her, grabbed her left arm with force that had caused a huge bruise from the wrist all around the elbow. V25 said she immediately informed nurse supervisor and they both informed V1 on 11/7/2023 at around 4:00 P.M. regarding the allegation of physical abuse by V15 towards R10. On 11/27/2023 at 5:15 P.M., R10, sitting in her wheelchair in her room. R10 said she remember the surveyor. R10 said so many people were asking me about this abuse, I am already overwhelmed with questions. The main issue here was that (V15) had jerked my arm, grabbed me roughly (pointed her left arm), and she should have not come back here when she did this to me Sunday (11/5/2023). (V15) was here before that (Wednesday) and broke by bed rail. I told the staff, showed to (V19/Nurse) that my bed rail on the floor because (V15) broke it. I was seen by a shrink because of this but was not seen by the social worker. On 11/29/2023 at 10:30 A.M., R10 was in her room. R10 was sitting in her wheelchair. R10 said her left arm was still sore from being jerked and grabbed by (V15). She should be in jail; I would like to pursue criminal charges against her (V15). Review of the police report dated 11/7/2023 showed that V15 was charged for aggravated battery and warrant of detention was processed. The facility's abuse policy dated 7/14/2023 showed It is the facility's policy to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and through investigations of allegations Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm maybe considered abuse. Types of abuse: 1. Physical 2. Verbal 3. Mental 9. Injury of unknown origin Prevention of abuse: Identify, correct, and intervene in situations in which abuse, neglect .is more likely to occur .Establish a safe environment Supervision of staff to identify inappropriate behaviors, such as derogatory language, rough handling, ignoring residents while giving care .Employee accused must be suspended pending investigation . Reporting . must be reported to the administrator immediately .

Based on observation, interview, and record review, the facility failed to follow their policy to assess and address significant weight losses in residents, failed to notify the physician and resident representative of significant weight loss, and failed to implement interventions to prevent future weight loss. This failure resulted in R1 and R4 experiencing significant weight loss. This applies to 2 of 3 residents (R1, R3) reviewed for improper nursing in the area of weight loss in the sample of 5. The findings include: 1. On April 26, 2023 at 3:44 PM, R1 was lying in bed. R1 was not able to answer questions due to her cognitive status. On April 27, 2023 at 9:15 AM, R1 was sitting up in her bed. Her breakfast tray was sitting on top of her bedside table. A hard-boiled egg, toast, and oatmeal was on the plate and appeared untouched. V15 (CNA-Certified Nursing Assistant) said R1 had not eaten any breakfast. V15 attempted to feed R1 food off of her breakfast tray. R1 refused to eat anything and V15 removed the tray from the room. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and transferred to the local hospital on April 18, 2023. R1 returned to the facility on [DATE]. The EMR continues to show R1 has multiple diagnoses including, cerebral infarction, myocardial infarction, heart disease, occlusion and stenosis of the right carotid artery, chronic congestive heart failure, PVD (Peripheral Vascular Disease), anxiety disorder, diabetes, bradycardia, dementia, and aphasia. R1's MDS (Minimum Data Set) dated January 17, 2023 shows R1 has severe cognitive impairment, requires supervision with bed mobility, transfers between surfaces, locomotion on the unit, eating and personal hygiene, limited assistance with walking in the room and corridor, locomotion off of the unit, and dressing, and extensive assistance with toilet use and bathing. R1 is frequently incontinent of urine, and occasionally incontinent of stool. Facility documentation shows R1 had a significant weight loss of 7.86 percent between October 24, 2022 and January 13, 2023, when R1's weight declined from 136.2 pounds on October 24, 2022 to 125.5 pounds on January 13, 2023. The facility does not have documentation to show care plan interventions were initiated to address R1's significant weight loss on January 13, 2023. The facility's records show R1 continued to experience monthly weight loss. On April 14, 2023, R1 weighed 112.9 pounds, a 17.11 percent weight loss between October 24, 2022 and April 14, 2023. The facility does not have documentation to show care plan interventions were initiated to address R1's ongoing, significant weight loss. The facility does not have documentation to show R1's physician or family member were notified of R1's significant weight losses. On April 26, 2023 at 9:05 AM, V10 (Sister of R1) said, No one notified me about her significant weight loss. I only found out when she was hospitalized on [DATE]. The EMR shows the following order for R1 dated March 22, 2023: Fortified cereal daily for supplement. The March 2023 and April 2023 MARs (Medication Administration Records) show the following intake documentation for R1's fortified cereal: March 31, 2023 - Ate 0 percent April 1, 2023 - Ate 0 percent April 2, 2023 - Ate 0 percent April 3, 2023 - Ate 0 percent April 4, 2023 - Refused April 5, 2023 - Ate 0 percent April 6, 2023 - Refused April 7, 2023 - Refused April 8, 2023 - Ate 10 percent April 9, 2023 - Ate 0 percent April 10, 2023 - Refused April 11, 2023 - Refused April 12, 2023 - Ate 0 percent April 13, 2023 - Ate 0 percent April 14, 2023 - Sleeping April 16, 2023 - Ate 0 percent April 17/2023 - Ate 0 percent The EMR shows the following order for R1 dated March 22, 2023: Sugar Free Health Shake two times a day for supplement, 4 ounces BID (Twice Daily), or Glucerna 8 ounces BID. The April 2023 MAR shows the following intake for R1's health shake: April 2, 2023 at 9:00 AM - Drank 50 percent April 5, 2023 at 9:00 AM - Drank 40 percent April 5, 2023 at 5:00 PM - Drank 10 percent April 6, 2023 at 9:00 AM - Drank 40 percent April 7, 2023 at 9:00 AM and 5:00 PM - Refused April 8, 2023 at 9:00 AM - Drank 0 percent April 10, 2023 at 9:00 AM - Refused April 11, 2023 at 9:00 AM - Drank 50 percent April 11, 2023 at 5:00 PM - Refused April 12, 2023 at 9:00 AM - Drank 50 percent April 12, 2023 at 5:00 PM - No administration documentation present April 13, 2023 at 9:00 AM - Drank 50 percent April 14, 2023 at 9:00 AM - Drank 80 percent April 14, 2023 at 5:00 PM - Drank 50 percent April 15, 2023 at 5:00 PM - Drank 40 percent April 17, 2023 at 5:00 PM - Drank 50 percent April 18, 2023 at 9:00 AM - Drank 50 percent On April 26, 2023 at 1:45 PM, V7 (Dietitian) said, I have not gotten to see [R1] yet this month. When I saw her a month or so ago, she was very happy. Her meal intake is not as good. She feeds herself but needs encouragement to eat. I am not sure how my dietary recommendations from my notes get to the staff, so they know what needs to be done for her. I did not see the documentation in the medical record about her not eating the fortified cereal or health shake. I have not contacted the family regarding the resident's weight loss. That is nursing's job. I did not update [R1's] care plan. That is my job, but I have not done it. On May 1, 2023 at 12:30 PM, V16 (Physician) said, I was never notified of [R1's] significant weight loss. With her dementia, there needed to be more close oversight. She needs one-to-one assistance with feeding. Had I been notified of her weight loss; I would have been more hands on in the oversight of her care. The facility has to ensure the person who is not eating is assisted in order to restore weight gain. I am the Medical Director of the facility, and it is the facility's responsibility to notify the physicians of their resident's significant weight loss. They must do that. 2. On April 26, 2023 at 3:58 PM, R3 was lying in bed sleeping. R3 appeared very thin, with protruding cheek bones and collar bones. An open nutritional shake bottle was sitting on R3's bedside table, next to R3. The bottle was open, and a straw was in the bottle. The liquid contents of the shake were visible up to the top of the bottle opening and it did not appear any of the shake had been consumed by R3. On April 27, 2023 at 12:35 PM, R3 was lying in bed. R3 was not able to be interviewed due to his cognitive status. V11 (Spouse of R3) said she was concerned because R3 appeared to have lost a lot of weight and no one had contacted her regarding his weight loss or possible interventions to prevent further weight loss. He was eating pureed food for a while, and he did not like that. I brought in my own diet supplement drinks and meal bars for him because those are his favorite. I did tell someone that he really likes ice cream, but they don't always bring it to him. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, non-traumatic subdural hemorrhage, depression, altered mental status, dysphagia, unsteadiness on feet, abnormal gait, lack of coordination, abnormal posture, cognitive communication deficit, aphasia, falls, atrial fibrillation, dementia, and elevated white blood cell count. R3's MDS (Minimum Data Set) dated March 21, 2023 shows R3 has severe cognitive impairment, is totally dependent on facility staff for dressing and personal hygiene and requires extensive assistance with all other ADLs (Activities of Daily Living). R3 is always incontinent of bowel and bladder. On March 17, 2023 at 10:58 AM, V7 (Dietitian) documented R3's admission weight of 124.7 pounds, classified R3 as underweight, and recommended a house supplement twice a day. Facility documentation shows the following weights for R3: 124.7 pounds - March 13, 2023 107.2 pounds - March 22, 2023 111.4 pounds - March 29, 2023 106.4 pounds - April 12, 2023 The facility's documented weights reflect a 14.68 percent weight loss between March 13, 2023 and April 12, 2023. The facility does not have documentation to show R3's physician or family were notified of R3's significant weight loss. The EMR shows the following order for R3 dated March 17, 2023: House supplement, two times a day, 4 ounces BID, may have Ensure, MedPass, or Two Cal. The April 2023 MAR (Medication Administration Record) shows the following amounts consumed of the supplement by R3: March 17, 2023 9:00 PM - Drank 50 percent March 18, 2023 9:00 AM - Drank 40 percent March 18, 2023 at 9:00 PM - Drank 25 percent March 19, 2023 at 9:00 AM - Drank 30 percent March 19, 2023 at 9:00 PM - Drank 15 percent March 20, 2023 at 9:00 AM - Drank 30 percent March 20, 2023 at 9:00 PM - Drank 0 percent March 21, 2023 at 9:00 AM - Drank 50 percent March 22, 2023 at 9:00 PM - Drank 0 percent March 26, 2023 at 9:00 PM - Drank 50 percent March 27, 2023 at 9:00 PM - Drank 40 percent March 28, 2023 at 9:00 PM - Drank 30 percent April 5, 2023 9:00 PM - Drank 50 percent April 14, 2023 9:00 AM - Drank 50 percent April 15, 2023 9:00 AM and 9:00 PM - Drank 0 percent April 17, 2023 9:00 PM - Drank 50 percent April 18, 2023 900 PM - Drank 50 percent April 19, 2023 9:00 PM - Drank 0 percent April 21, 2023 at 9:00 PM - Drank 25 percent April 23, 2023 at 9:00 AM - Drank 0 percent April 23, 2023 at 9:00 PM - Drank 50 percent April 24, 2023 at 9:00 AM - Drank 50 percent April 29, 2023 at 9:00 AM and 9:00 PM - Drank 50 percent April 30, 2023 at 9:00 PM - Drank 25 percent R3's care plan initiated on March 17, 2023 shows, Resident is at risk for alteration in nutritional status. R3's care plan has multiple interventions initiated March 17, 2023, including consider finger foods, elevate head of bed during feeding or meals if indicated, monitor for signs and symptoms of dehydration and weight loss, monitor resident with difficulty of chewing or swallowing, assess for signs of choking and/or aspiration, obtain labs as ordered, obtain weight as ordered, offer extra fluids if not contraindicated, provide assistance for meals if indicated, provide diet and supplements as ordered, and provide good oral hygiene. As of April 26, 2023 at 3:37 PM, the facility did not have documentation to show new care plan interventions were initiated following R3's significant weight loss. On April 26, 2023 at 1:45 PM, V7 (Dietitian) said, she was not aware R3 was not drinking his nutritional shake as ordered and she does not review the MAR to check for the resident's amount consumed of the nutritional shakes. V7 continued to say she has not attended any meetings at the facility regarding resident's significant weight loss. The facility's Weights Policy revised 5/19/2022 shows: Policy Statement: It is the facility's policy to obtain resident's monthly weight unless otherwise ordered differently by the physician. For a resident who is on dialysis, the resident's dry weight will be also obtained monthly. Procedures: .3. The significant weight changes (monthly 5%, quarterly 7.5%, and every 6 months 10%) will be assessed and addressed by the IDT (Interdisciplinary Team) which includes but not limited to the Dietitian, Physician, Medical Specialist, Speech Therapist, Nutritionist, and Nurses.

