Every finding on record at Thryve of Crestwood

Based on observation, interview and record review, the facility failed to ensure residents were free from physical and mental abuse. This failure affected two residents (R13 and R14) in a sample of three residents reviewed for abuse. This failure caused psychosocial harm to R14, as evidenced by R14 verbalizing feelings of emotional pain, and feelings of diminished self-worth; and caused psychosocial harm to R13 as evidenced by R13 verbalized feelings of fear. Applying a reasonable person concept due to the resident's cognitive impairment, a reasonable person would experience avoidable mood changes, agitation, anxiety, and being withdrawn/self-isolation.Findings include: On 8/18/2026 at 9:42 AM, V22 (Licensed Practical Nurse) affirmed V22 is assigned to care for R13 and R14. V22 explained V23 (Dietary Manager) reported to V22 that R13 and R14 were threatening each other in their room and trying to fight each other around 9:30 AM. V22 recalled hearing R14 threaten to hit R13 with a cane. The residents were separated, R13 was still in the room and R14 was being monitored in the dining room until housekeeping could finish cleaning another room on the unit to move R14. On 8/18/2026 at 9:46 AM, V23 (Dietary Manager) recalled performing her daily morning rounds when V23 heard R13 and R14 arguing aggressively. V23 entered the room and observed R13 and R14 arguing but couldn't remember exactly what was said. V23 remembered the two residents saying they were sick of each other and yelling back and forth. R13 told V23 that R14 had threatened to hit R13 with a cane. V23 separated the residents and alerted V22 of the situation while monitoring the residents. On 8/18/2026 at 9:48 AM, observed R13 sitting on a bed, gripping his left arm. R13 stated that R13 was doing bad and wanted to go home. R13 asked surveyor to take R13 home. R13 confirmed R14 hit R13 with a cane to his left shoulder and threatened him. R13 recalled R14 telling R13 to get the f***** out of the room or R14 was gonna beat him. R13 recalled regularly not getting along with R14 and R14 would regularly threaten R13. When asked how the incident made R13 feel, R13 began to be agitated and raised his voice, You sittin' up here asking how I feel when I just got hit?! By the man with his cane in my shoulder?! How you think I'm gonna f****** feel?! Scared!. On 8/18/2026 at 9:51 AM, observed R14 sitting in the dining room with other residents. R14 stated R14 cannot stand his roommate (R13). R14 recalled many issues R14 has had with R13, including R13 stealing R14's phone and other personal items, picking on R13 and repeatedly telling R13 he wants to fight. R14 recalled threatening R13, telling R13 he was going to hit him with his cane if he didn't stop messing with him. R14 recalled getting hit in the face yesterday (8/17/2026) by R13 and R13 punched R14 right below his eye in an argument. R14 explained today R14 was trying to get to the door and is handicapped so R14 pushed R13 to try to get R13 out of the way. In response, R14 hit R13 so R13 struck R14 with the cane. After, a woman pushed open the door, came into the room and R13 told the woman, what I (R14) did. R14 confirmed R14 struck R13 with the cane. After, the woman took R14 into the dining room away from R13. R14 explained, (R13) makes me feel bad about myself. He makes me feel like I ain't nobody, I am somebody. I am somebody son. I am a person. (R13) treats me differently, like I'm not. He makes me feel real low. When I hit (R13) with the cane, I wanted him to feel the pain I have been receiving from him. R13's face sheet documents R13 is a [AGE] year-old resident with diagnoses including unspecified dementia with agitation, cognitive communication deficit, unspecified protein-calorie malnutrition, congestive heart failure, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side.R13's Social Services Patient Interview (8/16/2026) documents R13 has a brief interview of mental status summary score of 4, indicating R13 has severe cognitive impairment. R13's criminal history report (8/10/2026) documents R13 has a criminal history of battery, domestic battery with bodily harm. R13's care plan (8/18/2026) documents is at risk for abuse due to dementia, being at SNF and having noted communication/cognition impairment and having a history of aggressive behavior. 8/18/2026- Resident alleged a peer hit him. R13's progress notes document 8/10/2026 at 10:45 AM, R13 exhibited severe behavior disturbance characterized by yelling, cursing, kicking striking at staff, attempting to physically assault staff, and throwing/damaging property within the room, all unprovoked. R13 was not redirectable despite multiple verbal de-escalation attempts, reassurance, provision of personal space and other non-pharmacological interventions. Behavior posing immediate risk of safety of staff other residents, and (R13) himself. At 1:34 PM, the ambulance arrived to transport resident to the hospital. Behaviors were still ongoing. On 8/11/2026 at 12:19 PM, R13 returned to the facility. At 1:38 PM, progress notes indicate (R13) was initially admitted to the facility with diagnosis of dementia w/agitation. Upon return from hospital, discharge diagnosis includes Lewy body dementia, and Alzheimer's Disease. Discharge medications include Seroquel and sertraline for mood and behavioral management. Due to recent behavioral escalation and updated diagnosis/medication regimen, Psych NP was notified and requested to evaluate the resident and review the current treatment plan. NP was informed of recent behaviors, hospital transfer, discharge diagnosis, and current medications. NP advised continuing current medication regimen as ordered and stated the resident will be evaluated at the next scheduled visit. MD was notified of residents return, current diagnosis, medication regimen, and psychiatric recommendations. MD acknowledged notification and indicated that psychiatric treatment recommendations and management should be addressed by the psychiatric provider. (R13) will continue to be monitored closely for behaviors. - Provider to be notified of any behavior escalation/changes in condition, or concerns regarding medication tolerance or effectiveness. V28 (R13's Family Member) called and made aware of residents return and rediscussed the events of the residents' behaviors, current condition and medication regimen. (V28) was informed of the current orders for Seroquel, and sertraline, including their intended use/possible side effects. (V28) verbalized understanding and provided consent as witnessed by two licensed staff. During discussion, (V28) expressed significant concern regarding (R13's) behaviors and V28's inability to safely manage R13 in the home setting. (V28) stated, (R13) is too much for me. (R13) can never come home with me. If (R13) can't stay in your facility, they will find me dead. (R13) was fighting me. I will get a divorce before I let (R13) come stay with me. Where else can (R13) go? Emotional support and reassurance were provided by staff. (V28) was informed that the facility is not currently attempting to discharge the resident to her home and that the interdisciplinary team will continue to evaluate the residents behavioral, psychiatric, safety, and placement needs. On 8/18/2026 at 11:45 AM, progress notes indicate R13 was involved in verbal altercation with another resident. During the incident the (R13) states he was struck on the left shoulder by another resident. Staff intervened and immediately, separated both residents, and ensured resident safety. Head to toe assessment completed. Resident assessed for pain, tenderness, swelling. ROM WNL No signs of apparent injury noted at the time of assessment. 131/71-97.8-72-18-96%. Resident denies being hit in the head; however, neuro checks were completed no abnormalities noted and appears to be at baseline. Resident with little pain of 4/10 . On 8/18/2026 at 7:46 PM, V35 (Psychiatric Nurse Practitioner)'s progress notes document (R13) is a 71 y/o male who presents for psychiatric intake evaluation. The resident is currently residing in the skilled nursing facility with a history of Severe Dementia with agitation and behavioral disturbance. Resident was previously hospitalized for fatigue and spouse reporting worsening dementia with mood swings. The resident was recently hospitalized for aggressive behaviors . R13 was alert and oriented during the visit. He reported a recent incident in which his roommate pushed him out of the way, stating he told me I couldn't go with him. Staff reports resident had a verbal altercation with his roommate and staff was able to deescalate the encounter .R14's face sheet documents R14 is a [AGE] year-old resident with diagnoses including chronic kidney disease stage 3, chronic obstructive pulmonary disease, history of transient ischemic attack and cerebral infarction, benign prostatic hyperplasia, and history of malignant neoplasm of the thyroid.R14's minimum data set (6/12/2026) documents a brief interview of mental status (BIMS) summary score of 10, indicating R14 has moderate cognitive impairment. Additionally, R14 requires staff assistance (partial to substantial/max) with activities of daily living, including locomotion when in the wheelchair.R14's care plan (8/18/2026) documents R14 is at risk for abuse and displays difficult behaviors when dealing with peers. R14 has the potential to become verbally/physical aggressive towards others. On 8/18/26, R14 had a physical altercation with a peer. R14's petition for involuntary admission [DATE]) documents R14 was petitioned for a psychiatric admission due to displaying physical aggression towards a peer allegedly with a cane. R14 required immediate psychiatric hospitalization for psychiatric evaluation and treatment. R14 was in need of immediate hospitalization for the prevention of harm. On 8/18/2026 at 3:28 PM, V2 (Director of Nursing) affirmed V2 was made aware of an incident that occurred between R13 and R14. V2 recalled being told R14 allegedly hit R13 with a cane. V2 stated R14 told V2 he didn't hit R13. R14 told V2 that R13 wanted to go with him to see somebody, and that's when the altercation started. V2 explained R13 is a newer resident to the facility. Shortly after arriving, V2 was working with R13 and asked to assist him with elevating his legs. R13 gave V2 permission. R13 after began to kick, assault V2, and threaten other staff. R13 was petitioned out for his behaviors and returned to the facility, where R13 was moved to the 4th floor dementia unit with R14. V2 recalled speaking with V28 (R13's Family Member) who told V2 R13 would beat V28 at home and was adamant that R13 could not return home. On 8/19/2026 at 1:09 PM, V4 (Social Services Director) affirmed V4 is familiar with both R13 and R14. V4 explained R13 was admitted recently and had a discharge to the hospital shortly after R13 arrived. V4 was told V4 was petitioned out because R13 was throwing items, hitting staff, and being resistive to cares. R4 returned back and was moved to the 4th floor after a dementia diagnosis was given. V4 recalled hearing about the altercation between R13 and R14 on 8/18/2026. V4 recalled talking to R14 after the incident and R14 was irritated and wanted to talk to his family. R14 told V4 R14 was upset with R13 because R13 was talking about R14's mother. V4 met with R13 and R13 was still a little riled up. R13 stated he was trying to go with R14 (out of the room). V4 affirmed R14's behavior was abnormal, and R14 generally gets along with other residents. V4 affirmed V4 was aware of R14 having a criminal conviction of battery and affirmed V28 (R13's Family Member) has reported prior history of violence at home. On 8/20/2026 at 12:35 PM, V35 (Psychiatric Nurse Practitioner) explained psychosocial signs of physical/mental abuse include, but are not limited to, mood changes, agitation, anxiety, and being withdrawn/self-isolation. V35 affirmed V35 assessed R13 after the incident. V35 was told by staff there was a verbal altercation between R13 and his roommate, and R13's roommate was petitioned out for a psychiatric eval. R13 reported to V35 that R13's roommate was agitated because R13 was trying to go with him (R14) somewhere so R14 pushed R13. V35 was unsure if the allegation was true and affirmed R13's cognition is moderately impaired but R13 knows who he is, his birthdate, he knows he is in a facility. On 8/20/2026 at 12:52 PM, V1 (Administrator) affirmed V1 is the abuse prevention coordinator. V1 affirmed physical abuse including pushing someone, striking someone, punching or hitting someone. Mental abuse includes talking down to residents, telling them to shut up, or threatening them. V1 recalled speaking with both R13 and R14 while conducting the abuse investigation. R13 told V1 R14 was stating in the doorway when R14 pushed him and hit him with a cane. R14 told V1 R14 was trying to go to a family member's house to get food and told R13 to move because R14 was standing in the doorway. R13 told R14 that R13 was going with R14 to his family's house and was going to get food too. That was when R14 pushed R13. R14 initially denied hitting R13 with a cane but eventually admitting to V1 to hitting R13 with a cane.Facility abuse policy (10/2025) documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents . Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR 483.12 Interpretive Guidelines). The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. (42 CFR 483.5) . Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines) . Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines) . Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines). Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation (42 CFR 483.12 Interpretive Guidelines) .

Based on interview and record review facility failed to ensure provider and clinical staff's documentation was accurate for one of three (R3) residents reviewed for professional standards.Findings include:R3 was admitted to facility on [DATE] with diagnoses that included mitral valve insufficiency, heart failure, difficulty walking, dysphagia, type two diabetes, acute respiratory failure, chronic obstructive pulmonary disease, hypertension, myocardial infarction, peripheral vascular disease, atherosclerotic heart disease, chronic kidney disease, atrial fibrillation, gastroesophageal reflux, obesity, enterocolitis due to clostridium difficile.Minimum Data Set (MDS) dated [DATE] included Brief interview of Mental Status (BIMS) of thirteen indicating R3 was cognitively intact. On [DATE] at 11:48 AM V20 (Medical Director) stated any medication order, admission, change of medication, labs or change in condition should be documented in the electronic health record (EHR). Everyone has computer access nowadays, but if the provider cannot document in real time the provider should document a note retrospectively in the EHR. V19 (Nurse Practitioner) should have documented the events of what happened, who was called when, and what orders were given. A few lines of what happened would have helped to understand what happened to R3.On [DATE] at 12:39 PM V31 (Director of Rehabilitation) reviewed R3's therapy progress note from [DATE] and stated it does not appear anything out of the ordinary happened with R3 in therapy that day. Anything that occurred with R3 during rehab should be documented.On [DATE] at 12:51 PM V32 (Physical Therapy Aide) stated on [DATE] R3 complained of feeling tired and R3's assistance with walking and transferring changed from supervision to moderate assist. R3's walking decreased on [DATE] from 75 feet to 30 feet. R3 complained of feeling tired. V32 stated I was worried about her fatigue. V32 stated R3's blood pressure was taken but not recorded. V32 did not remember R3's blood pressure that day. V32 told a nurse about R32 feeling tired and deceased walking distance, but V32 did not remember what nurse was told nor documented any communication with nursing.On [DATE] at 10:13 am V20 (Medical Director) stated he reviewed the chart but was unable to provide clarification of the timeline or when V19 (Nurse Practitioner) was called and gave orders.On [DATE] at 11:20 AM V41 (Regional Nurse Consultant) stated from the interviews completed R3 wasn't feeling very well and had low blood pressure sometime after 1:00 PM on [DATE]. Staff put R3 in Trendelenburg and the blood pressure rebounded to a normal parameter. V18 arrived and said R3 had another change. About 2:40 or 2:50 PM there was a change occurring. A rapid response was called. V41 stated the timeline in this case was not proper. V41 stated I don't want to answer whether we met the standards or professional practice and resident care.On [DATE] at 11:57 AM V40 (Chief Executive Officer) stated this was a sentinel event and there should have been a soft file making sure all of the documentation was correct. It was wrong documentation.Review of V32's (Physical Therapy Assistant) progress notes on [DATE] regarding R3 gait distance changed from 75 feet to 30 feet. Changing from sit to stand position changed from supervision to R3 requiring moderate assessment. No vital signs or nurse notification of R3's change was documented in the medical record.During the investigation, the facility was unable to provide documentation in the medical record by V19 regarding R3's what happened, who was called when, and what orders were given.During the investigation, V19 was unable to be contacted by the surveyor. Facility stated V19 was out of the country and unable to be contacted.Facility PolicyMedical Record policy dated 5/2026 document in part when an error is made in a medical record entry, the following error correction procedures must be followed: document the correct information. Physician Services policy dated 5/2026 documents in part the physician is responsible for reviewing the treatment plan, signing all orders in the medical record, as well as, completing the medical record upon discharge.

Based on observation and interviews, the facility failed to follow their incontinent care policy to keep residents as dry as possible. This failure affects one (R1) of three residents reviewed for incontinent care.Findings include: R1 is a [AGE] year-old female admitted in the facility on 4/29/2026. R1 has a brief interview for mental status score of 15 with a completion date of 8/6/2026. Review of R1's MDS on Self-care (Eating) coded R1 for set-up or clean up assistance. R1 is incontinent and uses diaper.On 8/8/2026 at 10:20 AM, R1 told the surveyor that R1 needs to be changed. R1 said that the staff do not change R1's diaper. Surveyor told V3 (CNA) that R1 is requesting for R1's diaper to be changed. At 10:28 AM, V3 came to change R1's diaper and V3 and surveyor observed that R1's diaper was full of urine that soaked to her sheet with good amount of soaked with urine. The surveyor requested V1 (Administrator) who observed with V3 and surveyor at 10:30 AM that R1's diaper was full of urine and that the urine soaked through R1's sheet with large amount. In the presence of V1, V3, and surveyor, R1 said that V3 did not change R1's diaper this morning. R1 also said that the night shift did not change R1.On 8/8/2026 at 1:02 PM, V3 (CNA) said that V3 has been working in the facility for about 3 years. V3 said that V3 has been taking care of R1 since R1 admission to the facility. V3 said that residents' diapers are changed every 2 hours and as needed. V3 said that R1 is alert some days and some days R1 is not alert. V3 said R1, can make her needs known. V3 said that V3 started her shift today at 07:00 AM. V3 said that R1 diaper was not changed until after R1's diaper was observed soaked around 10:28am with the surveyor. V3 said that R1 did not tell her that she needed to be changed when V3 set R1 up for breakfast. V3 said that R1 can feed herself but requires assistance to set-up and meat to be cut up. V3 said that R1 should not be sitting in a diaper full of urine that soaked through her sheet.On 8/8/2026 at 1:22 PM, V4 (CNA) said that V4 has been working in the facility for 5 years. V4 said that V4 has taken care of R1 before. V4 said R1 is alert x 3 and able to make her needs known. V4 said that residents' diapers are changed every 2 hours or as needed. V4 said that R1 knows how to put on the call light if R1 needs her diaper change and the staff are also supposed to check on R1 to see if she needs her diaper change. V4 said that R1 is not a feeder rather R1 needs to be set-up to feed herself. V4 said R1's meat is usually cut up for her. V4 said that no residents should be sitting in a diaper and sheet soaked with urine.On 8/08/2026 at 1:40 PM, V5 said that V5 has been working in the facility for about one year. V5 said that diaper changes are done every 2 hours or at the residents' request. V5 said that no resident should be sitting in a soaked diaper and sheet because it causes skin breakdown. V5 said that the residents that are taking diuretics or drinking a lot of water that causes them to urinate heavily should be checked on more frequently. V5 said that depending on how R1 is doing, she may require more assistance than just to set her up for feeding. V5 said that R1 has tremors and when she is shaking a lot, she may need to be fed. V5 said that R1 likes to do things for herself but as R1's nurse, V5 follows R1 cues to determine how much assistance she needs at the time.On 8/8/2026 at 2:03 PM, V1(ADMINISTRATOR) said that staff are supposed to make incontinent care round every 2 hours and as needed. V1 said that there should not be any residents sitting in a soaked diaper that went through their sheet. V1 said that V1's observation of R1's-soaked diaper and soaked sheet with urine is not what V1 expects to see with any resident. GUIDELINE: INCONTINENCEMANUAL: CLINCALREVIEW DATE: 5/2025 GENERAL: Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. LEVEL OF RESPONSIBILITY:All Nursing Staff GUIDELINE: 4. Remove all soiled clothing and linen.