Based on observation, interview and record review, the facility failed to supervise residents with wandering and elopement risks. The facility also failed to provide adequate supervision to prevent elopement from the facility. The facility failed to ensure all facility's exit door alarm systems (9 exit doors) were maintained in functioning order to alert staff and able to respond to residents exiting the facility. The facility also failed to follow its elopement policy by not determining the cause of the triggered alarms, failing to monitor safety alarm systems to ensure they function, and assessing residents for risk of elopement behavior. This failure resulted in Immediate Jeopardy when R1 and R2 had eloped from the facility without being witnessed by facility staff on 4/11/2023 at 4:30 P.M. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, R6) reviewed for supervision/elopement risk in the sample of 19. The Immediate Jeopardy began on 4/11/2023 at 4:30 P.M., when R1 and R2 eloped from the facility. R1 and R2, a husband and wife, both confused, with diagnoses of dementia, were wandering and unsupervised along well-traveled community roads when found by police officers due to a call from a concern citizen. R1 and R2 were a mile away from the facility when they were found. R1 and R2 were outside on a 4 lane well-traveled road with major intersections. This road included a hospital on one side of the road and a school on the opposite side and R1 and R2 also passed through roads that were elevated and hilly areas, with no walkways between pedestrians and vehicles. The police report shows that R1 and R2 were unsupervised and away from the facility caretakers for a period of approximately 90 minutes. The facility failed to report R1 and R2 were missing to the police department. The police determined which facility R1 and R2 resided. The clinical record dated 4/11/2023 shows that R1 and R2 was last seen by facility staff at 4:30 P.M., overhead paged for CODE YELLOW ALERT (missing residents) at 5:45 P.M. and police officer called facility at 6:25 P.M. to informed them they found R1 and R2. This was a two-hour duration that R1 and R2 was without supervision from staff. R1 refused to go back to the facility, hence, was taken to the hospital, but later was returned to the facility. R2 was picked from the location where she was found by a facility staff and returned to the facility at 7:30 P.M. The Immediate Jeopardy was identified on 4/17/2023. V1 (Administrator) was notified of the immediate jeopardy on 4/17/2023 at 11:24 A.M. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on 4/18/2023 at 11:49 A.M., but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan, including in-service training of staff on elopement drills and door alarm response, panel system of alarm exit doors replaced, and monitoring safety alarm device be in functioning order, to ensure that a resident wearing this device can be detected when enters the perimeter of the exit alarm exit door. The findings include: R1, an [AGE] year-old with diagnoses of dementia with behavioral symptoms, encephalopathy, cognitive communication deficit, PTSD (post-traumatic stress syndrome), paranoid personality disorder, altered mental status, anxiety disorder, depression, CKD (chronic kidney disease), gout, unsteadiness of feet, and lack of coordination. R1 was admitted to the facility on [DATE] from hospital admission on 2/27/2023 due to aggressive, belligerent behavior, confusion and change in mental status. The MDS (Minimum Data Set) dated 3/9/2023 shows R1's BIMS (Brief Interview Mental Status) score of 3/15 (severely impaired); with moods of feeling down, trouble falling asleep, feeling tired, poor appetite that were exhibited in 12 out of 14 days duration. R1 was also assessed with poor balance when moving around from surface to surface, transfers, and walking. R1's primary locomotion was a wheelchair. The EMR (Electronic Medical Record) of R1 have multiple physician progress notes that show the following: -3/13/2023; R1's dementia is getting worse -3/15/2023; R1 with aggressive behavior; will need Long Term Care Memory Care Unit. -3/15/2023; R1 was looking for papers to take to the bank -3/17/2023. R1's initial psychiatric visit in the facility: HISTORY OF PRESENT ILLNESS: (R1) is an [AGE] year-old male, with past medical history of: HTN (hypertension), HLD (hyperlipidemia), Gout, Colon Cancer s/p Colon Resection, CKD3, mild Dementia, Depression, left hip fracture with repair 9/2022, who present to (hospital) on 2/23/23 from PCP (primary care physician) office with confusion. (R1) was initially sent to ED (Emergency Department), due to altered mental status. (R1) was transferred to another hospital for further evaluation. (R1) was very belligerent and uncooperative, requiring Haldol (antipsychotic medication to treat schizophrenia and help rebalances and improve thinking, mood and behavior). (R1) was seen by Psychiatry and was diagnosed with dementia with behavioral disturbance. (R1) was started on Depakote, Risperdal, Trazodone, Donepezil (antipsychotic/mood stabilizers medications) -3/27/2023: R1 with aggressive behavior -4/3/2023: There were 2 notes on same day that R1 continues to ask to go home -4/6/2023; R1 was fixated going home -4/7/2023; R1 needed a secured unit due to dementia -4/10/2023; Further notes showing that R1 was fixated going home Review of R1's elopement risk assessment log shows that comprehensive elopement assessment was not done until R1 had eloped on 4/11/2023. Despite of the multiple notes from physician provider that R1 was fixated of going home with worsening dementia, the facility failed to assess R1 and provide preventative measure to prevent elopement. The care plan also shows that it was only on 4/13/2023 that interventions which included a monitoring alarm safety device to be applied, which obviously will not work since the facility was not equipped with detecting this monitoring alarm device. The EMR shows that R2, an [AGE] year-old female, wife of R1, was originally admitted to the facility on [DATE]. R2's diagnoses included but not limited to Alzheimer's disease, worsening dementia, anxiety disorder, major depressive disorder, lack of coordination, abnormality of gait and mobility, unsteadiness of feet, bilateral hearing loss, malignant neoplasm of breast, and gastrointestinal bleed. R2 was sent out to the hospital and was admitted from 3/22-27/2023. R2 returned to the facility on [DATE]. The MDS dated [DATE]; 3/17/2023; and 3/29/2023 shows that R2's BIMS (Brief Interview Mental Status) score of 5/15 (severely impaired); with moods of feeling down, trouble falling asleep, feeling tired, poor appetite that were exhibited in 12 out of 14 days duration. R2 was also assessed with poor balance when moving around from surface to surface, transfers, and walking. R2 was ambulatory and does not use assistive devices for ambulation. R2 was assessed requiring assistance from staff for her ADLs (Activities of Daily Living). The EMR of R2 have multiple physician progress notes that show the following: -3/5/2023; R2's insight was poor -3/14/2023; wander guard (monitoring alarm safety device ) -3/15/2023: needs memory care unit -3/30/2023: (R2) wants to go home with Bill (R1, the husband) -4/3/2023: (R2's) dementia is getting worse; has extreme short memory loss, need memory care unit placement, is Elopement Risk -3/27/2023: has order for monitoring alarm safety device received by V10 (RN). The assessment log from 3/9/2023 through 4/13/2023 shows that Elopement Risk was not done until 4/11/2023 after R2 had eloped. The care plan dated 3/10/2023 shows that R2 was to be applied a monitoring safety alarm device on 3/27/2023. The order was obtained by V10 (RN/Nurse). There was no documentation that the device was applied, monitored, or checked whether the exit door can detect the alarm device if R2 passes by. When interviewed on 4/14/2023 at 1:48 P.M., V10 said he does not remember if R2 wears the device nor had check if it was applied. The incidental progress note report dated 4/11/2023 shows at about 1630 (R1 and R2) not being seen in the facility, resulted in massive searching, in the building and around. patient was later found by the police and taken to the hospital for assessment. The social service notes dated 4/11/2023 shows that (R1 and R2) was last seen by facility staff at 4:30 P.M., overhead paged for CODE YELLOW ALERT (missing residents) at 5:45 P.M. and police officer called facility at 6:25 P.M. to informed them they found (R1 and R2). On 4/13/2023 at 10:45 A.M. R1 and R2 were observed in their room. R1 was sitting in his wheelchair. When asked his name, R1 did not response. R1 was asked what his current location was, R1 responded with a loud voice HELL! R1 continued to yell saying he was on his way TO HELL when he left the placed with his wife (R2). For the meantime, R2 was telling R1 to shut up, this lady is trying to help us. R2, knows her name, but does not know her location, time and no idea of the staff around her. When R2 was asked why they left the faciity on [DATE], R2 had no response and have a confuse look on her face what the surveyor was talking about. On 4/13/2023 at 11:00 A.M. V2 (Director of Nursing) showed to surveyor the exit door where R1 and R2 had exited. The exit door was called Southwest (SW) Exit door. This exit door was about 15 feet away from the SW nurses' station. There was also a wall that faces the exit door and was blocking the visibility whoever is entering or exiting the SW exit door. It is only through an alarm system to alert staff and detect anyone opening this exit door. The 300 residents' hallway connects vertically to the SW nurses' station and 200 hallway connects perpendicular to same nurse's station. The panel for the alarm system was located attached to the wall in the SW nurse' station. The panel for the alarm system was to help identify which exit door the alarm was triggered. During this observation, V2 had open the SW exit door, and alarm was triggered. There was no staff who came to check for the panel system nor check the SW exit door. Furthermore, the alarm sound was not audible to 200 and 300 hallways. These are the hallways that are of proximity to the SW exit door. After V2 had turned off the alarm, V6 (LPN/License Practical Nurse) came to the SW nurse' station. V6 said that the SW exit door alarm was not audible and if you are next to the SW exit door, you are lucky to hear that faint alarm. The alarm sound is also confusing because it sounded like an oxygen being administered or a gastric tube pump that was beeping. V6 said that she had worked around 300 hallway when R1 and R2 had eloped, but she did not hear the alarm sound. Together with V2, staff that had worked on 4/11/2023 when R1 and R2 had eloped were identified. Interviews were held with these staff on 4/14/2023 and 4/15/2023. -at 1:48 P.M, V10 (Registered Nurse/RN) said he was assigned to R1 and R2 the evening shift of 4/11/2023. V10 said he saw R1 and R2 wandering around the hallways of all units of the facility with R2, pushing R1 in a wheelchair. V10 said that he was not aware of their elopement risk. V10 said he was not aware that R2 wears a monitoring safety device and nor had checked if she has one. V10 said that he last saw them around 4:00 P.M. when he was passing medications. -at 2:08 P.M., V11(CNA/Certified Nurse Assistant) said that she was the assigned CNA for both R1 and R2 on 4/11/2023 for the evening shift. V11 said that she saw them wandering around all units of the facility. V11 said that she found out they were missing when R1 and R2's dinner trays were left in the dinner cart after she passed trays for her assigned residents. V11 said she then started to look and asked other staff if they saw R1 and R2 since she cannot find them. V11 said that this was 5:00 P.M. when she was done passing dinner trays and realized that R1 and R2 were nowhere to be found. V11 said she did not hear an alarm from any exit door. V11 also said that she did not know that R2 wears the monitoring safety device nor had checked R2 is she wears one. V11 said she did not know that R1 and R2 were elopement risk. V11 said that she last saw them at 4:00 P.M. on 4/11/2023. Interviews continued with other staff that worked at time of R1 and R2's elopement. They were V7 (LPN), V8 (RN), V9 (LPN), V12 (CNA), V13 (CNA), V14 (CNA), V15 (CNA), V16 (CNA), V17 (CNA), V18 (Receptionist), V19 (RN Supervisor), and V20 (Activity Director). All of them said that both R1 and R2 wanders around all the units, don't keep tract of their whereabouts, not knowing the time they left the facility and they do not know what time they last saw R1 and R2 the evening of 4/11/2023. Furthermore, they also said they did not hear the alarm sound off from any of the exit door nor had heard the alarm from R2's monitoring safety alarm device. There were 16 staff that were interviewed who worked the evening of 4/11/2023. They all said they did not hear any alarm that sounded off. Except one staff V7 (LPN) who said he heard a faint alarm when he was inside room [ROOM NUMBER] (300 hallway). V7 said that he came out of room [ROOM NUMBER] and a faint alarm sound was coming from the SW exit door. V7, said he started to walk towards the middle of hallway approaching the SW nurse's station and SW exit door. V7 continued to state that when he reached the middle of the hallway (room [ROOM NUMBER]), the alarm sound had stopped. V7 said from where he was at, he can view the SW nurse station where the panel was located. However, V7 said he did see who turned off the alarm from the panel system. V7 also said he did not attempt to find out who turned off the alarm, nor find out what caused the SW exit door alarm to be triggered. V7 said someone must have turned off the alarm from the panel system, otherwise the alarm will not shut off by itself, but when I'm on the middle of the hallway (room [ROOM NUMBER]), all of a sudden, the alarm had stopped, so someone had turned the alarm off. V7 also said that he did not check the SW exit door. V7 said he did not check the vicinity of the SW exit door to see possible elopement of resident(s). After the interview with V7, V2 accompanied the surveyor on 4/14/2023 at 2:45 P.M. and checked the distance and visibility between the location of where V7 was (room [ROOM NUMBER], 312), the panel system for alarm, SW nurse station and SW exit door. It shows that room [ROOM NUMBER] was the same hallway that extends all the way to the panel alarm system, which was approximately 15 feet away from the SW exit door. V2 asked V3 (Director of Maintenance) to measure the distance of these locations. The distance of room [ROOM NUMBER] to the SW nurse' station was 175 feet; from room [ROOM NUMBER] to the SW nurse' station was 115 feet. V2 stated that it was impossible for V7 not to see the individual that had turned off the alarm since it was of visible view where V7's location was. V2 said that nevertheless it was still expected that V7 should have checked the SW exit door and determine what cause the alarm to trigger. V2 also said that it was also expected that V7 should have check the vicinity around the exit door for possible elopement of resident(s). On 4/13/2023 at 1:20 P.M., V1 (Administrator), V2, V3 have all said that someone must had turned off the alarm without checking what had caused the alarm to trigger and failed to check if any residents had eloped. If someone had checked, (R1 and R2) would have been seen immediately after they exited the door. V1 said this is a serious matter and I do not get a straight answer from the staff. The alarm will not shut off by itself, it must be manually shut off from the panel system in the SW nurse's station to stop the alarm. V3 said if they did what they (staff) were supposed to do and check, this would have not happened that (R1 and R2) eloped. On 4/13/2023, at 1:40 P.M., V5 (Technician from an online communication company contracted by the facility) was interviewed with V2 and V3 present. V5 said the alarm system in the facility is old, not capable to alert/send signal to the staff when the alarm sound off. The staff might hear if near to the exit door that was triggered, but if the staff is far beyond 6 residents' room, the staff might not hear the alarm. We are waiting for the parts to replace the whole alarm/panel system and install new alarm system to all (9) exit doors of the facility. This is why the staff barely hear the alarm. It needed replacement. V3 commented he checks the 9 exit doors for lapse time required to close the door but did not ask staff if it was audible for all units. V3 also said that he does not check the monitoring alarm safety device if it was functioning. V3 said all I do is order the device but not check them if they were functioning. Anyway, there were only 2 doors that were supposed to trigger (the front and SW exit doors) when a resident wearing the monitoring alarm safety device passed by these doors. V3 added that the front and SW exit doors were nonfunctioning and do not detect the monitoring alarm safety device. Surveyor asked what the facility's current implementation since their exit doors alarm and monitoring alarm safety device was not detectable. V1, V2, V3 have all said that currently they do not have a plan to monitor their exit doors to ensure that their residents that are confused and have the potential for elopement be prevented from eloping. On 4/14/2023 at 9:30 A.M., V2 said that it is the responsibility of V3 to check the 2 doors (front and SW) if they were functional and can detect alarm for the monitoring alarm safety device. V3 was called and he said, I fixed the alarm on the SW exit door today, because the alarm system was bent down, and it was not producing an audible sound that alert staff. On 4/13/2023, together with V1, V2 and surveyor, the facility's video surveillance was reviewed for 4/11/2023 from 4:30 P.M. to 4:50 P.M. The video surveillance shows R1 and R2 had exited the SW exit door at 4:46 P.M. R2 was pushing R1 while seated in his wheelchair. The video shows that R1 and R2 headed to south parking lot of the facility. They headed to a direction that the only way out from the facility was to go to the main road. This main road has 2 opposite traffic lanes. There was also an adjacent building to this parking lot, however, the only way out from this adjacent building was to go to the same main road. The police report dated 4/11/2023 shows that R1 and R2 were unsupervised and away from the facility caretakers for a period of approximately 90 minutes. The facility failed to report R1 and R2 were missing, and with police investigation, they found out which facility R1 and R2 resides. The clinical record dated 4/11/2023 shows that R1 and R2 was last seen by facility staff at 4:30 P.M., overhead paged for CODE YELLOW ALERT (missing residents) at 5:45 P.M. and police officer called facility at 6:25 P.M. to informed them they found R1 and R2. This was a two-hour duration that R1 and R2 was without supervision from staff. R1 refused to go back to the facility, hence, was taken to the hospital, but later was returned to the facility. R2 was picked from the location where she was found by a facility staff and returned to the facility at 7:30 P.M. On 4/13/2023 at 3:00 P.M., V20 (Activity Director) said that she had picked R2 from the location where she and R1 were found. V20 said she had picked R2 on 4/11/2023 and returned to the facility at 7:30 P.M. On 4/13/2023 at 5:00 P.M., V20, V2, and surveyor drove and checked the roads and location where R1 and R2 were found. It was determined that it was one mile away from the facility. The route to the location shows that R1 and R2 must passed by main roads that encompasses 2 opposite traffic lanes, 2 traffic lights in major road intersections, 2 four way stop signs and a well-traveled areas as there was a hospital on one side of the road and a school on the opposite side. R1 and R2 also must passed through some roads that were elevated, hilly areas, with no walkways between pedestrians and vehicles. R1 and R2 was transferred on 4/13/2023 to another facility that has a secured/locked unit designated for residents with diagnosis of dementia. On 4/13/2023 at 11:34 A.M., V4 (Social Service Director) said that she did not do comprehensive elopement risk assessment for R1 and R2 until after they have eloped on 4/11/2023. V4 also said that R3 is an elopement risk, wanders around, exit seeking, and was applied a monitoring alarm safety device. When V4 and surveyor went to R3's room after the interview, R3 was sitting in a lounge chair in her room. V4 had checked R3's monitoring alarm safety device on R3's ankles and wrists and found none. V26 (R3's husband) was visiting. V26 was not aware that R3 was supposed to have the monitoring alarm safety device. V4 said to V26 that (R3) wanders around and was sundowning so we put the monitoring alarm safety device, but it does not work so we removed it already. V4 said that R3 is provided 1:1 supervision. However, on 4/14/2023 at 1:30 P.M., together with V2, the monitoring log for the morning shift of 4/14/2023 was blank and no documentation that sitter was provided. V27 (R3's 1:1 monitoring staff) said that when she came in at 11:00 A.M., there was no one providing 1:1 to R3. On 4/14/2023 at 3:00 P.M., V4 was asked for other residents who were at risk for elopement. V4 said the aside from R1 and R2, the other residents at risk for elopement were R3, R4, R5 and R6. On 4/14/2023 at 5:00 P.M., V21 (Social Service Director from sister company of the facility) said she is helping V4 to ensure accuracy and completeness of residents' assessment for the elopement risk. V21 said that for the total census of 102 residents/ 79 were so far reviewed for elopement risk. V21 also said that she had 10 residents that needed to have an extra look for elopement risk. V21 said that out of this 10, 4 residents (R12, R13, R14 and R5) do not have a completed BIMS. V21 also said that R5 is identified as an existing wanderer. V21 also said that 6 other residents were looked and reassessed because they are ambulatory and have lower BIMS score (R3, R15, R16, R17, R18, R19). The EMR of the following residents shows: -R3 is [AGE] year-old who was admitted to the facility on [DATE]. R3's diagnoses included but not limited to metabolic encephalopathy, dementia, altered mental status, cognitive communication deficit, unsteady gait and mobility, and lack of coordination. The MDS dated [DATE] shows that R3's BIMS score was 99 (meaning interview not completed). The assessment continued and showed R3's cognitive skill for decision making was moderately impaired, with short-term and long-term memory problem. R3 was assessed with moods of feeling down, depressed, hopeless, trouble falling asleep, feeling tired, poor appetite that were exhibited in 12 out of 14 days duration. R3 was also assessed with poor balance when moving around from surface to surface, transfers, and walking. R3 was ambulatory and does not use assistive device for ambulation. R3 requires assistance from staff for her ADLs. The assessment log from 3/9/2023 through 4/14/2023 shows that R3's Elopement Risk was not done until 4/14/2023. The assessment was inaccurately assessed since the it was not coded correctly. It was coded as 3 (low risk elopement) versus 4 (high risk elopement). The facility policy was not followed since the elopement assessment was not done timely. It was done on 4/14/2023 wherein R3 was admitted on [DATE]. The care plan dated 3/15/2023 shows that R3 was identified as elopement risk and with exit seeking behavior. The intervention shows that a monitor alarm safety device was the intervention. However, this intervention was not appropriate since the facility's exit door cannot detect the monitoring alarm safety device. On 4/13/2023 at 11:34 A.M., R3 was in her room. V4 checked R3's monitoring alarm safety device on ankles and wrist and none was found. R4 is a [AGE] year-old with diagnoses that includes but not limited to hydrocephalus, pre-diabetes, and benign neoplasm. R4 was admitted to the facility on [DATE]. The MDS dated [DATE] shows that R4's BIMS score was 3/15 (severely impaired). R4 was assessed with moods of feeling down, depressed, hopeless, trouble falling asleep, feeling tired, poor appetite that were exhibited in 12 out of 14 days duration. R4's primary locomotion was a wheelchair. R4 was able to propel his own wheelchair. The assessment log shows that R4's Elopement Risk were done on 11/16/2022 and 4/14/2023. The elopement risk was not done quarterly as per facility policy. R4 was a high risk for elopement. R5 is a [AGE] year-old admitted to the facility on [DATE]. R5 with multiple diagnoses included but not limited unsteadiness of feet, lack of coordination, diabetes mellitus, depression, repeated falls, and anxiety disorder. The elopement risk log shows that R5 was assessed for elopement on 1/11/2023 (high risk), 4/13/2023 (low risk) and 4/14/2023 (low risk). The facility policy was not followed by not assessing R5 timely. The MDS dated [DATE] and 2/3/2023 shows that R5 was assessed with moods of feeling down, depressed, hopeless, trouble falling asleep, feeling tired, poor appetite that were exhibited in 11-12 out of 14 days duration. R6, a [AGE] year-old with diagnoses that includes but not limited to rhabdomyolysis, history of falling, unsteadiness of feet, gait and mobility abnormality, lack of coordination, cognitive communication deficit, depression, seizures, and benign neoplasm of meninges. The MDS dated [DATE] and 3/27/2023 shows that R6 was assessed with moods of feeling down, depressed, hopeless, trouble falling asleep, feeling tired, poor appetite that were exhibited in 12 out of 14 days duration. The elopement risk log from shows that R6 was assessed for elopement on 4/14/2023 in which policy was not followed since it was untimely done. The progress notes from the physician dated 3/7/2023 shows that R6 planning to move to a long-term facility .will discuss with social services. HPI: 76 y/o admitted to hospital on 2/24/23 after fall, after he lost consciousness, he believes both are related to seizure, last seizure 9 years ago, it is believed that (R6) had been on the floor for 3 to 4 days. CT (Computerized Tomography) of the head showed Carotid Calcifications .MRI (Magnetic Imaging Reasoning) of the brain showed 1.5cm mass at level of cribriform plate without extension, meningioma. On 4/14/2023 at 1:45 P.M., V9 (LPN) stated that she noted R6 wandering around the facility with no direction where to go. The POS (Physician Order Sheet) for the month of March and April 2023 shows that there was no order for R6 to leave the facility unsupervised. On 4/13/2023 at 10:35 A.M., R6 was at the front lobby of the facility. R6 was waiting for the ambulance for a medical appointment. R6 was ambulatory. R6 was accompanied by a sitter. At 2:50 P.M., R6 was seen lying in his bed. R6 was asked about his appointment. R6 responded what appointment. V2 was present during this observation. The facility's policy regarding elopement dated 11/01/2016, revised 7/27/2022 shows: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors, or conditions that put them at risk for wandering/elopement. All residents identified will have these issues addressed in their individual plan of care Procedure. 1. Residents who have been assessed at risk for elopement /wandering shall be provided at least one of the following safety precautions by the facility; a) An adult electronic monitoring safety device will be used to notify /alert staff by sounding an alarm when the resident enters the perimeter around the alarmed door.b) Door alarms placed on facility exits.2) As part of preventative Maintenance Program, all doors will be checked for proper function daily by maintenance department 3. Residents with an adult electronic monitoring device will be checked every shift to ensure device is in place. 4. Adult electronic monitoring device will be checked weekly to ensure the device is functioning properly.5. At no time shall a door be TURNED OFF, without the continual supervision of the exit. If the alarm must be turned off, it is the responsibility of the person disarming it to make sure it is functioning properly once the alarm is turned back on .All residents shall be reviewed for safety awareness impairment and elopement /wandering concerns upon admission, readmission, quarterly, and significant change in condition and as needed. Residents identified at risk for elopement/wandering will have a plan of care implemented to address their elopement/wandering behaviors . When a door alarm sounds, staff members shall immediately respond to determine the cause of the alarm. The staff person responding to the alarm will check outside of the building/vicinity of the area to determine if a resident has exited the building. On 4/18/2023 at 11:00 A.M. V1, V2 and V3 (Regional Operation Manager) have all stated that comprehensive elopement risk assessment was supposed to be done within 48-72 hours upon admission and as needed to determine a specific plan of care to prevent elopement. V2 and V3 also said that the admission assessment done by the admitting nurse have few questions regarding elopement, but it was not considered a comprehensive elopement assessment that would determines an elopement risk. The Immediate Jeopardy that began on 4/11/2023 at 4:30 P.M. was removed on 4/18/2023 at 11:49 A.M. when the facility took the following actions to remove the immediacy: 1) R1 and R2 were located without any injuries within approximately two hours. Facility staff immediately arrived where the residents were found by the police approximately one mile away from the facility, she (V20) stayed onsite until R2 was brought back to the facility in stable condition at approximately 7:30p by the facility staff member, R1 was transported to the ED by [NAME] police and returned to the facility at approximately 1am in stable condition, neither had any injuries. 2) A head count was conducted on 4/11/23 immediately following the elopement incident with R1 and R2 on 4/11/23 and all residents were accounted for. Total census of 101 residents, all accounted for. 3) R1 & R2 were re-assessed for risk of elopement and care plan was initiated on 4/11/23. 4) R1 & R2 were placed on a 1:1 staff monitor until 4/13/23 and were discharged to a facility with a locked unit on 4/13/23. 5) All current residents were re-assessed for elopement risk by social service department and completed by 4/14/23. Care plans were revised as needed. 6) R3 and R4 are the only identified residents who are at risk for elopement at this time. Both R3 and R4 remain on a 1:1 staff monitor since 4/14/23 and this will continue until the new door alarms are upgraded. 7) R6 has a BIMS of 15/15 and therefore not an elopement risk per the MDS assessment on 3/27/23. Updated assessment competed on 4/14/23. R5 had a significant change on 2/3/23 and is no longer an elopement risk. Updated assessment and care plan completed on 4/14/23. 8) New admissions will be assessed for elopement risk upon admission by the nurse and/or designee and an interim care plan will be initiated. Social services department will update the elopement risk assessment for all new admissions within 72 hours of admission and update the care plan. Nurses who identify new admissions at risk for elopement will notify the Administrator and provide 1:1 staff monitoring until the new wander guard system/Door Alarm is installed. Nurse's including agency nurses were in serviced on this procedure on 4/14/23 and agency nurses will be educated on this prior to the start [TRUNCATED]

Based on interview and record review, the facility failed to provide narcotic pain medication per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure resulted in R1 not receiving the scheduled physician-ordered pain medication and experiencing uncontrolled pain. This failure also resulted in R1 being hospitalized due to worsening, uncontrolled pain. This applies to 1 of 3 residents (R1) reviewed for pain in a sample of 10. The findings include: 1), POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The document shows R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)], anxiety, and protein-calorie malnutrition. MDS (Minimum Data Sheet), dated [DATE], shows R1 was cognitively intact. On [DATE] at 12:45 PM, V3 (Friend of R1) stated R1 called V3 a couple days after she was admitted to the facility and told V3 that R1 had not been provided pain medications for at least 24 hours when she first arrived at the facility and was in severe pain. V3 stated R1 told V3 she was in great discomfort and R1 was crying. POS, printed on [DATE], shows R1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS also shows R1 had a physician order, dated [DATE], for a 2 mg [MEDICATION(S)] HCl ([MEDICATION(S)]) tablet to be given to R1 as needed for pain every three hours. MAR (Medication Administration Record), dated [DATE]-[DATE], shows R1 did not receive her first two doses of [MEDICATION(S)] extended release 15 mg tablet on [DATE] at 9:00 AM and 9:00 PM per physician order. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note, dated [DATE] at 6:00 AM, shows R1 stated her follow-up pain rating was 7 out of 10, with 10 being the worst pain possible. MAR, dated [DATE] at 6:02 AM shows R1 stated her pain level was 7 out of 10 and R1 was provided her [MEDICATION(S)] medication. Progress note, dated [DATE] at 7:54 AM, shows R1 stated her follow-up pain rating was 6 out of 10. MAR, dated [DATE] at 9:03 AM, shows R1 received a [MEDICATION(S)] tablet for pain that R1 reported measured 8 out of 10. Progress note, dated [DATE] at 10:03 AM, R1 stated her follow-up pain rating was documented as 5 out of 10. MAR, dated [DATE] at 12:03 PM, shows R1 again received her as needed [MEDICATION(S)] tablet for pain which R1 stated measured 7 out of 10. Progress note, dated [DATE] at 1:51 PM, shows R1 stated her follow-up pain rating was documented as 6 out of 10. Nursing progress notes, dated [DATE] to [DATE], failed to document any attempts to contact R1's physician regarding R1's undelivered [MEDICATION(S)] medication or R1's consistent pain ratings greater than, or equal to, 5 out of 10. The progress notes failed to document any attempts to obtain the [MEDICATION(S)] from the emergency narcotic storage. On [DATE] at 4:10 PM, V11 (Quality Assurance Pharmacist) stated the pharmacy received the first physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V11 stated the first valid prescription the pharmacy received from the facility for R1's [MEDICATION(S)] was on [DATE] at 7:03 PM. V11 stated the medication was delivered to the facility on [DATE] at 11:07 PM with the next scheduled pharmacy delivery. V11 stated the medication was not ordered as STAT (Urgent) so it was delivered during the next scheduled delivery. V11 stated the pharmacy received R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V11 stated the first valid prescription they received for R1's [MEDICATION(S)] medication was on [DATE] at 7:03 PM and the medication was delivered on [DATE] at 11:07 PM. On [DATE] at 10:45 AM, V12 (Physician) stated regarding R1 not receiving her scheduled pain medications on admission, I would have ordered a STAT order to the pharmacist. Same for when she ran out of the medication. There is no excuse With a patient like this I want uninterrupted medication. There is no excuse. V12 stated there were several options to avoid R1 missing her scheduled pain medications including V12 calling the pharmacist and providing a verbal STAT order for immediate delivery to the pharmacy. V12 stated his expectation was that the staff call him so that he could call the pharmacy. V12 stated someone was always on call for him if they could not reach him, but V12 stated he is always available by text and by cell phone. Care plan, initiated [DATE], shows, R1 would like the nurse to notify the physician if interventions are unsuccessful or if current complaint is a significant change from [R1's] past experience of pain. Narcotics emergency storage drug inventory, dated ,d+[DATE] and ,d+[DATE], show the facility had [MEDICATION(S)] 100 mg/5 ml (15 ml) on hand at the facility for use. Facility Pain Policy/Procedures, revised [DATE], show It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain 1. If available in the convenience box or facility house stock, the pain medication ordered will be administered to the resident as soon as possible. After the administration of PRN (As Needed) pain medication, the resident will be assessed for the effectiveness of the pain medication. If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident's physician will be called to refer the lack of relief. Pharmacy Controlled Substance Prescriptions Policy/Procedures, revised ,d+[DATE], show, Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete and signed written prescription from a person lawfully authorized to prescribe controlled substances. A chart order is not equivalent to a prescription for controlled medications. Therefore, the prescriber issuing the chart order must also provide the pharmacy with a valid prescription to ensure delivery of medication. The written prescription may be faxed to the pharmacy for long-term care facility residents. Verbal orders for controlled medications are permitted for Schedule II substances only in emergency situations Verbal orders received by pharmacists from prescribers must also be communicated to the facility before authorized nursing facility staff may access any controlled substances from the emergency supply located at the facility. This may be done either by the prescriber directly or via telephone order from the pharmacist to the facility II New Prescriptions - New prescriptions for controlled medications meeting all state and federal requirements must be received by the pharmacy in one of the following ways. 1. A valid hard copy of the prescription must be transmitted via fax to the pharmacy by the prescriber 2. A valid electronic prescription may be transmitted by the prescriber to the pharmacy . 