Based on interviews and record review, the facility failed to follow policy procedures, failed to ensure that staff documented medication administration, and/or failed to document medication as received or not received in the Nurses' notes for two of three residents (R1, R3) reviewed for medication administration.Findings include: R3's (3/27/26) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 6/3/26 at 1:47pm, R3 stated My (R3) potassium was missed (not received) because of the pharmacy a few days ago and affirmed that Potassium was received this morning. R3's (June 2026) MAR/Medication Administration Record (printed on 6/3/26 at 4:16pm) includes the following medications: Potassium Chloride, Cyanocobalamin, Ferrous Sulfate, Vitamin C, Carvedilol, Docusate Sodium, Famotidine, and Lactulose (scheduled for 9am administration) however the entries for each medication were blank on 6/3/26 - at 9am. On 6/4/26 at 1:19pm, surveyor inquired what blank entries on the MAR indicate V2 (DON/Director of Nursing) stated If its blank, they (staff) didn't sign it out or indicate if they (resident) didn't get it. On 6/4/26 at 1:32pm, V2 stated I V2 (DON) talked to the Nurse (V19/Registered Nurse) assigned to (R3) yesterday day shift. She (V19) told me she gave her (R3) all the scheduled meds (medications) yesterday. I (V2) also talked to the resident, she (R3) told me (V2) she got all her meds yesterday. R1's (5/12/26) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 6/2/26 at 2:25pm, R1 denied concerns with medication administration at the facility, however concerns were subsequently identified. R1's (June 2026) MAR includes Prednisolone Acetate Ophthalmic suspension (scheduled for 6am administration) and Ketorolac Tromethamine Ophthalmic solution (scheduled for 9am administration). R1's MAR affirms on 6/2/26 the (6am) Prednisolone Acetate Ophthalmic suspension is marked 9 (see Nurses Notes) and (9am) Ketorolac Tromethamine Ophthalmic suspension is marked 9 however nothing is documented in the (6/2/26) Nurses progress notes regarding administration or lack thereof for either medication. On 6/4/26 at 3:58pm, surveyor inquired what number 9 indicates on the MAR V1 (Administrator) stated Other, see Nurses note. Surveyor inquired if the Nurse entered a progress note for R1's (6/2/26) scheduled eye drops V1 responded I (V1) See a Nurses note there for the eye drops but it's just the order. Surveyor inquired if R1 received the eye drops on 6/2/26 as ordered. V1 replied I would have to contact the Nurse to see what occurred and why we (staff) documented 9. The facility medication administration policy (reviewed 2/2026) states document as each medication is prepared on the MAR. If medication is not given as ordered, document the reason on the MAR.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to provide supervision/touching assistance for eating and/or failed to provide transfer assistance from the bed to wheelchair for four of 42 residents (R6, R14, R37, R131) in the sample reviewed for ADL (Activities of Daily Living) care. These failures resulted in R131's reported discomfort/feelings of uselessness and R37's reported frustration. Findings include: R6's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) of 15 indicating R6 is cognitively intact and indicates that R6 is dependent in chair or bed-to-chair transfers. R6's medical history is significant for end stage renal disease, muscle wasting and atrophy, hemiplegia, dysarthria, unspecified lack of coordination and functional quadriplegia. R37's MDS dated [DATE] has a BIMS of 15 and indicates that R37 is dependent in chair or bed-to-chair transfers. R37's medical history is significant for cardiomegaly, cauda equina syndrome, paraplegia, chronic kidney disease, history of pressure ulcer, peripheral vascular disease, major depressive disorder, bilateral primary osteoarthritis, reduced mobility, obesity, diabetes, neuromuscular dysfunction and polyneuropathy. R131's MDS dated [DATE] has documented a BIMS of 15 and indicates that R131 is dependent in chair or bed-to-chair transfers. R131's medical history is significant for heart failure, muscle wasting and atrophy, peripheral vascular disease and history of acute embolism and thrombosis. R189 has a BIMS of 14 indicating that R189 is cognitively intact dated 5/3/2026. On 5/5/2026 at 8:59 AM R37 stated I need my wheelchair. R37 had a motorized wheelchair that stopped working approximately five years ago and had been using the facility's wheelchair, along with a seat cushion which belonged to R37. R37 reported not being out of bed for about three weeks because the wheelchair is missing. I want to get out of bed. I don't want to get up all the time, but it would be nice to get up when I want to and I can't do that here. On 5/5/2026 at 9:05 AM V35 (Licensed Practical Nurse) stated R37 gets up in the wheelchair with assistance. R37 can propel self once in the wheelchair. V35 was asked when R37 last got up to the wheelchair or whether R37 had refused to get up to the wheelchair. V35 stated staff document any resident activity or refusal in the electronic health record (EHR), in the nursing progress notes or the nursing daily skills. V35 reviewed the EHR and stated I am all the way to 3/13/2026 and don't see any documentation where R37 has gotten out of bed. R37 should be getting out of bed to the wheelchair at least three times a week. That is what R37's family wants. V35 stated R37 should be getting up daily. We don't have a standard for activity of how often residents should be gotten up. V35 stated if it is not documented, it wasn't done. V35 did not find EMR documentation that the staff tried to get R37 up or R37 refused to get up. V35 stated that the risk of R37 staying in bed include bed sores, clots, pneumonia, contractures, depression, loneliness, sadness. V35 stated R37 is at risk of all of those complications because we are not getting R37 up. On 5/5/2026 at 9:28 AM V29 (Unit Manager/Licensed Practical Nurse/LPN) stated we ask residents every day if they want to get up for breakfast. On 5/5/2026 at 9:31 AM V34 (Certified Nursing Assistant) was asked if residents were asked if they want to get up in the morning for breakfast. With V35 (LPN) present, V34 stated No, they don't ask. On 5/5/2026 at 9:34 AM V25 (Restorative Director/Licensed Practical Nurse/LPN) stated R37 can get up to the wheelchair with assistance. R37's wheelchair was put in storage. We took it for minor repairs, but it is not fixed yet. We normally ask if R37 wants to get up. The last time R37 was out of bed was last week, maybe Thursday. If R37 refuses to get up, it should be documented in the EMR in the progress notes. V25 reviewed the EMR. I don't see anything documented. I keep that information on the task sheet. V25 reviewed the task sheet from 5/4/2026 and stated on 5/4/2026 R37 did not get up but also did not refuse. Refusal would be documented with a check mark on the task sheet. V25 stated the task sheets for 5/3/2026 or any date in the last month are not available. V30 (Restorative Aide) who stated if a resident refuses to get up, the nurse documents that refusal in the POC (plan of care). On 5/5/2026 at 12:59 R189 volunteered that R189 has been R37's roommate for two weeks and today was the first time R37 has been out of bed. I have never seen R37 up out of bed. On 5/5/2026 at 1:02 PM R37 was observed up in an extra-large wheelchair. R37 stated I am better now that I am out of that bed. I would be better if I had my own wheelchair. This wheelchair that they gave me is too big, so it is a bit unyielding. They still have not found my wheelchair seat cushion. On 5/5/2026 at 3:49 PM V36 (R37's daughter) and R37 met with surveyor. V36 stated the facility has not gotten R37 up in 3 weeks and now R37 was gotten up today because the state raised it as an issue. The facility is always understaffed and cannot get residents out of bed. On 5/6/2026 at 2:49 PM V 25 (Restorative Manager) stated yesterday, V40 (Therapy Director) measured R37 for a motorized custom wheelchair and placed the order. On 5/6/2026 at 2:54 PM V40 stated R37 was measured for a power wheelchair and a power wheelchair was ordered yesterday. V40 stated if a resident has a diagnosis that supports motorized wheelchair use and the resident has the cognition to use a power wheelchair; the resident is given the option of ordering a power wheelchair. R37 can have a new power wheelchair every five years. V40 stated R37 was asked in the past if R37 would like a power wheelchair and R37 did not want one. V40 stated that those discussions with R37 were not documented anywhere. V40 stated R37 is now wanting to get out of bed, so R37 was asked yesterday. On 5/6/2026 at 2:59 PM R37 stated I don't remember being asked in the past about getting a new power wheelchair. I need to get up and exercise more, so it should help. On 05/04/2026 11:26 AM V131 stated I am getting up in the wheelchair this afternoon. I want to get up. On 05/05/2026 at 9:05 AM R131 stated R131 did not get up to the wheelchair yesterday. I wanted to get up yesterday. I was looking forward to it. They said that they had a lot of things going on so they couldn't get me up. They said that they had a lot of patients going to Dialysis so they couldn't get me up V131 reported leg soreness from lying in bed. On 5/5/2026 at 12:59 PM R131 was observed up in the wheelchair. R131 stated I feel better now that I am up. When asked if staff don't get R131 up how it makes R131 feel, R131 said, I feel useless and dissatisfied. When I sit in bed too long, I feel lost. R131 stated when R131 can get out of the room in the wheelchair, V131 feels good, happier. On 5/5/2026 at 10:02 AM R6 wants to get up, but R6 stated staff don't let R6 get up. R6 stated I did not eat lunch yesterday because I wanted to get up for lunch, but staff would not get me up. Staff got me up after lunch yesterday, but lunch was over, so I did not eat lunch. On 5/5/2026 at 12:48 PM R6 was sitting up in wheelchair eating with assistance by V34 (Certified Nursing Assistant). R6 was observed smiling and stated R6 was happy to be up. On 5/6/2026 at 1:21 V39 (Nurse Practitioner) stated I would like to see residents up every day. Risks of not getting out of bed include deep vein thrombosis (DVT). If residents lay in bed for greater than three days, they can decondition or develop muscle wasting. Depression is a big risk, as well as social isolation. R131 should be up daily. R131 has wounds, so he may not be able to be up for more than an hour or two, but R131 should be up daily. R37 should be getting up daily. R37 used to get up daily in the past, but that stopped. I don't know why. On 5/6/2026 at 3:45 PM V2 (Director of Nursing) stated expectation is that if a resident wants to get up, staff are getting the resident up. If a resident refuses to get up, the nursing assistants should talk to the nurse or nurse manager who would then encourage the resident to get up or document the refusal in the progress notes. The risks of prolonged bedrest include skin breakdown, depression, infection, there are too many risks to name them all. V2 was not aware that residents were asking to get out of bed but not getting up out of bed. On 5/6/2026 at 5:30 PM V2 (Director of Nursing) presented staff education dated 5/6/2026 that stated All residents are to be asked if they want to get out of bed daily. If they refuse, please reapproach later and ask again if they want to get out of bed if residents continue to refuse notify the nurse. The nurse must ask the residents if they want to get up and if the resident refuses, the nurse is to document under the progress notes, the resident refusal and initiate a refusal to get out of bed care plan. R14's diagnoses include generalized muscle weakness, and lack of coordination. R14's (4/8/26) BIMS (Brief Interview Mental Status) determined a score of 6 (severe impairment). R14's (4/8/26) functional assessment affirms the resident requires supervision or touching assistance for eating and substantial/maximal assistance with lying to sitting on the side of bed. On 5/4/26 at 1:04pm, R14 was lying in bed with the head of bed elevated roughly 45 degrees. R14's lunch was observed on a table adjacent to the bed - not over the bed or within reach. Staff were not present - to provide cues or feeding assistance. R14's meat was not cut into bite size pieces and the meal appeared barely touched. On 5/4/26 at approximately 1:05pm, surveyor inquired if R14 received assistance with eating lunch today R14 stated No. Surveyor inquired if R14 can sit up on the side of the bed without assistance V3 (Assistant Director of Nursing) responded No, he's (R14) able to move the remote. Surveyor inquired what percentage of food R14 ingested V3 replied Maybe about 10%, if that. V3 subsequently left R14's room without placing the meal within reach, elevating the head of bed, or offering feeding assistance. Facility policy titled Residents' Rights for People in Long Term Care Facilities states the facility must care for residents in a manner that promotes your quality of life and must provide services to keep residents' physical and mental health at their highest practical levels. The feeding assistance policy (revised 5/2025) states attempt to provide adequate nutrition to a resident who is unable to feed themselves by hand feeding the resident. Residents who are unable to feed themselves are encouraged, instructed, assisted and/or fed by a qualified staff member. Position resident in proper body alignment for eating. Cut food into small, easily chewable pieces.

Based on observation, interview and record review, the facility failed to post the list of names, addresses (mailing and email), and telephone numbers of the State Survey Agency and failed to post a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility. This failure affects all 200 residents that reside within the facility. Findings include: Facility census (5/4/2026) documents that 200 residents reside within the facility. R202's face sheet documents in part R202 is a [AGE] year-old resident with diagnoses including: displaced fracture of 3rd metatarsal bone right foot, type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, wedge compression fracture of 4th vetrebrae, unspecified muscle wasting and atrophy, personal history of transient ischemic and dysphagia. R202's minimum data set (4/7/2026) documents in part a brief interview of mental status (BIMS) summary score of 15, indicating R202 is cognitively intact. On 5/4/2026 at 11:35 AM, R202 stated the care here is not good. Not good at all. I'm trying to transfer out of here to another facility. You can complain about things, but nothing changes. I don't think people like to say anything, like they are afraid to talk about it. I don't know where the number to notify you guys (state survey agency) is. I think people have called, but I haven't seen it posted anywhere.On 5/5/2026 at 11:21 AM, V1 (Administrator) stated the state survey agency's contact information was posted in the elevators and on bulletin boards throughout the facility. A facility tour was completed with V1 of all floors, resident units, nurse's stations, bulletin boards, nurse's stations, elevators, reception areas, facility main entrance and did not observe the state survey agency's contact information on any unit or any statement that the resident may file a complaint with the state survey agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility. The elevator bulletin boards were covered in a glass casing to allow access for only staff. V1 confirmed these observations and confirmed that the state survey agency's contact information was not posted within the facility for the residents. V1 did not know why the posting was not posted. V1 stated, I have seen it in the elevators before. I don't know why it's not there. V1 explained the purpose of the posting is to residents can exercise their right to complain about their care to the state survey agency. On 5/5/2026 at 1:53 PM, observed V57 (Receptionist) at the front desk on the computer utilizing a word processing software. Observed V57 fabricating a posting that had the state survey agency's contact information on it. Surveyor inquired what V57 was creating on the computer and V7 stated, You don't see anything and minimized the screen. V57 affirmed V57 was creating a posting that had the state survey agency's contact information on it. On 5/7/2026 at 2:13 PM, V5 (Social Services Director) affirmed residents have the right to complain to the state survey agency about their care. V5 explained there are posters on the floors and in the elevators for the [NAME] retaliation hotline and ombudsman's hotline. V5 affirmed the state survey agency's hotline should be posted with the other postings. V5 recalled seeing the postings last in the elevators in the case within the last few weeks. V5 explained the state survey agency's contact information is important so residents know they can report concerns and complaints to the state survey. Facility policy titled, Required Postings (reviewed 7/2025) documents, It is the policy of the facility to comply with federal regulations in regard to the posting of information for the residents and staff . Other federally required postings such as names and telephone numbers of all pertinent state agencies and advocacy groups, such as the state survey agency, the state survey agency, the state licensure office, the office of the state long term care ombudsman program, the protection and advocacy network, home and community based service programs, Medicare and Medicaid contact numbers, grievance procedures and the Medicaid Fraud Control Unit will be posted in a form and manner accessible and understandable to residents and resident representatives .