4. A verbal prescription for a Schedule II medication may be called in to a pharmacist directly by the prescriber only, if: a. Immediate administration of the controlled medication is necessary for proper treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 2). On [DATE] at 12:45 PM, V3 (Friend of R1) stated on Memorial Day weekend of 2021 ([DATE] and [DATE]), R1 told V3 that R1 was again not receiving her scheduled pain medications and was in severe pain. V3 stated R1 told V3 the facility said they had nothing to give R1 for the pain because the physician had not provided a refill on her pain medication. R1 asked V3 and V3's husband to transport R1 from the facility to the hospital to get pain relief because she was in so much pain. V3 stated her husband transported R1 in their personal car from the facility to the hospital where she was admitted . V3 stated, Nobody who is a stage 4 cancer patient should have to go without their pain medication. Ever We got a phone call at 7:00 AM and she told us to come get her because she was in pain. She was sweating, shaking, and crying inconsolably. MAR, dated [DATE] at 9:00 PM, shows R1 reported her pain rating as 5 out of 10 however R1 did not receive her scheduled [MEDICATION(S)] pain medication at 9:00 PM as ordered. Progress notes, dated [DATE] at 10:33 PM, shows R1's [MEDICATION(S)] medication was on order from the pharmacy. Progress note, dated [DATE] at 10:33 PM shows R1 reported her pain rating was 5 out of 10. MAR, dated [DATE] at 3:47 AM shows R1 reported her pain rating was an 8 out of 10 and R1 was provided an as needed pain medication. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . MAR, dated [DATE] shows R1 again failed to receive her 9:00 AM scheduled [MEDICATION(S)] pain medication as ordered. Progress note associated with the missed dose, dated [DATE] at 10:15 AM, shows the medication was not delivered in spite of the prescription being faxed to the pharmacy on [DATE] and the nurses calling the pharmacy twice requesting the medication. MAR, dated [DATE] at 9:09 AM, shows R1 reported her pain as 7 out of 10 and received another as needed dose of pain medication at 9:13 AM. The record also shows R1 received Tylenol 325 mg on [DATE] at 9:07 AM however the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note, dated [DATE] at 9:54 AM shows R1 had a change of condition regarding generalized pain which began on [DATE] and worsened. The progress note shows R1 was transferred to the hospital by a friend, however does not specify at what time R1 was picked up. The progress note fails to provide any assessment regarding R1's pain evaluation and the pain section of the documentation was left blank. Face sheet, dated [DATE], shows R1 was discharged from the facility on [DATE] at 10:30 AM. Progress note, dated [DATE] at 1:48 PM shows Friend take her to [Hospital]. R1's Hospital Emergency Department Admission physician note, dated [DATE], shows, Patient presents with Pain Control - Patient is at a rehab center . and they do not have her pain medication. C/O (Complains of) severe spine and leg pain. This is a [AGE] year-old female . who presents with diffuse pain related to her metastatic [CONDITION(S)]. The patient is currently in a rehab facility and states that her medication orders expired and they could not contact her physician at the rehab center and so she has not had any pain medication for over two days. She states her pain is diffuse and that she is miserable Physical Exam- General: She is in acute distress. Physician Discharge Summary, dated [DATE], shows, R1 with a history of stage IV [CONDITION(S)] with metastases to the liver and spine is being admitted from her skilled nursing facility due to a poor pain control. She was unable to get her [MEDICATION(S)] over the holiday weekend and thus was admitted . On [DATE] at 4:10 PM, V11 (Quality Assurance Pharmacist) stated the pharmacy received a prescription from the facility for [MEDICATION(S)] [MEDICATION(S)] on [DATE] at 2:01 PM which was delivered on [DATE] at 4:02 PM. V11 stated if the facility needed it sooner, they could have had the physician contacted the pharmacy for a STAT delivery which would have been delivered within three to four hours. On [DATE] at 10:45 AM, V12 (Physician) stated, V12 stated his expectation for staff was that they know that R1 has a history of pain and if they do not have a prescription for pain medication, they should call V12 to call the pharmacy and order the medication STAT. V12 stated he would have also ordered R1's as needed pain medications differently to provide R1 better pain management. Pharmacy Controlled Substances Policy / Procedure, revised ,d+[DATE], shows, 8. All controlled medications are requested when a minimum of a five-day supply remains, or in accordance with facility policy, to allow time for acquisition and transmittal of the required original written prescription to the provider pharmacy, if necessary.

Based on interview and record review, the facility failed to implement timely interventions to prevent a high risk resident from developing a pressure injury, and failed to identify the resident's pressure injury before it became an unstageable wound. The wound subsequently became infected with a drug-resistant organism and the resident was sent to the emergency room . This applies to 1 of 5 residents (R1) reviewed for pressure ulcers in the sample of 8. The findings include: R1's Face Sheet showed he was admitted to the facility on (MONTH) 26, 2019, with [DIAGNOSES REDACTED]. R1's (MONTH) 2, 2019, Minimum Data Set (MDS) showed R1 required extensive assistance of two people for bed mobility, had impairments to both legs, and was always incontinent of bowel. The same MDS showed R1 had no pressure ulcers, and R1 was at risk of developing pressure ulcers. The MDS showed R1 was not using a pressure reducing device for R1's wheelchair or bed, and R1 was not on any turning and repositioning program. On (MONTH) 21, 2019, at 10:15 AM, V12 (Wound Physician) stated coming in the door (R1) was at high risk for skin breakdown. V12 stated [MEDICAL CONDITION] can affect a person's vasculature, and R1 was paraplegic and could not move or feel below the waist, was incontinent of stool, and was bony. V12 stated he expects things to be put in place to minimize risk. R1's (MONTH) 26, 2019, Nursing Admission Assessment in R1's EMR was incomplete, and the completed handwritten paper copy showed R1 was at high risk for skin breakdown. R1's EMR showed the paper copy was uploaded into R1's EMR on (MONTH) 19, 2019 (the day after R1 was sent to the hospital for his wound). R1's progress notes showed R1's coccyx wound was noted on (MONTH) 8, 2019, 13 days after his admission. V14's (Wound Nurse) (MONTH) 8, 2019, assessment of R1's wound showed it was first identified as a deep tissue pressure injury with 100% necrotic tissue and serosanguineous drainage. The photo included on the assessment showed black tissue on the bony prominence of R1's coccyx. On (MONTH) 21, 2019, at 8:55 AM, V3 RN (Registered Nurse) stated pressure injuries should be identified way before they're unstageable. V3 added residents should be assisted to turn if they are paraplegic. R1's EMR also showed CNA (Certified Nursing Assistant) Skin Observation documentation asking if R1 has a skin alteration. Every answer leading up to the identification of R1's pressure injury, including the day it was identified, and until R1's transfer to the hospital showed no. On (MONTH) 21, 2019, at 12:45 PM, V5 RN (Director of Nursing) stated CNAs have to really look at the resident and read when charting, adding they can't just go on 'auto-pilot'. On (MONTH) 21, 2019, at 10:35 AM, V11 (CNA) stated she usually works the long-term group and she just knows who to turn. V11 stated there is nothing in resident's rooms that lets staff know someone needs to be turned and repositioned. On (MONTH) 21, 2019, at 12:45 PM, V5 stated the use of turning and repositioning as an intervention has to be loaded into the system so CNAs are aware a resident needs to be turned, and it does not automatically trigger in the EMR system. R1's Electronic Medical Record (EMR) showed turning and repositioning was initiated on (MONTH) 13, 2019 (five days after the identification of the unstageable deep tissue injury). R1's (MONTH) 17, 2019, culture of his wound showed a positive result for drug-resistant bacterial growth. R1's (MONTH) 18, 2019, discharge note showed V12 (Wound Physician) gave orders to send R1 to the hospital for evaluation and treatment of [REDACTED]. The facility's (MONTH) 1, (YEAR), Wound Care Program policy showed It is the policy of this facility to ensure that residents whose clinical conditions and medical [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to ensure pressure ulcers were identified, changes in existing wounds were assessed and physicians were notified, and prevention interventions were in place for residents at risk for developing pressure ulcers. This failure resulted in R46 developing multiple unidentified, untreated pressure ulcers to R46's left foot and a worsening pressure ulcer condition which was not assessed and not reported to the physician on the right foot. Applies to 3 of 11 residents (R24, R46, and R55) reviewed for pressure in the sample of 22. The findings include: 1. Face sheet, dated 6/11/19, shows R46 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. MDS (Minimum Data Set), dated 5/6/19, shows R46's cognitive status was severely compromised and R46 required the extensive assistance of two staff for bed mobility, transfers, and toileting. The MDS shows R46 was totally dependent on staff for bathing. The MDS shows R46 was at risk of developing pressure ulcers/injuries and R46 did not have an pressure ulcer/injury at that time. ADL (Activities of Daily Living) care plan, initiated 4/8/19, shows R46 required the assistance of two staff to reposition and turn R46 in bed. Pressure ulcer care plan, initiated 5/14/19, shows R46 had a pressure ulcer to the right heel and R46's goal was to have intact skin free of redness, blisters, or discoloration by the next review. R46's goals also included the pressure ulcer will show signs of healing and remain free from infection. Hospice Aide Care Plan, undated, shows check pressure areas for sores. POS (Physician order [REDACTED]. - Skin assessment weekly on shower day as needed and every day shift every Wednesday (ordered 4/8/19) - Skin check daily every evening shift (ordered 4/8/19) - Treatment to left heel: Apply [MEDICATION NAME] for protection every evening shift (ordered 4/9/19) - Compression wraps for compression to bilateral lower extremities on in AM and off at HS (before bedtime) (ordered 4/9/19) - Heel protector boots while in bed every shift for protection (ordered 4/9/2019) - Hospice services (ordered 4/19/19) - [MEDICATION NAME] anti-septic paint to right heel and cover with dry dressing / Kerlix daily every evening shift (ordered 5/14/19 and discontinued 6/10/19) - Clean left toe with normal saline and apply dry dressing until healed (ordered 5/14/19) - Off load heels with pillows when in bed as preferred by resident every shift (ordered 6/10/19) - Wound physician for evaluation and treatment (ordered 6/10/19) Hospice nurse visit communication, dated 5/21/19, shows Blister on right heel, cleaned, [MEDICATION NAME] applied, and covered with dressing. Hospice nursing note, dated 5/22/19, shows R46 had a skin tear on his hands, no blisters/open areas on skin including heels were identified. Hospice nurse visit communication, dated 5/29/19, shows Right heel blister still being treated. Hospice visit communications, dated 6/10/19, 6/6/19 6/4/19, 5/30/19, 5/28/19, 5/20/19, and 5/13/19 all show R46 was given a bath by aides and no wounds on R46's heels were identified. The 6/6/19 documentation identified dressings on both arms, no other dressings were mentioned. R46's facility Admission Skin Assessment and Weekly Wound Progress Notes show the following: 5/14/19 right heel Stage 2 pressure ulcer, 5.0 cm (centimeters) length, 5 cm width, no drainage/odor, no undermining, and intact. 5/21/19 no changes 5/28/19 no changes 6/3/19 right heel blood blister popped open, unstageable, 4.0 cm length, 5 cm width, bloody wound bed due to fresh sore, moderate serosanguineous drainage, no odor, [DIAGNOSES REDACTED], [MEDICAL CONDITION], open. For Wound MD (Physician) referral. Late entry Skin/Wound Note, written 6/10/19 and backdated 6/3/19 in the facility EMR (Electronic Medical Record), shows Right heel blister popped open, dry dressing applied, for referral to Wound MD. Wound Summary, dated 6/6/2019, shows R46's wound as an active unstageable blood filled blister, no exudate, 4 cm length, 5 cm width, and showing probable improvement. On 6/11/19 10:39 AM, V6 (Wound Nurse) stated R46's heel blister popped open on 6/3/19 but R46 had not yet been seen by V26 (Wound Physician). On 6/12/19 at 12:00 PM, copies of all of R46's physician/nurse practitioner/physician assistant notes were requested from the facility. The facility provided progress notes dated 6/7/19, 5/21/19, 5/20/19, 5/6/19, and 4/28/19. None of the records showed a physician assessment of any of the pressure ulcers. On 6/10/19 at 10:24 AM, during initial tour of the facility, V27 (Registered Nurse) stated V27 had no residents with pressure ulcers on V27's assignment which included R46. On 6/11/19 at 1:20 PM, V7 (Registered Nurse) stated V7 had not changed R46's right heel dressings because evening shift completes the dressing changes. V7 stated V7 was not aware of any open areas on R46's left heel or toes. On 6/11/19 at 01:28 PM, R46 was lying in bed, feet were on the bed, knees were elevated. R46 was sporadically sliding left and right heels back and forth on R46's mattress halting with heels resting on the mattress. The mattress was a standard mattress and there were no pillows under R46's legs or feet and a white blanket covered R46's legs. V7 (Registered Nurse) entered R46's room and removed the covers on R46's legs. R46 had no protective footwear or boots on R46's feet. R46 had non-skid socks on both feet and a white dressing on right foot under the sock. A strong, foul odor was present. V7 stated R46 should have had protective boots on R46's feet, but the boots were in R46's closet. There was a spot of bright, red, fresh blood , measuring approximately 1.5 cm (centimeters) in diameter, on the white fitted sheet over the mattress. V7 removed R46's socks and there was blood on the left sock. R46's left foot had four smaller black circular areas with red boarders around the ulcers (two on the lateral side edge of the foot, one on the lateral malleolus, one on the medial malleolus), and one larger, open circular wound with a black center on the lateral side of the left heel. V7 and V6 (Wound Nurse) stated V6 had not previously seen any wounds on R46's left foot and was not aware of the wounds until that time. V7 and V6 removed the dressing on the right foot and a strong, foul odor was present. The bandage was heavily saturated with drainage from the wound. The wound was open and had yellow, purulent, thick drainage. The center of the wound had circular, hardened, dark purple tissue and the surrounding tissue surrounding was absent up to the perimeter of the wound. On 6/11/19 at 1:54 PM, V6 stated We don't date when asked to identify the date on the right heel dressing. V6 stated R46's original wound was an intact blister on R46's right foot. V6 looked at the left foot/heel, and stated, This, actually, I have not seen yet. This is the first I have seen of this one. V7 and V6 verified R46's mattress was a standard mattress and not a pressure relieving mattress or a low air loss mattress. V6 stated R46 did not have a low air loss/pressure relieving mattress because he doesn't have anything on the bottom, so we are doing the offloading. V7 stated, Even when R46 has the pillows, R46 constantly moves and they aren't under R46 anymore. V7 stated R46 also constantly kicks off pressure relieving boots. There were three pressure relieving boots in R46's closet. Wound Summary, dated 6/11/19, shows R46's right heel was an unstageable facility-acquired pressure ulcer with 100% slough loosely adherent, moderate serosanguineous drainage measuring 4.5 cm length, 4.5 cm width, 0.0 cm depth. R46's left heel was assessed as an unstageable facility-acquired pressure ulcer, 100% necrotic, hard, firm adherent tissue, 2.5 cm length, 3.5 cm width, and 0.0 cm depth. R46's left medial foot was assessed as a stage 2 pressure ulcer 100% blood-filled blister, 1.0 cm length, 1.0 cm width, and 0.0 cm depth. R46's left foot ankle was assessed as a stage 2 facility-acquired pressure ulcer, 100% blood filled blister, 2.2 cm length, 1.2 cm width, and 0.0 cm depth. R46's left lateral foot was assessed as a stage 2 facility-acquired pressure ulcer, 100% blood filled blister, 6.5 cm length, 1.5 cm width, 0.0 depth. On 6/11/19 at 03:00 PM, V2 (Director of Nursing) stated all nursing and CNAs (Certified Nursing Assistants) staff are expected to monitor skin daily. V2 stated the nurse signs off on a skin assessment on the treatment record and hospice should also report any skin concerns if identified when giving a resident baths twice weekly. V2 stated CNAs should notify their nurse and the wound care nurse if there are any concerns identified. V2 stated the nurse should then notify the physician to evaluate the current treatments for appropriateness or obtain new treatment/care orders for the wound. V2 stated if there is any change in a wound, including signs of infection, the nursing staff were expected to communicate the information to the physician if the nurse cannot handle it. V2 stated V25 (Wound Physician) comes once weekly on Sundays and as needed. V2 stated V6 (wound nurse) was not wound certified. V2 stated V6 assesses facility wounds and determines the stage/type of wound, and calls the physician to report V6's assessment. V2 stated a resident with a heel pressure ulcer should wear pressure relieving boots, use a pillow under their legs for offloading, and be provided a low air loss mattress. On 6/12/19 at 12:54 PM, V21 (Nurse Practitioner) stated V21 was not aware of the pressure ulcers on R46's right or left heel until 6/11/19 when V21 received a text regarding R46's left foot pressure ulcers. V21 stated V21 remembered a wound on the left toe, but nothing else had been communicated to V21. 2. On 6/10/19 at 10:30 AM, R55 was up in wheelchair in doorway of R55's room. R55's feet were resting on the foot pedals of the chair. R55 was not wearing shoes. R55's left heel had a gauze dressing in place and a sock was covering the rest of the left foot. R55 had only a sock on R55's right foot. R55 was not wearing heal lift boots. At 11:01 AM, V4 and V5 (CNAs) assisted R55 to stand to R55's feet to adjust clothing. V5 attempted to put R55's shoe on R55's left foot prior to standing and R55 yelled out in pain. R55 then yelled out in pain again while standing up with just R55's socks on. R55's left foot and ankle appeared dry and [MEDICAL CONDITION] when sock was removed. R55's bed sheets showed multiple spots of serosanguineous drainage near the foot of the bed. On 6/10/19 at 11:15 AM, V3 (RN) stated, R55 has a blister that burst so we are doing dressing changes on it. They are done in the evening and as needed. At 2:38 PM, V3 completed a dressing change to R55's left heel. R55 was in bed on a regular facility mattress with a heel lift boot only on R55's left foot. As V3 removed the gauze dressing on R55's left heel the heel showed a large open area about the size of a tennis ball. There was a large area of missing skin over the heel and the edges of the skin still present were white and macerated (looked wet). The center of the wound was a combination of deep red and purple tissue with some yellow strands of tissue present. R55 called out in pain several times throughout the dressing change. There was a slight foul odor present. V3 stated, I found it like this. It drains a lot. That is why the dressing change is ordered as needed. Found burst open, just like this on the 6th. I documented it. V3 did not address R55's right heel. On 6/11/19 at 8:15 AM, R55 was in R55's wheelchair after receiving a shower. R55 had a heel lift boot on the left foot but not on the right. The right foot had only a sock and was resting on the wheelchair foot rest. On 6/11/19 at 9:29 AM, V6 (RN) stated, R55's wounds were acquired here. R55 uses R55's heels to propel himself around in R55's wheelchair. The right heel has a deep tissue injury and the left heel had a blister and the skin came off. R55's Minimum (MDS) data set [DATE] shows R55 has [DIAGNOSES REDACTED]. This same assessment shows R55 requires extensive assist of 1 staff for locomotion on and off the unit. R55's Braden Scale (assessment for pressure ulcer risk) dated 6/10/19 shows R55 scores a 13 (Under 20 = high risk). R55's Skin Alteration Evaluation dated 6/6/19 states, Superficial/re-[MEDICATION NAME], regular/well defined edges, surrounding edges intact with scant drainage. No pain and no additional wounds. There is no assessment documented of R55's right heel. R55's Left heel Wound assessment dated [DATE] states, Facility acquired, Pressure, Blister, Stage 2, 100% Beefy red with a moderate amount of serous drainage. Size 6.0 x 6.0 x 0 cm. R55's Right heel Wound assessment dated [DATE] states, Facility acquired. Pressure, [DIAGNOSES REDACTED] Deep Tissue Injury. Non-blanchable, [DIAGNOSES REDACTED] 30%, Purple Ecchymosis 70% . Size 2.0 x 2.5 x 0.0 cm. Apply foam dressing every three days and as needed. Off load heel, Prevalon boot all the time. R55's care plan dated 6/6/19 states, R55 uses R55's feet to manipulate/mobilize wheelchair. Refuses to use leg rests despite explanation that R55 is running feet/heels against surface against surface and it will potentially cause breakdown and (R55) requires no shoes: use only non skid socks. Prevalon boots to both feet when in bed. 3. R24's Minimum (MDS) data set [DATE], showed R24 was severely cognitively impaired and required extensive to total assistance to complete activities of daily living. R24's Physician order [REDACTED]. R24's Care Plan dated 5/29/19, showed R24 has impairment to skin integrity .offload heels with pillows when in bed . R24's Skin assessment dated [DATE], showed R24 was at high risk for pressure injuries. On 6/11/19, at 8:00 AM, R24 was lying supine in R24's fully reclined high back wheelchair with no pillow or pressure relieving device under R24's heels. On 6/11/19, at 1:30 PM, R24 was lying supine in bed with no pillow or pressure relieving device under R24's heels. On 6/12/19, at 8:17 AM, R24 was lying supine in R24's fully reclined high back wheelchair with no pillow or pressure relieving device under R24's heels noted. At 8:18 AM, V8 Registered Nurse stated, Yes, (R24) is at risk for pressure injuries. R24 refuses foam heel protectors. We sometimes put a pillow under R24's heels to offload but not consistently. On 6/12/19, at 8:48 AM, V6 Wound Nurse stated R24 was at risk for pressure injuries with pressure relieving interventions for R24 including, offloading heels with pillows and daily skin checks. The facility's Wound Care Program Policy dated 8/2013 showed, It is the policy of this facility to ensure that residents whose clinical conditions and medical [DIAGNOSES REDACTED]. Timely identification of residents assessed to be at risk for skin breakdown .d. Facility shall develop a plan of care and implement interventions according to the resident's Braden Score and/or identified individual risk factor .4. Activity, Mobility, and Positioning .k. Elevate resident heels off the bed as indicated .10. Pressure Ulcer Treatment .c. Timely referral to the facilities wound care specialist for stage III/IV pressure ulcers .