Based on observation, interview and record review the facility failed to store/label food in accordance with professional standards for food safety, failed to provide a clean, sanitary kitchen environment, food preparation and food storage areas, and failed to follow the facility policies for safe food handling. These failures have the potential to affect all 195 residents that consume nutrition from the kitchen. Findings include: Facility census (5/4/2026) documents 200 residents reside in the facility. Record review of facility enteral feeding list (undated) documents five residents (R15, R69, R70, R157, R210) were on enteral nutrition and did not receive oral nutrition. On 5/04/2026 at 9:07 AM, the initial tour of the kitchen and food service areas was completed. Observed Worcestershire sauce in the cooler with a use-by date 3/6/2026. Observed Chicken salad in a tray, covered in plastic wrap with no date. These findings were confirmed with V7 (Dietary Manager). V7 affirmed the Worcestershire sauce was expired, and the chicken salad should have been dated. V7 removed the Worcestershire sauce from the refrigerator. Observed two visibly dirty scoops covered in a yellowish orange powder, in a plastic bag on a shelf of the dry storage area. No date was on the plastic bag. V7 (Dietary Manager) thought the scoops were used from a chicken [NAME] powder and was unsure when the scoops were last washed or used. V7 removed the scoops from the area. Observed a black dirt like substance caked across the floor of the dry storage room tiles across approximately 25% of the tiles. V7 confirmed the observation and stated that's how the floor is. They mop it every day and haven't mopped it yet. Surveyor wiped the black substance on the floor with a paper towel and the black substance transferred to the paper towel. V7 stated, it (the dry storage floors) doesn't look clean. On 05/04/2026 9:21 AM, observed black and reddish/brown stains the covered over 75% of the ceiling near the oven, range, and food prep areas. Observed old grease covered approximately 75% of the window of the oven, which was in use to cook meat, and dark brown grease/food particulate covering approximately 25% of the dials to operate the oven. Observed tan food particulate splattered across approximately 25% of the stainless-steel food storage area, black/tan dried food debris on the ceiling above the food prep area, and crumbs/dirt throughout the floor of the food prep area. These observations were confirmed with V31 (Cook). V31 stated, I don't know what those stains are on the ceiling. I think it is grease. V31 explained that the dried food particulate splatters were from the use of the food processors to make pureed food. V7 observed the ceiling and stated the stains were from grease/dirt and V7 had been asking the administration for the ceiling to be replaced for a long time. V7 confirmed the ceiling had been like that since before V7 had started as the dietary manager over a year ago. Observed plastic food bins of dried mashed potato flakes and powered thickener. The lids to both bins had a gray/black dirt like substance on them, and bits of dried shredded orange cheese. The dry mashed potato flakes bin had a sticker indicating a date of 2/2 and a use by date of 60 days. V7 confirmed these observations and affirmed the masked potato flake bin was mislabeled and stated, That date on there is wrong, they are good for a year. V7 described the lids as having dried grit and removed the lids to be cleaned. On 5/4/2026 at 10:21 AM, observed black and reddish/brown stains the covered over 75% of the ceiling near the oven, range, and food prep areas. Observed old grease covered approximately 75% of the window of the oven, which was in use to cook meat, and dark brown grease/food particulate covering approximately 25% of the dials to operate the oven. These findings were observed and confirmed with V8. V8 explained the stains were from dirt and grease. V8 affirmed the exhaust hood wasn't functioning properly and they had a vendor come and assess it. The vendor believed the exhaust ventilation system was not pulling enough air. V8 explained the reason why the oven had grease was the grease was located between two panes of glass, and there was no way to clean the glass. V8 explained dirt and grease on the ceiling of the kitchen can cause an unsanitary environment and increases the risk for a fire hazard. Observed the dry storage room with V8. The drywall/paint appeared brown and streaked, and the paint appeared to be falling from the wall. An approximately 12 inch by 6-inch portion of the wall did not have paint and left the base of the wall exposed. The tiles of the corner of the dry storage area were broken or absent, exposing black adhesive/underlayment. These observations were confirmed with V8. V8 explained the facility's pipe leak had caused water damage in the dry storage area. A plumber repaired the pipe, but the other broken areas of the dry storage room had not been repaired yet. Observed a black, spotted substance on the tiles of the dry storage room. This finding was confirmed with V8. V8 stated, it looks to me like it is black mold. The U.S. Food and Drug Administration (FDA) food code documents, .4-301.14 Ventilation Hood Systems, Adequacy. Ventilation hood systems and devices shall be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings . 6-304 Ventilation6-304.11 Mechanical. If necessary to keep rooms free of excessive heat, steam, condensation, vapors, obnoxious odors, smoke, and fumes, mechanical ventilation of sufficient capacity shall be provided . 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean . 4-301.14 Ventilation Hood Systems, Adequacy. If a ventilation system is inadequate, grease and condensate may build up on the floors, walls and ceilings of the food establishment, causing an insanitary condition and possible deterioration of the surfaces of walls and ceilings. The accumulation of grease and condensate may contaminate food and food-contact surfaces as well as present a possible fire hazard .4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . 6-201.18 Walls and Ceilings, Studs, Joists, and Rafters. Walls and ceilings that are of smooth construction, nonabsorbent, and in good repair can be easily and effectively cleaned. Special requirements related to the attachment of accessories and exposure of wall and ceiling studs, joists, and rafters are intended to ensure the cleanability of these surfaces . Facility policy titled Residents' Rights for People in Long Term Care Facilities states the facility must be safe and clean. Facility policy titled Safe Food Handling Practices states all food must be purchased, stored, prepared and distributed in a clean, safe and sanitary manner. The purpose is to minimize contamination and bacteria.

Based on observation, interview and record review, the facility failed to contain garbage/refuse within dumpsters and failed to maintain garbage storage areas in a sanitary condition. These failures affected all 200 residents that reside within the facility.Findings include: Facility census (5/4/2026) documents 200 residents reside in the facility. On 5/4/2026 at 1:36 PM, observed the garbage area and staff smoking area with V42 (Housekeeping/Laundry Manager). Outside of the dumpsters near the garbage area were food wrappers, loose medical waste including soiled gloves, flattened rotting cardboard, and cigarette butts. In the garbage area was over 6 palettes of wood, rotting pieces of wood stacked against the fence used, used milk crates on the ground, food wrappers/waste, broken medical equipment/beds, large spools of light blue fabric, large pieces of the fabric in piles on the ground, soiled plastic garbage bags, piles of used siding, piles of used PVC piping, rotting cardboard pieces and boxes, used plastic bags, and other unidentifiable garbage. V42 observed these areas and confirmed the observations. V42 affirmed the garbage was not contained and stated, Some of that stuff (garbage) is from last week. Some of it has been here for years. All of it needs to be cleaned out. I suggested we rent a dumpster a few weeks ago and get all of it cleaned out, it just hasn't happened yet. V42 explained the garbage not being contained creates an unsanitary environment and can become a pest control issue as the garbage can feed or harbor pests. Observed the smoking area with V48. The smoking receptacle attached to the building was completely full of cigarettes. Cigarette butts littered the back parking lot and staff smoking area. Observed a pail in the staff smoking area that had cigarette butts and discarded paper products including crumpled paper and paper straw wrappers. No sand was observed in the pail. V42 confirmed these observations. V42 affirmed it was V42's responsibility to remove the cigarette butts. V42 explained placing the used cigarettes in the pail with paper products could create a fire hazard. Facility policy titled Disposal of Garbage and Refuse (reviewed 5/2025) documents, The facility will dispose of garbage and refuse properly and in a timely manner . All garbage and refuse container will be maintained properly and in a timely manner . 1. The facility will assure all waste is properly contained in dumpster or compactors with lids and covered . 3. Garbage storage areas are maintained in a sanitary condition to prevent the harborage and feeding of pests and rodents .

Based on interview and record review, the facility failed to develop a facility assessment that a) accurately identified the capacity for residents b) identified ethnic, cultural or religious factors that potentially affected the care provided by the facility c) identified in-house dialysis unit services provided to the facility's residents d) accurately identified the staffing plan for direct care staff e) a recruitment and retention program plan for maximizing recruitment and retention of direct care staff. These failures affected all 200 residents that reside in the facility.Findings include: Facility census (5/4/2026) document 200 residents reside in the facility. Facility assessment (reviewed 3/2026) documents the following: 1) the facility's capacity for residents is 182 residents. 2) There is no ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. 3) the facility's dialysis unit is not identified in the facility assessment 4) 24 licensed nurses per day, 40 nursing aides per day, 1 dietician or qualified dietary manager per day, 5) 1:27 licensed nurse ratio in the post-acute care unit all shifts (1 RN, 1 LPN), 1:30 Licensed nurse ratio all units all shifts in long term care units (1 RN, 1 LPN). 6) Nurse's aides staffing ratio 1:13 on days/evenings, 1:18 ratio on nights on post-acute care units. 7) Nurse's aides staffing ratio 1:13 on days/evenings, 1:19 ratio on nights on post-acute care units. 8) There is no indication of a recruitment/retention plan for maximizing recruitment and retention of direct care staff.On 5/5/2026 at 1:48 PM, V1 (Administrator) affirmed V1 was involved in the completion of the facility assessment. V1 reviewed the facility assessment and affirmed the facility's capacity to care for residents was over 250 residents, not 182. V1 affirmed that the cultural needs of the facility's residents were not identified. V1 explained the facility does have residents of Latin descent, that are African American, Christian, and of Polish decent. V1 explained the facility does provide services to meet their needs such as Cinco de Mayo parties and in-house church services. V1 reviewed the staffing plan and affirmed the staffing plan was incorrect. V1 affirmed the purpose of the facility assessment is to identify the resources needed to care for the residents.On 5/6/2026 at 11:30 PM, V55 (Chief Operating Officer) affirmed V55, V56 (Chief Clinical Officer) and V50 (Vice President of Clinical Operations) serve as the governing body for the facility. V55 affirmed the governing body is responsible for the development and implementation of policies in the facility. V55 explained the facility had recently undergone a change of ownership on 3/1/2026 and the new governing body started overseeing on 3/1/2026. V55 affirmed V55 was involved in the revision of the facility assessment when the new governing body assumed the facility. V55 reviewed the facility assessment. V55 affirmed that the facility's capacity is incorrect and is not 182. V55 confirmed that the ethnic makeup and services provided to meet the residents ethnic, cultural and religious factors were not identified. V55 recalled that there were Spanish speaking residents, polish speaking residents, Christian residents. V55 confirmed the facility does not have a dietician/dietary manager one per day as indicated in the facility assessment. V55 confirmed the staffing ratio in the facility assessment was incorrect. V55 stated the staffing ratio should be 1:20 for licensed nurses and that the facility is staffing licensed nurses 2nd floor: 2 on AM shift, 2 on PM shift, and 2 on night shift. 3rd Floor: 3 on AM shift, 2 on PM shift, 2 on night shift, 4th floor 3 on AM shift, 2 on PM, and 2 on night shift. V55 affirmed there should be 15 CNAs per shift. V55 and V56 reviewed the facility assessment and confirmed the facility assessment does not address the in-house dialysis unit. V55 affirmed that the facility has a recruitment and retention program including a corporate recruiter, ad postings on job board websites, soliciting schools, and have a monthly allowance to build staff culture. V55 reviewed the facility assessment and affirmed the recruitment and retention plan is not identified in the facility assessment.Facility assessment policy (1/2026) documents in part, This facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. The purpose of this policy is to establish responsibilities and procedures for the facility assessment process. 1. The facility assessment will, at a minimum, address or include: a. The facility's resident population, including but not limited to: i. Number of residents and the facility's capacity; ii. The care required by the resident population, using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments; iii. The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population; iv. The physical environment, equipment, services and other physical plant considerations that are necessary to care for this population; and v. Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. b. The facility's resources, including but not limited to; i. All buildings and/or other physical structures and vehicles; ii. Equipment (medical and non-medical); iii. Services provided, such as physical therapy, pharmacy, behavioral health and specific rehabilitation therapies; iv. All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; v. Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and vi. Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. c. A facility-based and community-based risk assessment, utilizing an all-hazards approach. 2. In conducting the facility assessment, the facility will ensure: a. Active involvement of the following participants in the process: i. Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and ii. Direct care staff, including but not limited to RNs, LPNs/LVNs, NAs, and representatives of the direct care staff, if applicable. iii. The facility must also solicit and consider input received from residents, resident representatives, and family members. iv. The environmental operations manager, and other department heads (e.g., dietary manager, director of rehabilitation services, or other individuals) should be involved as needed. 3. The facility will use the facility assessment to: a. Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care. b. Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population. c. Consider specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on any changes to its resident population. d. Develop and maintain a plan to maximize recruitment and retention of direct care staff. e. Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care.

Based on observation, interview, and record review, the facility failed to follow policies and procedures; failed to initiate enhanced barrier precautions for a resident; failed to ensure that staff donned the require Personal Protective Equipment (PPE) while providing care for a resident with a known diagnosis of clostridioides difficile (C. diff); failed to perform proper hand hygiene after performing care with a resident with a known diagnosis of C. diff; failed to appropriately clean and disinfect a resident's room with a known diagnosis of C. diff; and failed to ensure soiled linen was securely bagged prior to placement in the laundry chute to prevent contamination and the potential spread of infection. These failures affected two residents (R26 and R210) out of a sample of 63 residents reviewed for infection control and has the potential to affect all 200 residents residing at the facility. Findings include: On 05/06/26 at 9:30AM, V1 (Administrator) stated the facility census is 200 residents residing at the facility. R26's face sheet documents an admission date of 04/21/2026 with diagnoses that include but are not limited to gastrointestinal hemorrhage, ulcerative colitis, colostomy, and enterocolitis due to clostridioides difficile (c. diff). R26's BIMS (brief interview for mental status) score, dated 04/29/2026, is 6 which indicates R26 has severe cognitive impairment. R26's progress note, dated 05/02/2026, documents, in part Resident (R26) continue on Vancomycin 125 mg PO q6H for C-diff stop date 5/10/26. On 5/05/26 at 1:00pm, observed one resident (R26) on transmission-based precautions in the facility. The facility verified R26 is on transmission-based precautions. R26 was in private rooms. R26 is on contact precautions for Clostridioides difficile (C. diff) with two signs on the resident (R26) room door (one for contact-precaution and one for enhanced barrier precaution (EBP). V29 (Unit Manger/LPN/Infection Preventionist) stated R26 is on contact precaution for C. Diff and on EBP for the foley catheter. On 5/05/26 at 1:30pm, V4 (Infection Preventionist/Unit Manager) stated R26's double signage (Contact and EBP) can be confusing. On 5/5/2025 at 5:13pm, V62 (Registered Nurse) was observed entering R26's room which had a contact precautions isolation sign on the door and personal protective equipment (PPE) in the overdoor PPE holder. V62 pushed medication cart in front of door, did not perform hand hygiene, assembled medications, did not perform hand hygiene, entered the room without donning gown or gloves, and administered medication. Surveyor attempted to stop V62 before administering medication, V62 did not respond. V62 exited the room without performing hand hygiene. V62 began to push medication cart to the next room. Surveyor asked V62 about the signage on the door of R26's room. V62 stated I should have used PPE. V62 proceeded to the next room and began assembling medications without performing hand hygiene. On 5/6/2026 at 10:00am, V44 stated that he cleaned R26's room along with all the other rooms in the same hallway earlier using the Neutral Cleaner 15 and Hospital Use Disinfectant-Cleaner and cleaned R26's because R26 is on contact isolation. V44 and V43 stated they use Neutral Cleaner 15 to clean the floors in all rooms and Hospital Use Disinfectant-Cleaner 11 for cleaning high touch surfaces and areas for all rooms. When asked specifically about the cleaning of resident rooms with contact isolation signs, both stated they use Neutral Cleaner 15 and Hospital Use Disinfectant-Cleaner 11 in all rooms including C. diff. rooms. On 5/6/2026 at 10:45am, V43 showed surveyor the housekeeping closet/room where chemical solutions (Neutral Cleaner 15 and Hospital Use Disinfectant-Cleaner 11) were stored. V43 stated that an automated predetermined mixing of solutions is used to fill the mop bucket and spray cleaning bottles that are used to clean resident rooms and hallways. Observed the automated mixture of cleaning and disinfecting solutions. There were no sporicidal solutions or mixtures (cleaners to kill C. diff) in the housekeeping closet/room. On 5/6/2026 at 12:45pm, V43 stated that the rooms like R26's room with a contact precaution sign and knowing the resident has C. diff would still be cleaned with the cleaning and disinfection solutions available to him in the housekeeping closet/room. Upon observation sporicidal solutions were stored in the housekeeping closet/room. On 5/6/2026 at 1:45pm, surveyor inquired to V44 specifically about how rooms with residents on contact precautions with C. diff are cleaned, and V44 replied that V44 would use Neutral Cleaner 15 to clean the floors in all rooms and Hospital Use Disinfectant-Cleaner 11 for cleaning high touch surfaces and areas. V42 (Housekeeping /Laundry Manager) stated a micro-kill bottle with a green label is available and micro-kill bleach white bottle with light blue label, is available for use. V44 stated he has never seen those bottled solutions and does not have them in V44's housekeeping cart. V44 stated that today (05/06/26) is the first time V44 has heard about and has seen the micro-kill (disinfectant that kills spores with bleach) bottle. Using a sporicidal agent targets spores such as C. diff and prevents the transmission of infections to facility residents, staff, and family members. On 5/6/26 at 10:44am, V60 (Sales Representative) said, This product (Hospital Use Disinfectant-Cleaner 11 disinfectant facility is using to clean resident rooms with C. diff) cannot make the claim that it kills C. diff because the product was never tested on C. diff. This product was specifically tested for the purpose of the things listed on the label and C. diff is not listed on the label. On 5/6/26 at 11:21am, V4 (Infection Preventionist/RN Unit Manager) said, Dirty linen is to bagged. The dirty linen should be bagged and secured to prevent the spread of infection. Wearing PPE in rooms where residents are contact precautions is to protect the resident and the staff. Again, wearing PPE and washing your hands when needed is to prevent the spread of infection. Yes, there are different disinfectant cleaners that kill different bacteria and viruses. If you don't use the cleaner that specifically targets what you're trying to kill, you can spread the infection. On 05/04/2026 at 11:30 AM, accompanied by V42 (Housekeeping/Laundry Manager), a tour of the facility's laundry room was conducted. Surveyor observed 2 opened bags of soiled linen in the laundry chute, and one soiled blanket with a golf ball sized yellow stain in the dirty laundry receiving bin not in a plastic bag. V42 said, Yeah, those bags (2 opened bags of soiled linen in the laundry chute) are opened up. They (2 opened bags of soiled linen in the laundry chute) popped open on the way down. They (2 opened bags of soiled linen) should be tied shut to prevent spreading germs. On 05/06/2026 at 9:00am, V4 (Infection Preventionist/Unit Manager) stated, I do not order cleaning chemicals for isolation. I am not responsible for that. That's housekeeping R210 is [AGE] years old admitted to the facility on [DATE], medical history includes, but not limited to metabolic encephalopathy, dysphagia oral phase, type 2 diabetes, gastrostomy status, unspecified dementia, essential primary hypertension, etc. On 05/04/2026 10:10AM, R210 observed up in wheelchair, awake and alert with some confusion stated she is doing okay. G- tube pole at bedside, no feeding or water noted to be infusing at this time. R210 was observed wearing a hospital gown, two staff members were in the room and transferred resident back to bed using a mechanical lift. V17 (Restorative Aide) said that resident was on the 4th floor and just transferred to the 3rd floor, not sure the exact date. On 05/05/2026 at 10:20AM, R210 was observed in bed, G-tube feeding infusing at 55ml (milliliters) per hour, an IV pole noted at the bedside. R210 was not on any type of precautions, there was no sign on resident's door or any personal protective equipment (PPE) set up by resident's room. R210 had a PICC line to right arm and was receiving IV antibiotic related to active infection of bacteremia. R210 had pressure ulcer to her coccyx and right lateral foot. On 5/5/2026 at 10:26AM V16 (MDS Coordinator) said that R210 transferred from the 4th floor to the third floor on 05/01/2025, indicating the R210 had been on the third floor for 4 days without being on any type of precaution. Active physician order documented the following: cefazolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2 gram intravenously every 12 hours for bacteremia for 13 Days. Enhanced Barrier Precautions d/t wounds and g tube, order date 4/29/2026. On 5/5/2026 at 10:36AM, V4 (Infection Prevention Nurse) said that she oversees the infection prevention program, but all the managers are supposed to be rounding to make sure that every precaution is in place. Surveyor asked V4 if R210 is supposed to be on any type of precautions. V4 said, She should be on enhanced barrier precaution because she has a G-tube. Surveyor walked with V4 to resident's room where there was no sign of any type of precaution, or an isolation set up. V4 said, I don't know what happened or who transferred resident from the 4th floor, but we will take care of it. Enhanced barrier precaution (EBP) policy revised 1/2026 states in part: General: EBP expands the use of PPE and refers to the use of gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDROs (multi drug resistant organisms) to staff hands and clothing. MDROs and XDROs (extensively drug-resistant organisms) may be indirectly transferred from resident to resident during these high contact care activities. High-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: Dressing Bathing/showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care Record review of Hospital Use Disinfectant-Cleaner 11 label documents, in part, Effective against Escherichia coli, Listeria monocytogenes, Pseudomonas aeruginosa, Staphylococcus aureus (MRSA), Staphylococcus aureus (CA-MRSA), Salmonella typhi, Norovirus, Influenza A (H1N1), Influenza A (H3N2), HIV-1, Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), SARS-CoV-2, Vaccinia Virus and other listed bacteria and viruses when used as directed. Treated surfaces must remain wet for 10 minutes. C. diff is not listed. Record review of the facility's housekeeping policy/guidelines dated 05/2026 documents in part To provide guidelines to maintain a safe and sanitary environment for residents, facility staff, and visitors. Record review of facility policy titled, Infection Control and Control Plan-General, dated 1/2026, documents, in part, (Facility) is committed to ensuring that all appropriate infection and control measures are in place as to be determined by State and Federal Regulations as well as CDC recommendations and guidance. The facility will have an Infection Preventionist to assist and oversee the infection control program. The facility shall comply with recommendations provided by IDPH or certified local health department, including, but not limited to, testing plans, infection control assessments, training, or other measures designed to reduce infection rates and disease outbreaks. Review of the facility's Housekeeping policy for linens section 1.f dated 01/02/2026 documents in part Environmental services staff shall not handle soiled linens unless it is properly bagged. Record review of Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must be safe, clean, comfortable and homelike.

Based on observation, interview and record review, the facility failed to follow their preventative maintenance policy, failed to maintain and provide preventative maintenance to ensure the environment was safe, functional, sanitary, and comfortable for residents and staff; failed to complete needed repairs to the environment; failed to ensure resident shower rooms were in good repair and had methods for enhancing privacy (curtains) for public shower rooms. These failures affect the 54 residents on the second floor that utilize the shower rooms and have the potential to affect all 200 residents that reside in the facility. Findings include: Facility census (5/4/2026) documents 54 residents reside on the 2nd floor, and 200 residents reside in the facility. On 5/4/2026 at 10:21 AM, observed three broken light fixtures in the kitchen with no lightbulbs. Three light covers (diffusers) were observed with cracks in the cover, and three other lights were observed without any cover, leaving exposed lightbulbs. These observations were confirmed with V8, Maintenance Director. V8 stated the purpose of the cover is to protect the bulbs and protect staff as the lightbulb can explode. Observed the ceiling above the clean dishware/pots/pans. The ceiling tile was discolored and largely bowed downward in the middle of the tile, causing the insulation above the tile to be exposed. This observation was confirmed with V8. V8 explained the ceiling tiles were fireproof and the material exposed out from the tile was insulation from the fireproofing. V8 explained there was a pipe that was leaking last month and believed the cause of the ceiling tiles being bowed was from water damage. V8 recalled the tile order was placed last week but did not know when the tiles would arrive. In the dry storage area, observed drywall peeling approximately 12 inches, with paint chips/debris on the ground. The drywall/paint appeared brown and streaked, and the paint appeared to be falling from the wall. An approximately 12 inch by 6-inch portion of the wall did not have paint and left the base of the wall exposed. The tiles of the corner of the dry storage area were broken or absent, exposing black adhesive/underlayment. These observations were confirmed with V8. V8 explained the facility's pipe leak had caused water damage in the dry storage area. A plumber repaired the pipe, but the other broken areas of the dry storage room had not been repaired yet. On 5/4/2026 at 12:24 PM, observed the 2nd floor shower rooms with V2 (Director of Nursing) and V8 (Maintenance Director). The shower rooms felt warm and humid. Observed linen on the ground on the shower room. V2 stated the linen was from a resident who had just taken a shower. Observed the shower area and a puddle of water was on the ground underneath the shower chair of the shower area. Observed a missing ceiling tile above the shower area with a rusted, exposed pipe. The pipe was wet and leaking with approximately 1 drop of water every 8-10 seconds that landed on the shower chair within the shower area (where the resident had been showering). These observations were confirmed with V2 and V8. V8 explained V8 was aware of the leak and that the pipe had rusted out to the point of water leaking. A plumbing contractor had been out to assess the leak but V8 was unsure if any quote was approved or when the pipe would be fixed. Surveyor flipped the light switch next to the unused shower stall, and nothing happened. V8 stated that goes to the exhaust fan. It doesn't work. There were no curtains or other privacy barriers in the shower area or within the shower room. This observation was confirmed with V2 and V8. On 5/6/2026 at 4:55 PM, requested any maintenance orders in TELS or records regarding the disrepair items in the facility. V8 searched through V8's phone and could not produce any documentation. V1 (Administrator) and V8 could not produce any work orders/documentation related to the items in disrepair. No further documentation was provided prior to the exit of the facility. V1 affirmed that ceiling tiles for the kitchen were on order to replace the ceiling tiles in the kitchen but would not be in until 5/16/2026. Facility preventative maintenance policy documents, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them. 4. The Maintenance Director shall utilize the TELS calendar and scheduled prompts to assist with keeping track of all tasks and work orders . The U.S. Food and Drug Administration (FDA) food code (2022) documents, 6-201.18 Walls and Ceilings, Studs, Joists, and Rafters. Walls and ceilings that are of smooth construction, nonabsorbent, and in good repair can be easily and effectively cleaned. Special requirements related to the attachment of accessories and exposure of wall and ceiling studs, joists, and rafters are intended to ensure the cleanability of these surfaces. 6-202.11 Light Bulbs, Protective Shielding. Shielding of light bulbs helps prevent breakage. Light bulbs that are shielded, coated, or otherwise shatter-resistant are necessary to protect exposed food, clean equipment, utensils and linens, and unwrapped single-service and single-use articles from glass fragments should the bulb break .

Based on observation, interview and record review, the facility failed to ensure adequate ventilation were in good working condition in the kitchen and the second-floor shower room. These failures caused excess grease and dirt to accumulate on the ceiling of the kitchen, which increased the risk of food contamination and created a potential fire hazard. These failures affected 54 residents that reside on the second floor and has the potential to affect all 195 residents that consume nutrition from the kitchen. Findings include: Facility census (5/4/2026) documents 200 residents reside in the facility.Record review of facility enteral feeding list (undated) documents five residents (R15, R69, R70, R157, R210) were on enteral nutrition and did not receive oral nutrition.On 05/04/2026 9:21 AM, observed black and reddish/brown stains the covered over 75% of the ceiling near the oven, range, and food prep areas. Observed old grease covered approximately 75% of the window of the oven, which was in use to cook meat, and dark brown grease/food particulate covering approximately 25% of the dials to operate the oven. V7 (Dietary manager) observed the ceiling and stated the stains were from grease/dirt and V7 had been asking the administration for the ceiling to be replaced for a long time. V7 confirmed the ceiling had been like that since before V7 had started as the dietary manager over a year ago. The hood did not appear to be functioning, and no sounds could be heard indicating the hood was on. No air could be felt moving upwards. V7 confirmed the hood was not on and told another staff member to turn on the exhaust hood. On 5/4/2026 at 10:21 AM, observed black and reddish/brown stains the covered over 75% of the ceiling near the oven, range, and food prep areas. Observed old grease covered approximately 75% of the window of the oven, which was in use to cook meat, and dark brown grease/food particulate covering approximately 25% of the dials to operate the oven. These findings were observed and confirmed with V8. V8 explained the stains were from dirt and grease. V8 affirmed the exhaust hood wasn't functioning properly and they had a vendor come and assess it. The vendor believed the exhaust ventilation system was not pulling enough air. V8 explained dirt and grease on the ceiling of the kitchen can cause an unsanitary environment and increases the risk for a fire hazard. On 5/4/2026 at 12:24 PM, observed the 2nd floor shower rooms with V2 (Director of Nursing) and V8 (Maintenance Director). The shower rooms felt warm and humid. Observed linen on the ground on the shower room. V2 stated the linen was from a resident who had just taken a shower. Observed the shower area and a puddle of water was on the ground underneath the shower chair of the shower area. Surveyor flipped the light switch next to the unused shower stall, and nothing happened. V8 stated that goes to the exhaust fan. It doesn't work. Both exhaust fan covers were covered in a thick layer of dust. V8 confirmed this observation. On 5/6/2026 at 4:55 PM, requested any maintenance orders in TELS or records regarding the disrepair items in the facility. V8 searched through V8's phone and could not produce any documentation. V1 (Administrator) and V8 could not produce any work orders/documentation related to the ventilation in disrepair. No further documentation was provided prior to the exit of the facility. V1 stated a vendor had come and assessed the exhaust van and that the ventilation system needed to be replaced. Facility preventative maintenance policy documents, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them. 4. The Maintenance Director shall utilize the TELS calendar and scheduled prompts to assist with keeping track of all tasks and work orders . The U.S. Food and Drug Administration (FDA) food code documents, .4-301.14 Ventilation Hood Systems, Adequacy. Ventilation hood systems and devices shall be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings . 6-304 Ventilation6-304.11 Mechanical. If necessary to keep rooms free of excessive heat, steam, condensation, vapors, obnoxious odors, smoke, and fumes, mechanical ventilation of sufficient capacity shall be provided . 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean . 4-301.14 Ventilation Hood Systems, Adequacy. If a ventilation system is inadequate, grease and condensate may build up on the floors, walls and ceilings of the food establishment, causing an insanitary condition and possible deterioration of the surfaces of walls and ceilings. The accumulation of grease and condensate may contaminate food and food-contact surfaces as well as present a possible fire hazard .

Based on observation, interview, record review, the facility failed to develop a smoking policy that meets state law requirements for the Smoke Free Illinois Act, failed to develop a resident smoking policy that includes use of e-cigarettes (vapes), and failed to implement/follow the staff smoking policy within the employee handbook. This failure affected all 45 residents that smoke in the facility and has the potential to affect all 200 residents that reside in the facility. Findings include: Facility census (5/4/2026) documents 200 residents reside in the facility. Facility smoking list (undated) documents 45 residents smoke in the facility. Record review of document titled THRYVE OF CRESTWOOD GARDEN PATIO documents the patio will be closed during mealtimes and after hours. The patio may also be closed due to inclement weather or any emergent situation and lists the smoking times. There is no instruction that residents cannot smoke within 15 feet of the entrance to the smoking patio. Record review of (410 ILCS 82/) Smoke Free Illinois Act (enacted 1/1/2028, revised 1/1/2024) documents in part, .Smoking in public places, places of employment, and governmental vehicles prohibited. No person shall smoke in a public place or in any place of employment or within 15 feet of any entrance to a public place or place of employment .On 5/4/2026 at 1:01 PM, observed R68 smoking less than 15 feet from the entrance to the smoking area (garden patio) near the handicap door access button. Observed V53 assisting other residents with smoking in the smoking area. V53 (Activity Aide) observed R68 smoking less than 15 feet from the entrance and confirmed the distance was less than 15 feet. V53 affirmed V53 was the staff member responsible for supervising the smoking area during the observation. V53 affirmed R68 should not be smoking that close to the door, and instructed R68 to go further into the smoking area to smoke away from the door. On 5/4/2026 at 1:17 PM, measured the distance from the threshold of the door to where R68 was observed smoking using a measuring tape. The distance was 91 inches (approximately 7.8 feet). This observation was confirmed with V53 and V53 confirmed R68 was smoking less than 15 feet from the threshold of the door. On 5/4/2026 at 1:36 PM, observed the garbage area and staff smoking area with V42 (Housekeeping/Laundry Manager). Outside of the dumpsters near the garbage area were food wrappers, loose medical waste including soiled gloves, flattened rotting cardboard, and cigarette butts. Observed the smoking area with V48. The smoking receptacle attached to the building was completely full of cigarettes. Cigarette butts littered the back parking lot and staff smoking area. Observed a pail in the staff smoking area that had cigarette butts and discarded paper products including crumpled paper and paper straw wrappers. No sand was observed in the pail. V42 confirmed these observations. V42 affirmed it was V42's responsibility to remove the cigarette butts. V42 explained placing the used cigarettes in the pail with paper products could create a fire hazard. V42 affirmed staff should be using the appropriate receptacles for discarding used cigarettes. On 5/6/2026 at 2:13 PM, V5 (Social Services Director) affirmed V5 is responsible for assessing smoking ability for the residents in the facility. V5 affirmed that R68 is safe to smoke. V5 explained that residents should not be smoking within 15 feet of the door in the smoking area. On 5/6/2026 at 4:50 PM, V1 (Administrator) affirmed residents should be smoking at least 15 feet away from the facility. V1 affirmed residents do use electronic cigarettes (vapes). V1 reviewed the resident smoking policy and the staff smoking expectations in the staff handbook. V1 affirmed the resident smoking policy does not address smoking within 15 feet of an entrance to the facility and does not identify resident e-cigarette use in the facility. No other policies were presented to the survey team prior to the exit of the survey that identify resident e-cigarette use or the requirement that residents must smoke 15 feet from an entrance to the facility. Facility policy titled Resident Smoking (Revised November 2013) documents, PURPOSE: To establish guidelines to prohibit smoking by residents and visitors in the building except in designated areas. To establish guidelines for the specific circumstances in whichresidents may smoke in the designated areas and when increased supervision is required. Policy Specifications: 1. All residents who desire to smoke will be assessed by the Interdisciplinary Team to determine if the individual is appropriate for independent smoking. 2. If assessed to be appropriate for independent smoking, the resident must sign a Smoking Contract with the facility. 3. Only those residents assessed to be appropriate for independent smoking and who have executed a Safe Smoking Contract with the facility may smoke in the designated areas. 4. Some residents may require more intensive staff supervision while smoking. These residents smoke separately from other residents, under the supervision of a staff member specifically designated to assist them. Behaviors that may trigger additional resident supervision whilesmoking include, but are not limited to: a. Being unable to state facility smoking rules b. Being unable to follow facility smoking rules without prompts c. Using smoking materials in an inappropriate manner d. Giving or selling cigarettes and/or smoking materials to other residents e. Collecting or attempting to use discarded smoking materials f. Asking for smoking materials from other residents g. Attempting to take other residents' smoking materials h. Attempting to intimidate another resident for the purpose of taking cigarettes or smoking materials 5. Smoking by residents and their visitors is permitted only in designated areas. 6. Possessing, carrying, or holding materials used to light cigarettes, cigars (including but not limited to lighters, torches, etc.) by residents is prohibited inside the building. Residents must give smoking lighting materials to staff when they enter the building, even if the resident has been assessed to be independent in carrying such materials when off the premises. 7. Persons bringing smoking materials into the facility for residents' use must leave these items at the front desk. Smoking materials left for an individual resident will be labeled and forwarded to an assigned staff member who will ensure they are available to the resident for whom the materials have been labeled. 8. Residents are prohibited from giving smoking materials to other residents. 9. Residents are prohibited from asking other residents for smoking materials. The policy does not address resident use of e-cigarettes/vapes and does not address the state requirement that prohibits smoking 15 feet from any entrance. Facility smoking policy and smoking contract (revised 1/2026) does not indicate where the smoking area of the facility is, or that residents should not be smoking within 15 feet of the entrance to the facility in the smoking area. Vaping or other e-cigarette use is not addressed in this policy. The facility's employee handbook (undated) documents This Smoke Free Policy includes the use of electronic nicotine delivery systems - known as e-cigarettes, e-cigars, e-hookahs and e-pipes. To protect and enhance indoor air quality and contribute to the health and well-being of all employees and visitors, [NAME] HEALTHCARE shall be entirely smoke free and vape free. [NAME] Healthcare is committed to providing a smoke and vape free environment. Smoking and vaping is not permitted inside the facility at any time. Smoking and vaping is only permitted outside the facility in designated areas where smokers will not interfere with those entering and leaving the facility. All cigarette butts and wrappers must be deposited in waste containers. Smokers are not entitled to special smoking breaks and smoking will be permitted only during break or lunch periods. Cigarette butts and other waste must be disposed of properly.