Based on observation, interview and record review, the facility failed to monitor and provide assistance during transfer by not applying alarm monitoring device to promote resident safety. This failure resulted in R1 sustaining 2 consecutive falls that resulted in injury to R1's right eye causing deterioration of vision. This applies to 1 of 3 residents (R1) reviewed for falls. The findings include: The POS (Physician order [REDACTED]. R1 was a [AGE] year old and was admitted to the facility on [DATE] from the hospital due to new onset of UTI (urinary tract infection). The nurse's notes dated 12/30/2018 showed that R1 was able to walk with one person assistance but also prefers to use wheelchair. The nurse practitioner notes dated 1/11/2019 showed that R1 had markedly abnormal event monitor , with baseline NSR (normal sinus rhythm) with episodes of first degree AV (atrio ventricular block), with occasional PAC (premature [MEDICAL CONDITION] contraction) and unifocal PVCs (premature ventricular contractions ) with 1 episode of 5 to 6 beat of NSVT (normal sinus [MEDICAL CONDITION]). The plan was for R1 to continue on Eliquis (anticoagulant/blood thinner). The MDS (Minimum Data Set) dated 1/26/2019 showed that R1 scored 10 for cognition (moderately impaired); 1 for vision (impaired, sees large print, but not large print in newspaper/books); had mood of feeling down, depressed that occurs 2-6 days/2 week period; 3/2 (extensive assistance with 1 person assist) for bed mobility, bathing and locomotion on and off the unit. R1 scored 2/2 (limited assistance with 1 person assist) for transfer, walk in room and corridor, toilet use, and hygiene. The MDS also showed that R1 scored 2 (not steady, ONLY ABLE to stabilize with staff assistance for moving from seated to standing position, walking, turning around, moving on and off bed and surface to surface transfer (transfer between bed and chair or wheelchair). The MDS also showed that R1 scored 1 (impairment on one side) on upper and lower extremities. R1's mobility devices were walker and wheelchair. The active [DIAGNOSES REDACTED]. R1 was also identified on this assessment that she had a fall incident prior to this assessment. The care plan dated 12/30/2018 showed that R1 was at risk for fall secondary to unsteady gait. The interventions for fall prevention showed but not limited to the following: instruct on appropriate use of call light ; keep environment well lit and free from clutter; mobility monitor in place at all times; chair pad alarm at all times when up in wheelchair and bed pad alarm at all times when in bed. On 3/19/2019 at 2:00 P.M., both V3 (Assistant Director of Nursing) and V4 (Nurse Consultant) had confirmed that the 12/30/2018 care plan were the interventions for R1's fall prevention. The facility's incident report showed that R1 was found on the floor on 1/21/2019 at 10:30 P.M. and on 1/30/2019 at 11:05 A.M. These were 2 fall incidents in over a period of 9 days. The facility's incident report showed that on 1/21/2019 at 10:30 P.M., R1 was found sitting on the floor beside her bed. There was a slight discoloration and bump on the left eyebrow. The report also showed that R1 stated that she got up to go to toilet without asking for help and utilizing call light. The patient said she slid on the floor. The post fall assessment showed that R1's lack of safety awareness was considered one of the predisposing physiological factor of the fall. The predisposing situation factors for the fall showed: trying to stand without assist; ambulating without assist; toileting needs; and unsafe transfer without assist. The care plan revision for 1/21/2019 fall episode showed to continue with current intervention; chair and bed alarm; reminded /education to use call light for help. There was also an hourly rounding with staff to monitor patient. When V3 and V4 were asked during the survey, for the documentation regarding hourly rounding, they both stated that there was no documentation of hourly rounding. V3 and V4 were not able to explain whether reminding R1 to use call light would be applicable since R1 was assessed with [REDACTED]. The revised care plan was not resident specific needs and interventions were not nonspecific. On 3/27/2019 at 11:49 A.M., V5 (CNA; Certified Nurse Assistant), stated that on 1/21/2018, around 10:30 P.M., she heard someone screamed Help, Help, coming from R1's room. V5 stated she immediately went to R1's room. V5 added that she found R1 lying on the floor next to bed. V5 further stated that R1 did not pull her call light button and that R1 was not wearing a monitoring alarm, otherwise V5 would have heard the monitoring device. V5 also stated that R1 was not consistent using her call light button and is forgetful. On 3/21/2019 at 3:45 P.M., V6 (Nurse) stated that she was called by a CNA that R1 was on the floor. V6 also stated that she immediately went to R1's room and found R1 lying on the floor. V6 added that R1 did not have an alarm monitoring device at time of the fall. V6 also stated that R1 hit her face on the floor and sustained skin discoloration on the left side of the face, bump on the left eyebrow and a skin tear on the elbow. The facility's incident report dated 1/30/2019 at 11:05 A.M., showed that R1 had a fall witnessed by V8 (Occupational Therapist). The report showed patient fell forward in the wheelchair and landed to the floor on her left side. (R1) remains with large bruise on left side of face from previous fall. The report also showed that R1 was forgetful and has lack of safety awareness. On 3/21/2019 at 1:20 P.M., V8 stated that she was passing R1's room and saw R1 sitting in the wheelchair on 1/30/2019 at around 11:05 A.M V8 also added seconds later she heard a thud and saw R1 landed with face down to the floor. V8 also stated that R1 was not wearing a monitoring alarm device and there was no alarm triggered when R1 landed to the floor. On 3/27/2019 at 11:00 A.M., V7 (Nurse) stated that she immediately went to R1's room when she was called that R1 fell to the floor on 1/30/2019. V7 added that R1 had no monitoring alarm device otherwise she would have heard the alarm. V7 also stated that V8 was there when she came to see R1. The nurse's notes dated 2/7/2019 showed that R1 was discharged to another facility. The admission assessment from another facility dated 2/7/2019 showed that R1 has multiple bruises on her body from previous fall. The following bruises were described as follows: -left elbow 2.5 cm; x 2.0 cm. purple yellow -right elbow 5.5 cm. x 2.5 cm. purple green -left medial knee 1 cm. x 1 cm. purple -left lateral knee 7.0 cm. x 6.0 cm purple -right knee 4.0 x 8.0 cm purple -left hip 2 cm. x 5.0 cm. purple -left lateral thigh 5.0 cm. x 3.5 cm. bruise -left side of face 16 cm. x 6.0 cm. purple On 3/20/2019 at 4:00 P.M., R1 was seen at another facility. R1 still noted with faint bruise on the left side of face. R1 stated that she fell twice at another facility. R1 also added that she has always had blurry vision in her right eye due to a stroke. However, a few weeks after the fall, she felt a strong pain in her right eye and her blurry vision became worse. R1 also added that aside from the deteriorated vision of her right eye, R1 also had a bad headache. R1 further stated that she was taken to eye specialist and that she was told that she had bleeding in the left eye that seeped through to her right eye. On 3/20/2019 at 3:50 P.M., V12 (Assistant Director of Nursing, current facility) stated that R1 did not have a fall at their facility. The physician progress notes [REDACTED]. An ophthalmology consult was ordered. V10 (ophthalmologist) consultation report dated 3/7/2019 showed that R1 complained my eyeball hurts and above my eye at my eyebrow and my cheek. The report also showed that R1's right eye has hyphema, increased intraocular pressure. It was also documented to see V11 (Retinal Specialist) ASAP (as soon as possible) for scan /ultrasound of the eyes. ) The documentation dated 3/7/2019 from V11, Retinal Specialist showed that R1 has [MEDICATION NAME] hemorrhage of the right eye, hyphema of the right eye, ocular hypertension of the right eye and [MEDICATION NAME] opacities of the left eye. V11's notes also showed that R1 appears to have spill-over hemorrhage from the hyphema. It was discussed with (R1) and family about proceeding with surgery to clear this. However, given (R1's) history stroke history and age and poor visual potential in this eye, recommend observation. (V10) already has (R1) on a dilating drop which should help with headache and eye pressure. On 3/21/2019 at 2:40 P.M., V10 stated that R1's hyphema/hemorrhage of the right eye was a spill over hemorrhage from the left eye. V10 also added that the hemorrhage/hyphema was caused from a traumatic injury like a fall. As V10 continued to state, that it was a delayed process to show the signs such as headache and worsened vision. V10 explained that the headache was caused from the increased intraocular pressure of the right eye. V10 also added that the hyphema was not caused from just plain rubbing of the eye but was a caused by a traumatic injury such as a fall and hitting the face. V10 also stated that R1 already has poor vision of the right eye due to history of stroke and this had made it difficult to detect the hyphema sooner until it was kind of late when R1 already showed accumulation of increased ocular pressure that had led to headache and that was when hyphema was identified. V10 also stated that when she examined R1 on 1/9/2019 for regular eye appointment, there was no concern identified. V10 also explained that it was only on 3/7/2019 that the hyphema was identified and it relate to R1's fall history that occurred after 1/9/2019.