Based on observation, interview, and record review, the facility failed to follow policy procedure, failed to ensure that call lights were within reach, and failed to ensure that call lights were functioning for four of 42 dependent residents (R11, R14, R27, R84) in the sample reviewed for accommodation of needs. Findings include: R27's face sheet documents diagnoses that include but are not limited to acquired absence of right ankle, type 2 diabetes, necrotizing fasciitis, pneumonia, and renal dialysis. R27's BIMS (brief interview for mental status) score, dated 5/04/26, is 12 which indicates R27's cognition is moderately impaired. On 5/4/26 at 10:00am, R27 was observed laying on her back and said, Can you move my table closer to me? Surveyor asked, Where is your call light? R27 replied, I don't know, can you just move my table closer to me? I'd do it myself, but I can't. Surveyor observed R27's call light behind R27's bed not within reach. R27's care plan, dated 4/28/26, documents, in part, Falls: (R27) is at risk for Falls r/t (related to) acquired absence of right ankle, with interventions that documents, in part, promote placement of call light within reach. On 5/4/26 at 10:02am, V11 (Wound Care Nurse/LPN/Licensed Practical Nurse) said, Geez. We (staff) just provided care to her (R27) a few minutes ago. Yes, it's (R27's call light) behind her (R27) bed. No, it's (R27's call light) not within reach. On 5/06/25 at 4:45pm, V2 (Director of Nursing/DON) said, Our (facility) expectation is that the call lights should be within reach so we (facility staff) can address the residents' needs. R11's diagnoses include hemiplegia and hemiparesis. R11's (2/26/26) BIMS (Brief Interview Mental Status) determined a score of 15. R11's (2/26/26) functional assessment affirms resident requires partial/moderate assistance with chair/bed to chair transfer. R11's (3/8/24) care plan includes ADL (Activities of Daily Living) self-care performance deficit related to hemiplegia, interventions: encourage resident to use call bell for assistance. On 5/4/26 at 10:23am, R11 was observed sitting on the bed, however the call light was on the dresser - out of reach. Upon further inspection the call light was also noted to be unplugged. On 5/4/26 at 10:30am, surveyor inquired about concerns with R11's call light V14 (LPN/Licensed Practical Nurse) entered the room and stated It's not plugged up, your call light don't work? R11 responded I (R11) don't think so, I'm not sure. Surveyor inquired if R11's call light was plugged into the wall V14 replied It's not plugged in. __ R14's diagnoses include lack of coordination, history of falling, and repeated falls. R14's (4/8/26) BIMS determined a score of 6 (severe impairment). R14's (4/8/26) functional assessment affirms resident required substantial/maximal assistance to roll left and right. R14's (10/21/24) care plan states encourage the resident to use call bell for assistance. On 5/4/26 at 10:51am, R14's call light was dangling from the side rail below the mattress - out of reach. V13 (LPN) entered the room to inspect R14's indwelling urinary catheter (as requested) however left the room without placing R14's call light within reach. Surveyor inquired if R14 was able to reach the call light R14 nodded his head no. __ R84's diagnoses include cerebral infarction and cognitive communication deficit. R84's (1/28/26) BIMS determined a score of 13 (cognition intact). R84's (1/28/26) functional assessment affirms resident requires partial/moderate assistance with chair/bed to chair transfer. R84's (1/7/25) care plan states encourage the resident to use bell to call for assistance. On 5/4/26 at 11:02am, R84's call light was observed on the floor and was not plugged into the wall. Surveyor inquired about concerns with R84's call light V15 (LPN) entered the room and stated This here is the call light and there's nothing plugged in. It's a cord down here on the floor that appears to be it. The call light response policy (reviewed 5/1/25) states ensure the call light is always within the resident's reach. When the patient or resident is in bed or confined to a bed or chair, provide the call light within easy reach of the patient or resident. Report all defective call lights to the nurse supervisor or maintenance director promptly. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff identify/address housekeeping/maintenance concerns, and/or failed to repair broken equipment for nine of 42 residents (R1, R7, R8, R15, R23, R27, R91, R99, R110) in the sample reviewed for safe/clean/comfortable/homelike environment. Findings include: R15's face sheet documents diagnoses that include but are not limited to dementia, type 2 diabetes, and metabolic encephalopathy. R15's MDS (Minimum Data Set), Section C, dated 2/25/26, documents, in part, that R15 is rarely understood and that R15's Cognitive Skills for Daily Decision Making is Severely Impaired. R15 unable to be interviewed due to altered mental stratus. On 5/04/26 at 9:55am, surveyor attempted to read R15's tube feeding bottle; however, the room was very dark. There were no ceiling lights observed in R15's room. Surveyor observed a fluorescent tube light attached to the wall behind R15's bed. Surveyor asked V9 (Certified Nursing Assistant/CNA) if V9 could turn the light on. V9 replied, The lights behind the residents' (R15, R23, R27) beds in this room do not work. They (lights) haven't worked for some time. I'm not sure how long they (lights) haven't worked. There's only that light. V9 pointed to one fluorescent light on the wall, in the middle of the room, across from R15, R23, and R27's beds). V9 said, Yes, it a little difficult to see, but we (staff) use that one light and the lights coming from the outside through the windows. R27's face sheet documents diagnoses that include but are not limited to type 2 diabetes, necrotizing fasciitis, acquired absence of right ankle, pneumonia, and renal dialysis. R27's BIMS (brief interview for mental status) score, dated 5/04/26, is 12 which indicates R27's cognition is moderately impaired. On 5/4/26 at 10:00am, R27 said, Yeah, there need to be more light in here. It's nighttime all day. Can you move my table closer to me? R23's face sheet documents diagnoses that include but are not limited to type 2 diabetes, dementia, and opioid abuse. R23's BIMS (brief interview for mental status) score, dated 2/13/26, is 15 which indicates R23 is cognitively intact. On 5/4/26 at 10:17am, R23 said, Well, I'm by the window, so I get more light than them (R23's roommates). I don't know. I don't wanna complain. I'm sure they'll (facility staff) will get us more lighting. R7's face sheet documents diagnoses that include but are not limited to type 2 diabetes, depression, and seizures. R7's BIMS (brief interview for mental status) score, dated 5/01/26, is 15 which indicates R7 is cognitively intact. On 5/4/26 at 10:25am, surveyor observed no overhead light in R7's room. Surveyor observed a table lamp next to R7's bed on R7's dresser. R7 said, The light in this lamp don't work. See. R7 attempted to turn on R7's lamp, but R7's lamp would not turn on. R7 said, This lightbulb has been out for days. Yeah, they (facility staff) know about it. They (facility staff) keep saying they (facility staff) gonna change but never do. Of course, I need more light in here. It's (inadequate lighting) depressing. R110's face sheet documents diagnoses that include but are not limited to chronic obstructive pulmonary disease, type 2 diabetes, hypoxemia, and depression. R110's BIMS (brief interview for mental status) score, dated 3/20//26, is 13 which indicates R110 is cognitively intact. On 5/4/26 at 10:28am, surveyor observed no overhead light nor a bedside lamp in R110's room. R110 said, The staff complain about how dark it is all the time. It's (lighting) better during the day, but once it gets dark out, you can't see sh** up in here. I be bumping into everything. On 5/4/26 at 10:30am, surveyor observed a damaged metal faucet with frayed, sharp edges in the shared bathroom for R8, R91, and R99. While attempting to turn the faucet handle, surveyor experienced discomfort due to the exposed sharp metal edges. R8's face sheet documents diagnoses that include but are not limited to chronic obstructive pulmonary disease, depression, and acquired absence of right leg. R8's BIMS (brief interview for mental status) score, dated 4/24/26, is 15 which indicates R8 is cognitively intact. R91's face sheet documents diagnoses that include but are not limited to prediabetes, weakness, and seizures. R91's BIMS (brief interview for mental status) score, dated 3/28/26, is 15 which indicates R91 is cognitively intact. R99's face sheet documents diagnoses that include but are not limited to cardiomyopathy, heart failure and depression. R99's BIMS (brief interview for mental status) score, dated 3/20/26, is 15 which indicates R99 is cognitively intact. On 4/4/26 at 10:32am, R99 said, I'm not surprised the faucet in my bathroom is that way (in disrepair). I don't use it (bathroom), but other people do. I bet the staff don't live like this. On 5/5/26 from 9:28am to 9:46am, surveyor and V8 (Maintenance Director) took a tour of the facility and observed R7, R15, R23, R72, and R110 lacked overhead lighting and/or the overhead light fixture was not operational at the time of observation. V8 said, These lights don't work. I'm not sure for how long. I ordered them, but they are on back order. Yes, every resident should have some type of overhead lighting. Once the lights are not on backorder, every resident will have one (overhead lighting). Also observed was a damaged metal faucet with frayed, sharp edges in the shared bathroom for R8, R91, and R99. V8 said, Oh. That's bad. I was not aware of this. If I was aware, we wouldn't be looking at this right now. Yeah, that's pretty sharp. Someone can cut themselves. I will get this (faucet) changed right away. Record review of facility policy titled, Preventative Maintenance, dated 1/01/26, documents, in part, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents and staff, and the public. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them. Record review of facility job description titled, Maintenance Director, dated 10/11/2019, documents, in part, The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner. Repair facility/resident property as necessary. In the event of inability to repair coordinate with outside vendors to make repair or replace as cost effectively as possible. Also ensure that services provided by outside vendors are properly completed/supervised in accordance with contracts/work orders. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care. On 5/4/26 at 10:35am, oatmeal was noted to be splattered across the floor in R1's room - which was near the door. On 5/4/26 at 10:37am, surveyor inquired about the substance on R1's floor. V14 (Licensed Practical Nurse) subsequently entered the room and stated, Is it oatmeal, cereal? It's some type of oatmeal or something on the floor. The safe and homelike environment policy (reviewed 1/14/25) states housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to identify safety hazards, failed to implement fall prevention interventions, and/or failed to provide supervision for five of 42 residents (R1, R12, R16, R33, R84) in the sample reviewed for falls/hazards. Findings include: R16 was hospitalized on [DATE] for an unwitnessed fall in his room with a closed head injury and head laceration with repair above the left eye with five sutures in place. R16 is [AGE] years of age. Current diagnoses include but are not limited to Dementia, Seizures, Essential Hypertension, Anemia, and Protein Calorie Malnutrition. R16's comprehensive assessment section C Cognitive Patterns dated 08/22/2025 documents a (BIMS) brief interview for mental status score of 6 out of 15 which indicates severe cognitive impairment. This suggests significant challenges with memory, orientation, and decision-making abilities. This was the documented BIMS score prior to the fall. On 05/05/2026 at 11:42 AM, V27 CNA Certified Nurse Assistant was inquired of R16. V27 CNA said, R16 can be dressed with one person but transfer will need one to two staff. He does try to get up without help. On 05/05/2026 at 11:50 AM, R16 is lying in bed with a call light in reach. No fall mat on floor next to either side of the bed in the room. On 05/06/2026 at 1:19 PM, V26 RN Registered Nurse was inquired of R16's fall on 11/23/2025. V26 said, He (R16) needs assistance with one person to get out of bed and transfer. He always tried to get up. He was trying to get into his wheelchair. It was early in the morning at the start of my shift. That day he was trying to get up by himself. V41 CNA Certified Nurse was his aide; she was in another room helping a resident. I did my rounds that morning and he was still in bed, and it was in a low position. When he fell, he hit his head. He was on the floor near the bed on his right side. He was talking, he said he was trying to get to the wheelchair. The aides try to change him and get him up quickly because he tries to get up. He keeps doing that all the time. The call light was in his bed. The problem was sometimes he doesn't know how to use the call light, other times he tries to get up without using it. He was alert x 1 to 2 (to person and place), that day he didn't use the call light. It was around shift change early in the morning between 7:30 - 8 AM.On 05/06/2026 at 1:35 PM, V25 Restorative Nurse was inquired of R16's fall on 11/23/2025. V25 said, He (R16) was a high fall risk. It's because of his BIMS (Brief Interview for Mental Status) score 3 and Dementia. He needed assistance with one person to transfer. He could stand and pivot with extensive assistance of one person. He wasn't able to walk independently. This was the very first time he attempted to walk independently. His fall preventions were a Dycem in the wheelchair, encourage to change position slowly with partial assistance, keep call light within reach, keep immediate environment clutter free, and adequate lighting. He didn't have floor mats because staff were getting him in and out his wheelchair and he could self-propel his wheelchair once he was in it. He wouldn't be able to understand how to use the call light. I'm not sure if he'd be able to remember all the time. V25 Restorative Nurse confirmed R16 was unable to understand or remember how to use his call light due to his diagnosis of Dementia and low BIMS score identifying his severe cognitive impairment.On 05/06/2026 at 3:00 PM, V41 CNA Certified Nurse Assistant was inquired of R16's fall on 11/23/2025. V41 said, I did my rounds at 6:30 and got all my stuff that morning. He (R16) gets up right before breakfast. I came back from helping another resident and the nurse said he was on the floor. I went in his room earlier and he was in bed. He's a stand and pivot, but he does try to get up by himself. He can self-propel his own wheelchair and often tries to put himself back to bed. That's why we have to keep redirecting him. He's demented, I don't think he knew how to use his call light, but there wasn't a visible call light in the room. There wasn't a call light in his wall. I worked there for a year, and he always used to put himself back in bed after he eats unless he was going to smoke. On 05/07/2026 at 11:08 AM, V1 Administrator was inquired of R16's nurse practitioner V64 who documented his post fall evaluation. V1 said, She resigned a couple of weeks ago and moved out of town. V1 provided the contact information for R16's physician V63 Physician. On 05/07/2026 at 11:12 AM, V63 Physician was called and inquired of R16's fall from11/23/2025. V63 said, I'm driving now but I can call you back after 1PM if that's OK. On 05/07/2026 at 11:44 AM V64 NP Nurse Practitioner regarding R16's 11/23/2025 fall. V64 said, I no longer work with that facility and don't have access to my notes. I don't recall the circumstances around his (R16's) fall unfortunately. On 05/07/2026 at 4:31 PM, V67 Physician was inquired of R16's 11/23/2025 fall. V67 said, I spoke with V2 DON Director of Nursing. He (R16) has Dementia and was found on the floor with a cut on his forehead. They sent him to the hospital, and he got stitches. His bed was low. A while ago he was falling and tripping over the floor mat, so he didn't have one when he fell. They had PT (physical therapy) to see him and moved him closer to the nurse's station after the fall. It would depend on how bad his Dementia is if he could even use the call light because they forget things. Having him visible to staff may have helped. The 11/23/2025 fall scene investigation report states in part: R16 had an unwitnessed fall, was found on the floor next to his bed after attempting to self-transfer alone and unattended. He has dementia but is alert and oriented x 2 (person and place). Neurological examinations reviewed from 11/23/2026 - 11/26/2026. Witness statements from staff on 11/23/25 reviewed. Fall risk assessment from 8/27/2025 (prior to the fall) indicates R16 is a high fall risk. Urinalysis and urine culture indicated elevated white blood cells. R16's fall incident documentation of the fall on 11/23/2025 by V26 RN was reviewed. V26 documented R16 stated, R16 tried to get his ass out the bed. Progress notes document R16 was prescribed ABT (Antibiotic) Amoxicillin-Pot Clavulanate Tablet 875-125 MG 1 tablet by mouth two times a day for prophylaxis for urine, WBC (White Blood Count) lab result, and left eye sutures for 7 Days. Hospital discharge documentation indicates closed head injury with head laceration to left eye with five sutures in place. R16's follow up Nurse Practitioner evaluation by V64. 12/1/2025 15:45 np subsequent visit Date of Service: 12/01/2025 03:45 PMVisit Type: NP SUBSEQUENT VISITTransition of Care: N/AHistory Details: N/ADetails: NP Subsequent VisitPROVIDER: V64, N.P.PATIENT NAME: R16FACILITY: REHABILITATION CENTER, LLCdate of birth : 12/05/1953DATE OF SERVICE: 12/01/2025CHIEF COMPLAINT: follow-up post fall, facial lacerationHPI: Pt is a [AGE] year-old AA male with a pmhx (past medical history) detailed below who has been a LTC (long term care) resident of Nursing Rehabilitation Center on the Men's Village memory care unit since 10/2018. He is seen and examined today for a follow-up visit for a fall that occurred on 11/23. He was seen in the ED (emergency department) for evaluation at the time of fall and received sutures to the forehead laceration. Today, he is seen lying in bed today. He is aox1, forgetful, pleasant and cooperative, AFVSS (Afebrile, vital signs stable), in NAD (No acute distress). His neuro status is baseline. He denies pain or headache. There continues to be mild bruising around laceration and left eye that is improving. Forehead laceration with sutures intact, no redness, warmth, bogginess, or drainage noted. See wound rounds for detailed assessment. IDNP (Infectious Disease Nurse Practitioner) placed pt (patient) on Augmentin BID (twice a day) x7 days and he is tolerating antibiotic well with no adverse reactions. His blood pressure is stable on his current medication. No respiratory distress is noted. He denies fevers, malaise, dizziness, CP (chest pain), cough, SOB (shortness of breath), abdominal pain, NVDC (nausea, vomiting, diarrhea, constipation), or dysuria.Staff report no behaviors, issues, or concerns at this time.PAST MEDICAL HISTORY: Other SeizuresUnspecified Protein-calorie MalnutritionObstructive And Reflux Uropathy, UnspecifiedUnspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And AnxietyEssential (Primary) HypertensionUnspecified Sequelae Of Unspecified Cerebrovascular DiseaseMajor Depressive Disorder, Single Episode, UnspecifiedBenign Prostatic Hyperplasia With Lower Urinary Tract SymptomsUnspecified HydronephrosisEncounter For Screening For Covid-19Anemia, UnspecifiedDisorder Of Adrenal Gland, UnspecifiedBenign Neoplasm Of Right KidneyAllergic Rhinitis, UnspecifiedVitamin Deficiency, UnspecifiedGastro-esophageal Reflux Disease Without EsophagitisHyperlipidemia, UnspecifiedContact With And (Suspected) Exposure To Covid-19Cellulitis Of Right Lower LimbCovid-19Gross HematuriaContact With And (Suspected) Exposure To Other Viral Communicable DiseasesPAST SURGICAL HISTORY: non-contributorySOCIAL HISTORY: non-contributoryFAMILY HISTORY: non-contributoryCODE STATUS: Code Status: Full CodeALLERGIES: No Known Drug AllergiesMEDICATIONS:Valproic Acid Capsule 250 MG two times a dayMultivitamin Tablet one time a dayLoratadine Tablet 10 MG one time a dayDonepezil HCl Tablet 10 MG at bedtimeSimvastatin Tablet 20 MG at bedtimeTamsulosin HCl Capsule 0.4 MG at bedtimePropranolol HCl Tablet 10 MG one time a dayhydroCHLOROthiazide Tablet 25 MG one time a dayFerrous Sulfate Tablet 325 (65 Fe) MG two times a daylevETIRAcetam Tablet 1000 MG one time a dayAspirin Oral Capsule one time a dayTriamcinolone Acetonide External Cream 0.1 % two times a dayTylenol Extra Strength Oral Tablet 500 MG as neededPantoprazole Sodium Oral Tablet Delayed Release 20 MG one time a dayAmoxicillin-Pot Clavulanate Tablet 875-125 MG two times a dayLABS: reviewedIMAGING: No imaging data availableREVIEW OF SYSTEMS (ROS): A 14 point review of systems was completed and negative except as documented in HPIPHYSICAL EXAMINATION:Vitals - T 97.2, BP 118/67, HR 69, R 18, O2 SAT 97%General - well developed, well-nourished, in NAD, AOx1 (alert, oriented x 1 (to self)Eyes: Conjunctivae are anicteric, lids are normal. EOMI (Extraocular movements intact)Ears, Nose, Mouth, Throat: External inspection of ears and nose is normal.Respiratory: Normal respiratory effort. No accessory muscle use. No audible wheezing.CV: regular, S1 S2, no BLE (bilateral lower extremity) edemaABD: Soft, non-tender, +BS (bowel sounds)Skin: No visible skin lesions or rashes noted in exposed BUE or BLE. Forehead laceration w suturesMSK: No asymmetry or masses noted in b/l (bilateral) UE (upper extremity) and LE (lower extremity).Muscle strength: moves all 4 extremities against gravity. Grossly normal tone.Neuro: Good coordination in extremities.Psych: Normal mood. Normal affect. Patient responds appropriately to examiner. Judgment and insight appear grossly impaired.ASSESSMENT/PLAN:Unspecified fall, initial encounter (W19.XXXA)Laceration without foreign body of other part of head, initial encounter (S01.81XA)Unspecified dementia without behavioral disturbance (F03.90)-neuro checks per facility protocol-monitor laceration for s/s infection-continue Augmentin per ID (Infectious Disease) recs-Tylenol for pain-wound care following-encourage PO (by mouth) fluids-continue double protein and nutritional supplements w meals.-chart reviewed-medications reviewed; continue current medication regimen-maintain seizure, safety and fall precautions-monitor for changes in CV (cardiovascular)/resp, GU (Genitourinary), neuro status or behavior/mood-cardiology NP (nurse practitioner) following-Palliative care NP following-discussed with pt (patient), nursing---Time of the note does not necessarily correlate to the time the patient was seen.Total time spent reviewing obtained history and/or testing, examining and evaluating patient, counseling/educatingpatient/family/caregiver, providing orders, independently interpreting results/communicating results withpatient/family/caregiver, and coordinating care not separately reported: 30 MinutesMIPS 130 - Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient'scurrent medications---V64, N.P.Provider: V64, N.P.Signed Date: 12/01/2025 03:50 PM R16's comprehensive assessment section GG Functional Abilities dated 08/22/2025 documents the following: He uses a wheelchair. Mobility: C. 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. 04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. 09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. Care planR16 is at HIGH risk for falls and fall injuries 02/24/2023.Goal: R16 will not fall leading injury through next review 06/23/2025. Revised post fall: The facility will reduce/minimize falls causing injury to R16 through next review 11/23/2025.Interventions: Encourage R16 to transfer and change positions slowly 02/24/2023. Revised post fall: Encourage R16 to change positions slowly with partial assist x 1 staff participation 11/23/2025.Get to know R16's habits to anticipate needs 02/24/2023.Keep call light within reach and instruct R16 to use it for assistance. Educate on how to use call light and receive a return demonstration 02/24/2023.Keep resident in visible view of staff as resident will allow 12/29/2023. R16 has impaired cognitive function/dementia r/t Dementia 05/24/2022. Goal: R16 will maintain current level of cognitive function through the review date.Interventions: Identify yourself at each interaction, face resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. the resident understands consistent, simple, directive sentences 07/31/2019. Keep The resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion 07/31/2019.R16's care plan documents interventions that are not effective (education and use of call light) and were not implemented on 11/23/2025 related to R16's diagnosis of Dementia and BIMS (Brief Interview for Mental Status) score of 6 indicating severe cognitive impairment. V26 RN Registered Nurse and V41 CNA Certified Nurse Assistant confirmed R16 routinely attempted to transfer himself unassisted numerous times. Staff did not implement R16's fall care plan interventions as documented. R33 is [AGE] years of age. Current diagnoses include but are not limited to Traumatic Subdural Hemorrhage with Loss of Consciousness, Epilepsy, Alcohol Use with Withdrawal Delirium, Dementia, Depression, Nicotine Dependence, Fall with Head Injury, and Hypertension. R33's comprehensive assessment section C Cognitive Patterns dated 03/31/2026 documents a (BIMS) brief interview for mental status score of 8 out of 15 which indicates moderate cognitive impairment. On 05/05/2026 at 12:01 PM, R33 is in his room with a cigarette behind his ear. R33 said, I'm waiting to go smoke, do you know when it is? On 05/05/2026 at 2:31 PM, V26 RN Registered Nurse was inquired of R33 having a cigarette in his possession. V26 RN said, Sometimes the family comes and gives them their cigarettes, but because of him having dementia staff takes them to their breaks. We usually don't allow that. On 05/05/2026 at 3:01 PM, V27 CNA Certified Nurse Assistant was inquired of R33 having a cigarette in his possession. V26 said, He (R33) is allowed to leave this side of the unit and walk around on 4th floor. He visits his friends and asks them for a cigarette so that's probably how he got it. We keep them (cigarettes) at the receptionist desk in a box downstairs. On 05/06/2026 at 2:46 PM, V5 Social Service Director was inquired of R33 smoking contract. V5 said, He's (R33) a supervised smoker. V28 Activity Aide brings the residents down to smoke. V28 gets the cigarettes from the receptionist at the front desk, and they're labeled. He walks the residents outside, hands them cigarettes and lights them. Because of his cognition and Dementia, it's not safe for him to have his smoking materials. R33's 01/01/2026 Smoking Risk Observation documents he is a supervised smoker. R33's signed Resident Smoking Contract dated 01/14/2026 states in part: Based on an interdisciplinary team assessment, possession and storage of my smoking materials will be as follows: b. May not carry smoking materials or lighters. Smoking materials will be labeled with the resident's name at the nursing station or other designated area. R1's diagnoses include bipolar disorder. R1's (2/1/26) BIMS (Brief Interview Mental Status) determined a score of 12 (moderate impairment). On 5/4/26 at 10:39am, 3 razors were observed on R1's bathroom sink (unattended by staff). Surveyor inquired if residents are allowed to have razors in their possession V14 (LPN/Licensed Practical Nurse) stated No. Surveyor inquired how many razors were on R1's sink V14 responded Three. --- On 5/4/26 at 11:02am, the curtain rod in R84's room appeared bent, falling down, and the left side was leaning against the wall. Upon further inspection, the curtain rod was not secured on the hook - it was completely off. Surveyor inquired about safety concerns with R84's dangling curtain rod V15 (LPN) stated The rod is off of the part that it sits on. Surveyor inquired if V15 was able to open R84's curtain at this time V15 responded I'm (V15) not gonna do that, it's gonna fall. --- R12's diagnoses include cerebral ischemia and metabolic encephalopathy. R12's (3/22/26) BIMS determined a score of 15 (cognition intact). On 5/4/26 at 12:21pm, a pack of cigarettes was observed in R12's hoodie pocket. Surveyor inquired how many cigarettes were in the pack R12 stated It's a new pack. Surveyor inquired how R12 obtained the cigarettes R12 responded Somebody brought it in, my sister. Surveyor inquired if residents are allowed to have cigarettes in their possession, R12 replied Not really, they normally be at the front desk downstairs in the drawers. On 5/4/26 at 12:30pm, surveyor inquired if residents are allowed to have cigarettes in their possession V14 (LPN) stated Yes. Surveyor inquired if residents are allowed to have smoking paraphernalia (cigarettes, cigars, lighters, etc.) in their possession V14 responded Oh, no. On 5/6/26 at 8:34am, surveyor requested the policy for razor containment V1 (Administrator) responded We (facility) only got like the homelike environment policy. Surveyor inquired where razors should be contained, V1 replied After they are used? in the sharps container. On 5/6/26 at 9:35am, surveyor inquired if residents are allowed to have cigarettes in their possession V6 (Activities Director) stated Not no more, since (facility name) took over they (residents) can't have them. I (V6) don't think we (staff) have all their (residents) cigarettes cause family will bring them but the smoking materials are kept at the front desk. Surveyor inquired if residents are allowed to have razors in their possession V6 responded No, the CNAS (Certified Nursing Assistants) have em and most of the time they (CNAS) shave them (residents). Surveyor inquired where razors are disposed V6 responded I (V6) think they got a box for em. FALL PREVENTION AND MANAGEMENT policy reviewed on 2/2026 states in part: GENERAL: This facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. RESPONSIBLE PARTY: RN, LPN, DON GUIDELINES Upon admission: A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. Smoking Policy Effective Date: January 2023 Review Date: January 2026 PURPOSE: To establish guidelines to prohibit smoking by residents and visitors in the building except in designated areas. To establish guidelines for the specific circumstances in which residents may smoke in the designated areas and when increased supervision is required. Policy Specifications: 1. All residents who desire to smoke will be assessed by the Interdisciplinary Team to determine if the individual is appropriate for independent smoking. 2. If assessed to be appropriate for independent smoking, the resident must sign a Facility Smoking Contract. 3. If a resident breaks the smoking contract the facility may revoke the residents' smoking privilege. 5. Some residents may require more intensive staff supervision while smoking. These residents smoke separately from other residents, under the supervision of a staff member specifically designated to assist them. Behaviors that may trigger additional resident supervision while smoking include, but are not limited to: Being unable to state facility smoking rules Being unable to follow facility smoking rules without prompts Using smoking materials in an inappropriate manner Giving or selling cigarettes and/or smoking materials to other residents Collecting or attempting to use discarded smoking materials Asking for smoking materials from other residents Attempting to take other residents' smoking materials Attempting to intimidate another resident for the purpose of taking cigarettes or smoking materials 7. Possessing, carrying, or holding materials used to smoke (including, but not limited to, cigarettes, cigars, loose tobacco, pipes, lighters, and matches) by residents is prohibited inside the building. Residents must give smoking materials to designated staff when they enter the building, even if the resident has been assessed to be independent in carrying such materials when off the premises. 8. Residents are prohibited from giving smoking materials to other residents. 9. Residents are prohibited from asking other residents for smoking materials. 10. The facility may limit smoking to designated times for both independent and supervised residents. The safe and homelike environment policy (reviewed 1/14/25) states maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Report any unresolved environmental concerns to the Administrator. The (November 2013) resident smoking policy states persons bringing smoking materials into the facility for resident's use must leave these items at the front desk. Smoking materials left for an individual resident will be labeled and forwarded to an assigned staff member. The (03/01) contraband policy states the following items are not allowed in resident rooms at any time and are not allowed on the resident's person unless permission has been granted from administration and supervision is being provided: cigarettes, razor blades.

Based on observation, interview, and record review the facility failed to have a policy/procedures for maintaining respiratory equipment, failed to ensure that respiratory equipment was discarded weekly, and failed to maintain respiratory equipment in a bag when not in use for four of 42 residents (R1, R108, R135, R190) in the sample reviewed for respiratory care. Findings include: 1) R108 is [AGE] years old and has resided at the facility since 2025. Past medical history includes but is not limited to chronic obstructive pulmonary disease with acute exacerbation, other specified disorders of muscle, essential primary hypertension, type 2 diabetes, anemia, hyperlipidemia, chronic respiratory failure, need for assistance with personal care, etc. On 05/04/2026 10:05AM, R108 was observed in room, awake and alert stated that she is doing okay, just that she is on antibiotics for upper respiratory infection and just got over pneumonia. R108 said that she is tired of being sick. On 05/04/2026 10:27AM, observed incontinence care for R108 with V10 (CNA) and V17 (Restorative aid). V10 removed resident's CPAP mask that was on her bed and placed it directly on top of the CPAP machine without it being contained. On 5/5/2026 at 9:55AM, R108 was observed in bed, awake and alert and stated that she is doing okay, respiratory mask was observed in a plastic bag, R108 said, that only happened because State is in the building otherwise, they usually leave it uncontained all the time. Active physician order dated 4/30/2026 documents the following: per record review, R108 is on the following medication: Levaquin tablet 500 MG (Levofloxacin) give 1 tablet by mouth one time a day for respiratory infection for 7 Days. 2) R190's (4/2/26) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 5/4/26 at 10:13am, R190's nebulizer mask was observed on the dresser uncontained, and the tubing was dated 3/16/26. Surveyor inquired when R190's respiratory equipment is changed/replaced R190 stated They (staff) do change the tubing once in a while. On 5/4/26 at 10:15am, surveyor inquired if R190's nebulizer mask was contained in a bag. V13 (LPN/Licensed Practical Nurse) stated, No, it's not but I (V13) can do it. Surveyor inquired about the date on R190's nebulizer tubing. V13 responded, 3/16/26 (49 days ago). Surveyor inquired when should nebulizer tubing and/or masks be changed. V13 replied, Weekly. On 5/4/26 at 10:35am, R1's nebulizer mask was observed uncontained on the windowsill. R1's nebulizer mask was dated 4/3 (roughly 1 month ago). On 5/4/26 at 10:37am, surveyor inquired about concerns with R1's nebulizer mask. V14 (LPN) stated, The date is April 3rd. Surveyor inquired if R1's nebulizer mask was contained while not in use V14 responded No, it's not in a bag. On 5/4/26 at 10:49am R135's uncontained Bipap mask was observed on the dresser. Surveyor inquired if R135's Bipap mask was contained while not in use. V13 (LPN) stated, No, it should be in a bag. On 5/6/26 at 8:34am, surveyor requested the respiratory equipment (re: Nebulizer, Bipap, Cpap) policy. V1 (Administrator) stated, I (V1) don't have one for the respiratory equipment. Surveyor inquired where respiratory equipment should be stored when not in use. V1 responded, It can be contained in a plastic bag due to infection control purposes. On 5/6/26 at 4:51pm, surveyor inquired when nebulizer masks/mouthpiece should be changed. V2 (Director of Nursing) stated, My (V2) protocol is that we (staff) do it weekly. Surveyor inquired how respiratory equipment should be stored when not in use. V2 responded, If it's not in use, we put it in a bag. The oxygen safety/use policy (reviewed 1/2026) states oxygen tubing will be changed weekly and appropriately stored to prevent contamination when not in use.