Based on observation, record review, and interview the facility failed to provide supervision and implement appropriate fall prevention measures. The facility also failed to develop a policy for supervision. This failure led to R274 sustaining a laceration to the scalp, being sent to the emergency room and receiving staples to the scalp. This applies to 2 of 3 residents (R274, R325) reviewed for falls in a sample of 13. Findings include: The Face Sheet documents R274 is [AGE] years old and was admitted to the facility on [DATE]. The POS/MAR (physician's orders [REDACTED]. 5/30/18 [MEDICATION NAME] (with dose adjustments) 5/30/18 [MEDICATION NAME] 50mg ER oral 2 X day (anti-hypertensive) 6/6/18 [MEDICATION NAME]/HCTZ 37.5/25mg oral daily (Thiazide diuretic combo); 5/30/18 [MEDICATION NAME] 0.125 by mouth daily (Inotropic Agent/Antidysrhythmic) The fall risk assessment 5/30/18 documents score of 13, indicating fall risk. The medical [DIAGNOSES REDACTED]. The care plan dated 5/30/18 documents chair pad alarm at all times. The facility incident reports read R274 fell the following dates in the facility: 5/31/18 in R274's room at 5:15 PM; 6/15/18 in R274's room at 12:20 PM; sent to emergency room and received staples 6/21/18 in R274's room at 3:15 PM; 6/25/18 in R274's room at 6:20 AM On 6/28/18 at 1:36 PM, V15 (Registered Nurse/RN) stated on 6/15/18 staff was passing lunch trays when V16 (Certified Nursing Assistant/CNA) notified her that R274 was lying on the floor. V15 stated It was lunch time. R274 will get up from the chair. I think R274 wanted to go to the bathroom. R274 was lying on the ground next to the bed. V15 stated that R274 stated that R274 had tripped. It could've been the bed side table, it was near. R274 was on [MEDICATION NAME]. R274 had a history of [REDACTED]. R274 does not stand up straight. R274 is confused and requires assistance with everything. On 6/28/18 at 2:10 PM, V16 stated she was the caregiver for R274. V16 stated R274 is confused at times and bends down while in the chair. V16 stated Someone has to be with R274. R274 keeps falling down. R274 thinks R274 can do everything R274's self. V16 stated on 6/15/18 when R274 fell the alarm was not sounding. V16 stated I heard a hitting something. I was passing food trays on the hall. When I got there, R274 was on the floor beneath the bed. R274 was bleeding from the back of the head. The nurse was saying the bleed was from a bump R274 had with a previous fall. V16 stated there was an alarm but it wasn't on. V16 stated that R274 can turn the alarm off, but if R274 comes off the attached pad, the alarm will sound. V16 stated the alarm can be placed out of reach where R274 cannot reach it. V16 stated sometimes we hide it in the pocket on back of the chair and R274 can't find it. V16 stated when R274 fell , the alarm was attached at the top of the chair and not in the pocket. V16 stated R274 was in the room without staff supervision. On 6/28/18 at 2:21 PM V2 (Director of Nursing) stated she and V13 (Nursing Supervisor) are the fall coordinators. V2 stated R274 is high risk for falls and has history of falls at home. V2 also stated R274 was a previous resident of the facility in March/2018 where R274 also sustained a fall in the facility. V2 stated R274 requires supervision when out of bed, staff supervision. V2 stated the nurses' stations aren't centered where the nurses can see into R274's room. Ideally they would be centered to monitor rooms. R274 is forgetful. When asked about medical [DIAGNOSES REDACTED]. Located in R274's medical record was a physician's progress note which documented [DIAGNOSES REDACTED]. V2 stated when R274 fell on [DATE] the interventions added were to instruct R274 to call for assistance. V2 stated however, R274 is non-compliant with this intervention. V2 added R274 believes R274 is independent but is not. R274 needs supervision. V2 also stated R274 has an unsteady gait. V2 stated the intervention after the fall on 5/31/18 was staff educated on regular rounding to check alarms. V2 stated R274 again fell on [DATE] and hit the back of R274's head and went to the emergency room and received staples. V2 stated R274 was in the room without staff supervision. Review of the care plan reads that when R274 fell and sustained a laceration to the head on 6/15/18, R274 stated I removed the pad because it will beep when I stand up. V2 stated V13 wrote this on the care plan. V2 stated V13 was not working on 6/15/18. V2 stated if R274 removed the pad, it would beep. If pressure is off the pad, it beeps. On 6/28/18 at 2:50 PM, V13 stated sometimes R274 can removed the alarm pad. V13 stated she did not interview R274 and R274 did not state to her that R274 removed the alarm on 6/15/18. V13 stated R274 requires supervision and is occasionally confused. R274 has multiple falls. When asked if the alarm can be placed out of R274's sight, V13 stated I don't think so. It always has to be on the chair. We normally don't place it in the pocket, it will fall. V13 stated the conclusion was that on 6/15/18 R274 was attempting to walk to the bathroom per self. R274 fell and hit R274's head. V13 stated on 6/21/18, R274 fell again in R274's room without supervision. V13 stated R274 was trying to pull the privacy curtains when R274 fell . The care plan did not list alternate interventions for when R274 turns off the alarm or does not call for assistance. On 6/28/18 at 3:10 PM, along with V13, R274 was in R274's room. The alarm was on the chair handle just above R274's left shoulder. R274 was able to remove the alarm when asked, but not able to place it back on the chair. The alarm was then placed in the pocket of the attachment to the back of the chair. As V16 had stated, R274 was unable to visualize the alarm. The alarm was out of R274's reach. The cords and alarm remained in place and the alarm was functioning. V13 then stated Well R274 can't reach that unless R274 stands up. 6/29/18 10:07 AM, V17 (Nurse Practitioner/Primary Care Provider) stated R274 is a unique case. R274 is in a room with R274's spouse. V17 stated the spouse is the one watching R274 and telling R274 to sit down while in the facility. V17 stated R274's spouse is here for rehab and acknowledged the spouse is unable to take care of R274 at this time. V17 stated on 6/15/18, R274 fell and required staples to the back of the head. V17 added I can't speak to terms of the facility. I can speak to the fact of R274 being high fall risk. I believe they are responsible for providing supervision. R274 has poor safety awareness. The Minimum Data Set documents that R274 is not steady, and only able to stabilize with staff assistance when moving from seated to standing position; when moving on and off toilet; and when transferring from surface to surface. On 6/29/18 at 7:30 AM, V2 stated the facility does not have a policy for supervision. The Patient Summary from the local hospital dated 6/15/18 reads: Chief Complaint TRAUMA LEVEL 3 FALL. Remove staples in 5-7 days. 2.) On (MONTH) 26, (YEAR) at 12:00 PM, R324 was sitting up in bed eating mechanical soft lunch in R324's room without supervision and his anti-slip mat was laying sideways up against the wall and not at the side of bed. On (MONTH) 27, (YEAR) at 11:50 AM, V9 RN (Wound Care Registered Nurse) stated to V10 RN to bring R324 a lunch tray to his room in case R324 wants lunch. V9 provided R324's wound care treatment and exited the room while leaving R324'santi-slip mat sideways against the wall and not at the side of bed. On (MONTH) 28, (YEAR) at 8:20 AM, R324 was sitting up in bed eating breakfast with no staff supervision and anti-slip mat was laying up against the wall by door. On (MONTH) 28, (YEAR), at 3:16PM, V2 (Director of Nursing) stated R324 is a fall risk and should have anti-slip mat next to bed when R324 is bed and next to R324 when up in wheelchair in his room. V2 stated R324 should be supervised when eating and if R324 does not want to eat in room staff should be assisting/supervising meal intake. R324's Baseline Care Plan and Fall Risk assessment dated (MONTH) 13, (YEAR), shows R324 as at a risk for falls. R324's fall intervention is an anti-slip mat. R324's POS (Physician Orders) dated (MONTH) 15, (YEAR), shows mechanical soft- chopped diet and to eat in dining room supervised. R324's Speech Therapy Care Plan dated (MONTH) 15, (YEAR) shows problem as Aspiration with Swallowing/Aspiration Precautions. R324's Care Conference Patient Summary dated (MONTH) 21, (YEAR), shows current diet as Mechanical soft with thin liquids. On (MONTH) 29, (YEAR) at 8:30 AM, V2 (Director of Nursing) stated the facility does not have a resident Supervision Policy. V2 stated the staff should know better and not leave R324 in room unsupervised when eating. The Facility's Fall Risk Policy revised (MONTH) (YEAR) shows Facility will identify residents/patients at high risk for falling, upon admission and quarterly, when there is a significant change in condition, using developed criteria so special precautions can be instituted to prevent potential falls reassess each resident every ninety (90) days or when a significant change in condition occurs, and post fall .update resident/patient individualized care plan, documenting the fall, date and alternative interventions/approaches implemented.

Based on observation, record review and interview the facility failed to properly assess a resident with change in condition. This failure led to R1 receiving a delay in treatment and being sent to the emergency room with a [DIAGNOSES REDACTED]. This applies to 1 of 1 resident (R1) reviewed for change in condition in a sample of 13. Findings include: The Face Sheet shows R1 is [AGE] years old and was admitted on [DATE]. The MDS (Minimum Data Set) reads R1 is taking anti-coagulants. The physician's orders [REDACTED]. The POS and MAR (Medication Administration Record) documents the following medication: [MEDICATION NAME] 5,000 units inject 1 ml SQ (subcutaneous) every 12 hours, ***NSAIDS increase GI (gastrointestinal) bleed risk; Aspirin EC 81mg tablet by mouth once daily; [MEDICATION NAME] 325mg by mouth twice daily On 06/26/18 at 10:55 AM, R1 was awake in bed with a wash basin lined with paper towels. R1 stated staff gave R1 the wash basin because R1 was nauseated. V11 (CNA/Certified Nursing Assistant) provided morning care for R1. R1 was pointing to R1's epigastric region stating this is where it hurts. It hurts every time she turns me. On 6/27/18 at 9:00 AM, R1 was sitting in the chair in R1's room. R1 had 02 (oxygen) per nasal cannula. R1 stated I am very short of breath and therapy gave me oxygen. R1 stated R1 is not usually this short of breath. R1 stated I can't breathe every time I turn. R1's skin was very pale. R1 stated R1 still feels nauseated. R1 stated these dry heaves are awful. R1 stated R1's abdomen is still very uncomfortable and more painful than before. R1 stated the pain is worse and occurs every time R1 moves. R1 stated its worse when I eat. At this time V3 (Registered Nurse/RN) was outside of R1's room. V3 was notified of R1's concerns but failed to go assess R1. 6/27/18, at 9:15 AM, R1 was stating R1 wants to go to the toilet. V3 placed R1 on the toilet and exited the room. R1 had a large dark BM (bowel movement) and was assisted off the toilet by V14 (RN). On 6/27/18 as of 12:00 PM, R1's condition had not changed and R1's medical record reflected no documented assessment, VS (vital signs) or follow up on R1's condition. R1 was still complaining of abdominal pain and skin was pale. V2 (Director of Nursing) was notified. On 6/27/18 at 2:00 PM, V2 came to the surveyor and stated I just want to let you know V3 is updating the physician on R1's condition. On 6/27/18 at 4:00 PM, V3 stated I just got orders 10 minutes ago. The POS documented orders for lab work, [MEDICATION NAME] (GI) appointment and chest x-ray. V3 stated the orders had not been called in yet. I was being pulled in every direction. V2 was asked when R1's blood will be drawn. V2 stated the lab orders will not be carried out today because they were not ordered STAT. V2 stated the blood work will be drawn tomorrow. On 6/28/18 at 9:00 am, R1 was sitting in the chair stating the nausea and abdominal pain is still there. R1 was still very pale. As of 9:52 AM, R1 had a large bowel movement with bleeding and had to be sent to the emergency room . V12 (RN) stated it is dark with a large amount of blood. At 4:00 PM, V2 stated to the survey team I forgot to tell you, R1 was admitted to the hospital with [REDACTED]. Although R1 had been complaining of nausea on 6/27/18 - 6/28/18, the nursing notes documents: no nausea. The nursing notes on 6/27/18 documents that R1 has no pain, even though R1 complained of abdominal pain. R1's Care Plan for Alteration in Comfort reads: Gastric distress. There were no interventions checked or documented on the care plan for the gastric distress. The section was not completed. On 6/28/18 the facility was asked for the policy for Physician Notification which the facility did not present. On 6/29/18 at 7:40 AM, V2 presented the policy titled Notifying Physician of Changes in Patient Condition. V2 stated I just updated the policy last night. The policy read: The nurse will complete a thorough assessment of the patient condition. If the change in condition persists, the nurse will notify the physician using the SBAR format (situation, background, assessment, recommendation). The policy did not denote the timeframe in which the physician should be notified. On 6/29/18 at 12:30 PM, V18 (Medical Doctor) stated on 6/27/18 he was not informed that R1 had dark stools, was pale, or of any assessment. V18 stated R1 has a history of nausea and epigastric discomfort and he ordered the labs because the facility called him and stated somebody suggests you orders labs for R1. V18 stated he then received a call on 6/28/18 when R1 had bloody stools and sent R1 to the emergency room . V18 stated if he was informed sooner of R1's additional symptoms he would've sent R1 out sooner. V18 added that R1's admitting [DIAGNOSES REDACTED].