Based on observation, interview and record review, the facility failed to immediately sign out controlled substances prior to administration and failed to maintain documented accountability for controlled substances not in use. These failures affected four residents (R14, R87, R119, R11), and seven discharged residents (R214, R215, R216, R217, R218, R219, R220) in a sample of 63 residents.Findings Include: On 5/5/2026 at 4:50 PM, V3, Assistant Director of Nursing (ADON) was assigned to care for patients that received medication from the cart and had taken possession of the cart key following shift change. Observed medication cart with V3. Observed controlled medication count and reviewed the controlled drug receipt/record/disposition forms with V3. Observed the following discrepancies with V3: A) R14 - Tramadol 25mg (milligram), 19 tablets available. According to the controlled drug receipt/record/disposition form, 20 tablets should be present. Additionally, the back of the medication card revealed a patient label for a different resident.B) R119 - Pregabalin 75mg, 2 capsules available. According to the controlled drug receipt/record/disposition form, 3 capsules should be present.C) R87 - Clonazepam 1mg, 3 tablets available. According to the controlled drug receipt/record/disposition form, 4 tablets should be present.These discrepancies were confirmed with V3. V3 affirmed controlled medications should be signed out on the Controlled Drug Receipt/Record/Disposition Form immediately upon removal of the controlled medication to be sure of an accurate count. On 5/5/2026 at 4:55 PM, V52 (Registered Nurse) confirmed being the day shift nurse and said they should have signed the medications out at the time they were given in the morning but forgot to do so before shift change and did not count with V3 before handing off the medication cart keys. V52 stated that medications were administered to R87 and R119 during the 9am med pass but could not recall administering the Tramadol to R14. When asked about the protocol of signing out the controlled medications on the Controlled Drug Receipt/Record/Disposition Forms, V52 stated that the medications should be signed as you go (documented when medication is withdrawn from the cart to administer) and not multiple hours later. Record review of Medication Administration Records (MAR) for R14, R87, and R119 show the following medications were administered on 5/5/26:R14 - Tramadol 25mg was administered by V52 at 1:30PMR87 - Clonazepam 1mg was administered by V52 at 09:00AM.R119 - Pregabalin 75mg was administered by V52 at 09:00AM. On 5/6/26 at 9:10AM, surveyors identified an unmarked storage room with V47 (Central Supply Manager) in search of incontinence briefs. V47 referred to the room as a supply overstock room. Upon entry, there was a large quantity of medications scattered around the room amongst general supplies such as personal protective equipment, oxygen tubing and rolls of garbage bags. Large drawers filled with medication blister pack from the pharmacy were visualized along the right wall. Multiple brown boxes contained additional packs of resident-specific medications, and three boxes of various injectable medications were on a table. Medications dispensed from current and previously used pharmacies and included controlled medications. There were no Controlled Drug Receipt/Record/Disposition forms accompanying the controlled medications, nor a tracking system/log of the medications present in the room. On 5/6/26 at 9:15AM, V29 (Nursing Unit Manager) was called to the room and said the facility recently changed pharmacy companies and that some of the medications in the room were from the old pharmacy and awaiting to be returned, some were discontinued medications and no longer needed, and some medications were being held for residents that were currently hospitalized . V29 said the policy was that medications would be held for 10 days before returning them to the pharmacy. V29 said the medications have been in the room for at least two weeks awaiting pick-up. On 5/6/26 at 9:21AM, V2 DON (Director of Nursing) confirmed there should be no controlled medications in this room, and any discontinued controlled medications should have been destroyed. The other medications were to be sent back to the pharmacy for disposal and reimbursement. V2 stated that V29 is responsible for coordinating the pickup with the pharmacy for the other remaining medications. Controlled medications present in the unmarked storage room without the accompanying Controlled Drug Receipt/Record/Disposition Form Include:R11 - Lorazepam 2mg IM Injection vials. R11 is currently residing in the facility.R214 (according to face sheet discharged [DATE]) - Buprenorphine HCl-Naloxone HCl Sublingual FilmsR215 (discharge date unknown) - Lorazepam 2mg/ml liquid. Physician's order sheet indicates medication was discontinued 11/3/25.R216 (a discharged resident) - one unopened box of five Fentanyl patches 12mcg (micrograms). R217 (a discharged resident) - Midazolam Nasal Spray. R218 (a discharged resident) - Dronabinol 2.5mg capsulesR219 (a discharged resident) - Lacosamide 100mg tabletsR220 (a discharged resident) - Lorazepam 2mg/ml liquid Face sheets, Medication Administration Records and Physician Order Sheets were requested to investigate the accounting for all controlled medications. On 5/6/26 V50 [NAME] President of Clinical Operations said R214, R215, R216, R217, R218, R219 and R220 had been discharged from the facility and many of the records for the residents could not be found due to change of ownership twice over. Facility Controlled Substance Policy (reviewed 5/2026) states in part; General: Medications classified by the FDA as controlled substances have high abuse potential and may be subject to special handling, storage, and record keeping. Policy: 1. Only authorized personnel involved in the residents care will have access to medication. The Director of Nursing is responsible for the control of these medications. 11. All schedule II-controlled substances (and other schedules if facility policy so dictates) will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will: a. Inspect both the drug package and the corresponding count sheet to verify the accuracy of the amount remaining. b. Both nurses will count the number of packages of controlled substances that are being reconciled during the shift/shift count and document on the Shift Controlled Substance Count Sheet. c. Both nurses will count the Controlled Substances count sheets and verify the accuracy of the number of remaining count sheets. d. Both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to store medications safely/securely, failed to make sure medications were not accessible to unauthorized individuals, and failed to make sure controlled substances were double locked for two of 42 residents (R1, R11) in the sample and seven of 63 residents (R214, R215, R216, R217, R218, R219, R220) in the supplemental sample reviewed for medication storage.Findings include: R11's (2/26/26) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 5/4/26 at 10:23am, a medication cup - which contained a white liquid was observed on R11's bedside table. Surveyor inquired what was in the medication cup. R11 stated, Milk of Magnesia I (R11) believe they call it, its gonna make you poop. Surveyor inquired how long the medication was sitting on the table R11 responded, Since yesterday. On 5/4/26 at 10:30am, surveyor inquired about the Milk of Magnesia left at R11's bedside. V14 (LPN/Licensed Practical Nurse) responded, I'm (V14) not sure if its Milk of Magnesia. Surveyor inquired if staff are allowed to leave medications at resident's bedside. V14 replied, No. __ On 5/4/26 at 10:35am, a white pill was observed on R1's windowsill. On 5/4/26 at 10:37am, surveyor inquired about the pill on R1's windowsill. V14 (LPN) stated, I'm (V14) not sure what med (medication) it is. V16 (Minimum Data Set Coordinator) subsequently inspected the pill and responded, It looks like a calcium pill. __ On 5/4/26 at 12:53pm, a Symbicort inhaler was observed on R11's bedside table. R11's (9/17/25) physician order includes Symbicort every 12 hours (may keep at bedside is excluded). On 5/4/26 at 12:54pm, surveyor inquired about the medication left on R11's table. V14 (LPN) entered the room, inspected the inhaler and stated, Symbicort. Surveyor inquired (again) if staff are allowed to leave medications at bedside. V14 responded, No. On 5/6/26 at 4:49pm, surveyor inquired if medications are allowed to be left at bedside. V2 (Director of Nursing) stated, No, ma am. On 5/6/26 at 9:10AM, surveyors inspected an unmarked storage room with V47 (Central Supply Manager) in search of incontinence briefs. V47 referred to this room as supply overstock room. There was a numeric keypad entry to the door. Upon entry, there was a large quantity of medications scattered around the room, among general supplies such as personal protective equipment, oxygen tubing, and rolls of garbage bags. Two large drawers filled with medication cards from current and previous pharmacy were visualized along the right wall. Multiple brown boxes contained additional packs of patient-specific medications, and three boxes of various injectable medications were on a table. Medication review revealed both controlled and non- controlled medications. There were no Controlled Drug Receipt/Record/Disposition forms accompanying the controlled medications, nor a tracking system/log of the medications present in the room. Controlled medications were not secured by a second lock within the room. V47 was not licensed to access medication rooms or supplies. V47 stated that surplus supplies are put in this room on the 2nd floor, and that the manager of the unit has access to the room as well. On 5/6/26 at 9:15AM, V29 (Unit Manager/Licensed Practical Nurse) came to the unmarked storage room. V29 stated all of these medications were either from the previous pharmacy and awaiting return to there, discontinued medications/no longer needed from current pharmacy, or medications remaining from patients that have been hospitalized longer than 10 days. V29 confirmed that pharmacy was called within the last 2 weeks for pickup but pick up date is unknown. V29 had access to this room via the numeric keypad. On 5/6/26 at 9:21AM, V2 (Director of Nursing) observed the medications in the storage room. V2 stated that the facility underwent a transition of pharmacies in recent weeks but is unsure of the exact date. V2 denied having access code to this room and was unaware of the quantity/types of medications in the room. When asked if there should be controlled medications in this room, V2 confirmed that any discontinued controlled medications should have been destroyed, not stored. V2's understanding is that V29 was utilizing this room as an office, and that V47 should not have access to medications. On 5/6/26 at 10AM, V50 (VP of Clinical Operations) observed the ongoing inspection of the medications in the supply room. V50 affirmed that unlicensed personnel should not have access to these medications. The (2/2026) medication storage policy states medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Policy Medication Storage in the Facility (1/2023) documents in part .Medication rooms, carts, and medication supplies are locked or attended by person with authorized access: Licensed Nurses, Consultant Pharmacist, Pharmacist Technician, Individual lawfully authorized to administer drugs, Consultant Nurses. Also, the policy states All drugs classified as Schedule II of the Controlled Substances Act will be stored under double locks. Schedule II-V medications must be maintained in separately locked permanently affixed compartments and cannot be stored with other nonscheduled medications.

Based on observation, interview and record review, the failed to provide a thermometer for a resident's personal refrigerator; failed to date outside open food items in a resident's personal refrigerator; failed to clean residents' refrigerators; and failed to discard expired food items from a resident's personal refrigerator. These failures affected 6 residents (R3, R4, R8, R89, R91, and R163) reviewed for safety of personal food items, in a total sample of 63 residents. Findings include: R4's face sheet documents diagnoses that include but are not limited to history of falling, need for assistance with personal care, disorder of muscle, and reduced mobility. R4's BIMS (brief interview for mental status) score, dated 4/8/26, is 12 which indicates R4's cognition is moderately impaired. On 5/4/26 at 10:21am, observation of R4's personal refrigerator revealed an undated Styrofoam take-out container with partially eaten ribs and partially eaten fried onion blossom and an undated Styrofoam take out container of partially eaten grits (the word grits written on top of container). R4 said, those (take out containers) have been in there a few days. Not sure (how long). The grits definitely need to be thrown out. The CNAs usually are in there (personal refrigerator) checking things out. No, not every day. R163's face sheet documents diagnoses that include but are not limited to central cord syndrome at unspecified level of cervical spinal cord, fusion of spine, fall, and paraplegia. R163's BIMS (brief interview for mental status) score, dated 3/26/26, is 15 which indicates R163 is cognitively intact. On 5/4/26 at 10:30am, observation of R163's personal refrigerator revealed no thermometer to check the temperature of the fridge. R163 said, They (staff) checked it (personal refrigerator) today. There hasn't been a thermometer in my fridge for a while now. R8's face sheet documents diagnoses that include but are not limited to chronic obstructive pulmonary disease, depression, and acquired absence of right leg. R8's BIMS (brief interview for mental status) score, dated 4/24/26, is 15 which indicates R8 is cognitively intact. On 5/4/26 at 10:32am, observation of R8's personal refrigerator revealed an undated Styrofoam take-out container of hot wings and bread that is wrapped in undated aluminum foil. R8 said, Ha Ha! I don't even know what day it is, so I'm not really sure how old that stuff it is. R91's face sheet documents diagnoses that include but are not limited to prediabetes, weakness, and seizures. R91's BIMS (brief interview for mental status) score, dated 3/28/26, is 15 which indicates R91 is cognitively intact. On 5/4/26 at 10:34am, observation of R91's pink personal refrigerator revealed no thermometer to check the temperature of the fridge. On 5/4/26 at 10:43am, V4 (Infection Preventionist/Unit Manager) said, I'll get thermometers for the personal refrigerators. Yes, they (personal refrigerators) all should have thermometers to make sure the food doesn't spoil. The outside food (personal refrigerators) should be dated. We (facility) usually keep it only 3 days. To prevent residents from getting a food borne illness. R3 is 68 years assessed with a brief interview for mental status of 15 according to minimum data set assessment (MDS) dated [DATE]. Section gg (functional) of the same assessment documented that R3 is dependent on staff for Activities of daily Living (ADL) care needs. On 05/04/2026 10:45 AM, R3 was observed in her room, awake and alert, stated that she is doing okay. R3 has a personal refrigerator that is noted to be very dirty, inside the refrigerator was noted a gallon of 2% milk dated 4/25/2026 and 1 bottle of Mayonnaise dated 6/11/2024. On 05/04/2026 11:12 AM, this observation was presented to V18 (C.N.A) who said that staff only clean the refrigerator if the residents ask them to, V18 was informed that there are some expired items in resident's refrigerator but V18 did not say anything. 05/05/2026 9:44 AM and 5/6/2026 at 10:31AM, surveyor checked resident's refrigerator and the expired items remained in the refrigerator. R89 is 76 years, MD assessment dated [DATE] section C (cognitive) documented a BIMs score of 15, section gg (functional) of the same assessment documented that resident is dependent on staff for some ADL care needs. On 05/04/2026 at 10:50 AM, R89 was in bed, awake and alert, and stated that she is doing okay. R89 has a personal refrigerator that was noted with some dark liquid spilled at the bottom of the refrigerator, there was no thermometer noted inside the refrigerator. R89 said that staff come in and check their refrigerator occasionally. On 05/04/2026 11:12 AM, V18 (C.N.A) was observed putting a plate of carry-out food inside the refrigerator with the liquid spill inside. Surveyor presented this observation to V18 who still put the food inside the refrigerator and said she will come back to clean it later. V18 added that staff only clean the refrigerator if the residents ask them to. On 5/6/2026 at 2:40PM V2 (DON) said that nursing department is responsible for cleaning the personal refrigerators and making sure that expired food items are removed. V2 said that housekeeping does not want to do it because they said it is not part of their job, so the decision is still up in the air but at this time, nursing department is responsible. Personal food storage-Room refrigerator policy (undated) documented in part: Residents may obtain and store a personal refrigerator in their rooms, according to facility policy. Housekeeping to ensure that fridge is cleaned and spoiled items are removed. Procedure: Housekeeping should be assigned to monitor individual room storage and refrigerator unit temperature as well as the disposal of food and beverages to ensure food safety. All refrigerator units should have an internal thermometer which should be monitored by housekeeping. Refrigerator units must maintain safe internal temperatures in accordance with state and federal guidelines, Housekeeping is responsible for keeping personal refrigerators clean. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike.

Based on interview and record review, the facility failed to implement a physician's order for an as soon as possible (STAT) X-ray after one resident (R1) sustained an unwitnessed fall and complained of pain in the right hip area. This failure affected one resident (R1) who was transferred to a local emergency room eighteen hours after the unwitnessed fall took place, and R1 was diagnosed with a right hip fracture. It can be determined that the reasonable person in the residents' position would have experienced psychosocial harm related to pain (eg: facial grimacing and guarding of the right leg) as a result. Findings include:R1 is a [AGE] year-old male, originally admitted on [DATE] with medical diagnoses that include and are not limited to: metabolic encephalopathy, diabetes, seizures, and major depressive disorder.According to the Minimum Data Set (MDS), R1 had a brief interview for mental status (BIMS) dated 11-21-2025, with a score of 3/15, which indicates impaired cognition and needs maximum assistance on transfers to the chair, bed, and shower. On 2/1/2026 at 12:00 p.m., V7 (Certified Nurse Assistant) said on 11/19/2025, while working the 7:00 a.m. to 3:00 p.m. shift, I was called by V16 (Certified Nurse Assistant) to R1's room. R1 was alert but confused, dependent on staff for all activities of daily living, non-ambulatory, and required a mechanical lift for transfers from the bed to a geriatric chair. Upon entering the room, R1 was observed on top of the floor mat. I do not recall whether R1 was lying on the right or left side. I assisted in transferring R1 back to bed using a mechanical lift. V12 (Licensed Practical Nurse) was in and out of the room during this time due to the emergency with R1. V7 said I did not observe any changes in R1's behavior, vocalizing as usual, saying ouch, ouch. V12 and I transferred R1 to the bed using the mechanical lift. After completing the transfer, I exited the room. I do not know what happened with R1 after that. On 1-31-2026 at 4:10 PM V12 (Licensed Practical Nurse) said I was the nurse in charge when R1 was noted on the floor, the fall took place on 11-19-2025 at 2:52 PM, I did not see when R1 fell, I was called to the room by V16 (Certified Nurse Assistant) who reported hearing a sound coming from R1's and when she went to the room R1 was on the floor mat. I went to see R1, and I saw R1 next to a low bed in top of the floor mat. I completed a head-to-toe assessment, and R1 complained of pain in the right hip area. I medicated the patient, and the provider ordered a soon as possible (STAT) X-ray of the right hip; results should be back within 4-6 hours. I also contacted the family and hospice company. On 2-2-2026 at 3:20 PM, V13 (Licensed Practical Nurse) said I was the nurse who transferred R1 to the hospital because he was complaining of pain in the right leg. R1 was supposed to have a stat X-ray, but it was not done, which is the reason I called the doctor and obtained an order to transfer to the hospital.R1's medical record documents on 11/20/2025 at 6:44AM, Resident complaints of pain to right hip (pain medication given). At 9:33AM Upon rounds resident was noted with facial grimacing and guarding of the right leg.On 2-1-2026 at 3:55 PM V8 (Medical Doctor) said, do remember R1. My expectation is for the stat x-rays to be done as soon as possible and to have results on the same day the order was given.Per local hospital emergency room documentation dated 11-20-2025 at 2:25 PM reads: (R1) presented due to fall and right hip pain, patient reportedly had a mechanical fall the day prior to presentation. X-ray of the right hip and right femur showing a superior laterally displaced commuted intertrochanteric right femoral fracture.On 2-2-2026 at 1:00 PM. V2 (Director of Nursing) said, my expectation is for the STAT x-ray to be completed within 4-6 hours. The nurse needs to notify the medical provider if any order is not followed and see what to do next. I do not remember if I was informed that the stat x-ray was not completed; the nursing team needs to let you know.On 2-2-2026 at 1:15 PM, V1 (Administrator) said, the stat x-ray needs to be completed within 4-6 hours. We do not have any policy that indicates that. The nurse is responsible for carrying out the provider's orders in a timely manner.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services to prevent urinary tract infection for a resident with an indwelling urinary catheter and failed to provide timely and appropriate assessment for the removal of the indwelling urinary catheter. This failure affected one (R1) of three residents reviewed for care of indwelling urinary catheter and resulted in R1 having four urinary tract infections since being admitted to the facility. Findings include: R1 is [AGE] years old admitted to the facility on [DATE], diagnosis include, but not limited to Type 2 diabetes, Rhabdomyolysis, unspecified asthma, chronic obstructive pulmonary disease, disorder of muscle, neuromuscular dysfunction of bladder, pressure ulcer of sacral region, dysphagia pharyngeal phase, history of falling, essential primary hypertension, chronic kidney disease stage 2, etc. On 5/5/2025 at 1:30PM, R1 observed in room sitting in a motorized wheelchair, alert and oriented x3 and stated that she is doing okay, trying to get her strength back. R1 said that she used to have a indwelling urinary catheter, but they took it out, she was in so much pain, begged staff to remove the urinary catheter but they refused, finally one nurse was kind enough to remove the urinary catheter. R1 added that she feels better and urinating with no problems. R1 stated that she has had urinary tract infections four times while she had the urinary catheter and they continued treating her for the UTI (urinary tract infection) with antibiotics, but it comes back after each treatment. Per record review, R1 was admitted from the hospital with an indwelling urinary catheter. Review of resident's medical record showed several nurse's progress notes indicating the R1 has been complaining of discomfort due to the indwelling urinary catheter since 11/29/2024. Review of antibiotic therapy for R1 since admission shows the following: 9/24/2024, Ciprofloxacin HCl Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth every 12 hours for UTI for 7 Days. 12/3/2024 Cipro Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth every 12 hours for uti for 5 Days. 12/5/2024 Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every 12 hours for UTI, E Coli for 7 Days. 3/13/2025 Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day for uti E. coli for 7 Days. 4/3/2024 Cefuroxime Axetil Oral Tablet 250 MG (Cefuroxime Axetil) Give 1 tablet by mouth one time only for uti E. coli and proteus for 1 Day. On 5/6/2025 at 11:33AM, V12 (Infectious disease NP) said that he is familiar with R1, she was constantly having urinary tract infection (UTI) with e. coli as the bacteria and that could be a result of not being cleaned properly. Resident also had a sacral wound, the constant infection could be addressed with better care by avoiding poop from getting into the vaginal area, and in turn getting into the catheter, causing UTI. On 4/23/2025 V12 documented in part, patient states have some discomfort from urinary catheter, speaking to facility nurse practitioner about whether she needs same. 4/16/2025, V12 documented in part, patient still relates some dysuria (pain with urination). V12 said that the urinary catheter may also help with wound healing, resident complained to him of discomfort to the urinary catheter area but stated that it occurs when she wants to urinate. R1 has been treated so many times for UTI, surveyor asked V12 if anyone considered removing the urinary catheter to see if it will help with the constant UTI and he said that he does not make decision when it comes to discontinuing the urinary catheter, that will be a question for the medical doctor. On 5/7/2025 at 2:53PM, V12 (Infectious disease NP) said that he is not sure if R1 have seen a urologist or not, he just looked at resident's record and saw that staff were documenting no post void residual and that is good. V12 added that if R1 did not have a indwelling urinary catheter, she probably wouldn't have this many UTIs. On 5/7/2025 at 9:29AM, V13 (LPN/ Infection Prevention Nurse) said that she oversees the antibiotic stewardship, she works with the infectious disease nurse practitioner. V13 said that R1 has been on a lot of antibiotics for dysuria (Pain and burning during urination), resident had a urinary catheter for a diagnosis of neurogenic bladder. V12 said that she has never reached out to the doctor and not sure if anyone has reached out to the doctor or suggested discontinuing the urinary catheter for a while since admission. R1 complained of pain due to the urinary catheter but not all the time, when she gets treated, she will say that she feels better. 5/6/2025 at 10:16AM V8 (LPN) said that she has worked at the facility since March 2025, and has been the 4th floor supervisor since then. V8 is familiar with R1, have seen and talks to her every day. V8 is aware that R1 had a urinary catheter and was present the day it was dislodged, V8 spoke to the nurse practitioner after the urinary catheter came out and attempted to re-insert urinary catheter but resident was complaining of pain. V8 received an order to monitor resident's output and measure post void residual. R1 never complained of pain to V8, R1 have been on antibiotics for UTI for the one month that V8 has been here, not sure of what happened before she started. On 5/7/2025 at 11:52AM, V17 (Attending physician) said that he is familiar with R1, she was having some urine retention issues, that is the reason for the indwelling urinary catheter, they were planning to remove it and try weaning the resident off, she was supposed to see a urologist but V17 is not sure if she did or not. V17 said that he will review resident's chart and call surveyor back. On 5/7/2025 at 3:15PM, V17 called back and said that resident's urinary catheter is now out and they are mentoring her post void residual (PVR), so far it is negative and if it continues to be negative, they will keep the urinary catheter out. The resident needed the urinary catheter due to a diagnosis of neurogenic bladder, not sure if resident was getting UTI because of the urinary catheter, she also had a sacral pressure ulcer and the urinary catheter was needed for the healing of the ulcer. V17 added that there has never been an attempt to reassess resident or discontinue the urinary catheter prior to it coming out few days ago. Indwelling urinary catheter care procedure revised September 2005 states it purposes as to prevent infections of the resident's urinary tract. Under general guidelines, #18 states to report to the supervisor. Urinary tract infections/ bacteriuria policy revised April 2007 states that as part of the initial assessment, the physician will help identify individuals who have a history of symptomatic indwelling urinary tract infections and those who have risk factors, for example, an indwelling urinary catheter. Under monitoring, the policy states that the physician and nursing staff will review the status of the individuals who are being treated for UTI and adjust treatment accordingly. 2. When someone's urinary tract infection persists or recurs after treatment with an initial course of antibiotics, the physician should review the situation carefully with the nursing staff and possibly examine the individual or review the situation in detail before prescribing repeated courses of antibiotics.

Based on interviews and record reviews, the facility failed to follow its change in resident's condition policy and its urgent laboratory testing protocol and notify the attending physician/nurse practitioner the urgent laboratory tests ordered were not done within the 4-6-hour time frame. This affects one of three residents (R1) reviewed for notification of physician of changes in condition. This failure resulted in over a nine-hour delay of labs being obtained. R1 was subsequently sent to the local hospital. R1 was admitted and treated for the diagnosis of dehydration, pneumonia, and urinary tract infection. Findings include: On 2/27/25 at 10:07AM, V5 RN (registered nurse) stated that V5 is familiar with R1. V5 stated that V5 sent R1 to the hospital on 1/19 for pneumonia. Stated that R1's family member took R1 home for a couple of days. V5 stated that shortly thereafter R1 got sick. V5 stated that urgent laboratory tests should be done within 4-6 hours, if not done within that time, the nurse is expected to call the primary physician/primary nurse practitioner and ask want he/she wants to do; wait or send resident out to hospital. V5 stated that the nurse is expected to document in the resident's progress notes urgent orders and if not done within time frame document physician notification and any follow up orders. V5 stated that the nurse also documents on 24 report sheet that laboratory tests are pending. V5 stated that R1's eating had decreased and R1 was weak. V5 stated that V5 would assist R1 with eating. On 2/27/25 at 12:20PM, V6 CNA (certified nurse aide) stated that V6 is familiar with R1. V6 stated that R1 started eating and drinking less mid January when R1 became sick. V6 stated that the CNAs are expected to document the amount eaten and fluids in POC (point of care) charting. V6 stated that the CNAs are expected to report if the resident has decreased intake or refusal to eat to the nurse. V6 stated that when R1 started to get sick, R1 stopped getting out of bed. V6 stated that R1 was more tired and weak, coughing and looked dehydrated; R1 just looked sick. V6 stated that R1 started becoming incontinent of bowel and bladder, staff had to feed him. The facility's staffing assignment sheets note V6 provided care for R1 on the day shift on 1/12, 1/14, 1/16, and 1/17. On 1/17 V6 also provided care for R1 on the evening shift. On 2/27/25 at 2:05PM, V8 (primary NP) stated that when V8 orders testing to be done, V8 expects it to be done. V8 stated that when V8 was informed of R1's BMP results, R1 was really dehydrated. V8 stated that V8 ordered intravenous fluids for R1. V8 stated that when V8 was notified that V5 nor the outside midline catheter insertion nurse could not access a vein, V8 knew R1 was severely dehydrated. V8 stated that at a critical time V8 did not know what was going on with R1 because the nurses were calling any NP and not V8 or V9 (primary physician). V8 stated that V8 and V9 are responsible for managing R1's care and this can't be done if V8 and V9 are not kept informed of R1's changes in condition. On 2/28/25 at 1:50PM, V8 NP stated that R1 was not eating or drinking which would be a factor in R1's dehydration. V8 stated that V8 can only implement interventions as soon as V8 knows the test results. R1's dietary assessment, dated 1/5/25, notes R1's fluid needs are 1330-1600ml (milliliters) of fluids/day. R1's POS (physician order sheet), dated 10/19/24, notes to encourage R1 to increase fluid intake to 8 cups of water per day every shift for chemical imbalance. R1's POS, dated 1/17/25 at 1:03PM, notes orders for UA/C&S (urinalysis/culture and sensitivity), urgent BMP (basic metabolic panel) and CBC (complete blood count). R1's POC (point of care) charting notes document fluid intake - amount of milliliters R1 drank each shift. The facility is unable to provide any POC documentation of R1's fluid intake since 10/19/24. R1's urgent laboratory test results, dated 1/19/25 at 11:14AM, R1's creatinine was 4.42 (normal range is 0.67 - 1.17) and BUN was 103 (normal range is 5 -20) and WBC (white blood cell count) was 18.3 (normal range is 4.2 - 11). R1's last dehydration risk assessment was completed on 6/15/2023. On 1/17/25 at 12:45PM, V5 RN noted R1 received in bed, alert and oriented x 1-2 with confusion. R1 noted to be lethargic and fatigued while in bed. Appetite poor for breakfast. R1 able to respond to name and verbal stimuli. V8 NP notified with new orders for UA/C&S, chest x-ray, and BMP. Orders rendered and carried out. At 1:38PM, V5 called and spoke with staff from the outside laboratory company for urgent CBC/BMP. ETA 4-6 hours. On 1/18/25 at 10:13AM, V5 RN noted R1 able to tolerate 30% of breakfast. On 1/18/25 at 11:27AM, urgent chest x-ray completed. On 1/18/25 at 6:46PM, V8 NP noted R1 with generalized muscle weakness ,unsteady gait, using wheelchair. Chest x-ray positive for pneumonia. 1/18/25 at 7:00PM, V5 RN noted R1 able to consume 30% of dinner. R1 has been resting in bed during shift. R1 noted to have congestion while trying to communicate. As needed albuterol sulfate inhaler administered and tolerated well. There is no documentation in R1's MAR (medication administration record) noting R1 received albuterol inhaler. 1/18/25 at 9:55PM, V5 RN noted Still awaiting urgent laboratory testing. V5 called the outside laboratory company. New order placed urgent CBC/BMP. No ETA given. 1/18/25 at 10:24PM, urgent laboratory testing done. 1/19/25 at 9:24AM, V5 RN noted R1 received resting in bed, alert, responsive to verbal stimuli. Fluids encouraged and given. R1 able to tolerate 1 cup of water. R1 appetite poor for breakfast. V5 able to feed R1 20%. On 1/19/25 at 12:34PM, V5 RN noted abnormal laboratory results relayed to V8 NP. Per NP, new orders to give sodium chloride solution 0.9% 3 liters intravenously at 100ml/hour; repeat BMP after infusion. Orders carried out. On 1/19 at 1:21PM, V8 attempted x2 to insert peripheral intravenous line without success. Outside company was called for urgent peripheral intravenous line insertion. 1/19 at 2pm, the outside company in facility for peripheral intravenous line insertion. Unsuccessful in establishing intravenous access. On 1/19/25 at 3:27PM, R1's family member requested for R1 to be sent to the hospital. On 1/19/25 at 5:09PM, an outside ambulance service transported R1 to the hospital. R1's bladder incontinence care plan, dated 7/3/24, notes monitor R1's fluid intake. Monitor/document for signs/symptoms of UTI (urinary tract infection) no urine output, altered mental status, change in behavior, change in eating pattern. There is no documentation found in R1's medical record noting the number of bladder continence episodes or the number and quantity of urine with each incontinent episode. There is no documentation found in R1's medical record noting urine was collected for urinalysis prior to hospitalization on [DATE]. The hospital record provided to the facility, dated 1/19/25, notes R1's urinalysis was positive for nitrites, white blood cells, and ketones; confirming R1 had a UTI. Chest x-ray showed pneumonia. Laboratory confirmed dehydration.

Based on interview and record review, facility lacked an effective system to prevent fluid volume overload, assess and monitor fluid volume status, and notify the nephrologist of treatment refusals and abnormal radiology results for one (R8) out of three residents reviewed for dialysis in a total sample of ten. This failure resulted in staff failing to recognize R8's change in condition as fluid volume overload after R8 complained of shortness of breath, and R8 expired in the facility after being found unresponsive. The Immediate Jeopardy began on [DATE]. When R8 went over 5 days without a dialysis treatment and the facility staff failed to notify the nephrologist of R8's refusal to go the hospital as ordered and failed to notify the nephrologist/attending physician of an abnormal chest X-ray and failed to prevent and assess for fluid volume overload. R8 complained of shortness of breath and later found to be unresponsive. V1 (Asst Administrator) was notified on [DATE] at 12:13 PM of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on 1.30.25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: R8 is a [AGE] year old with the following diagnosis: chronic respiratory failure with hypoxia and hypercapnia, morbid obesity, congestive heart failure, cardiomegaly, lymphedema, end stage renal disease with dependence on renal dialysis, and encounter for tracheostomy and gastrostomy. A Nursing note dated [DATE] at 4:30 PM documents R8 refused to go to dialysis. The nurse explained the importance of dialysis and risks for not receiving treatment. The dialysis nurse spoke with the nephrologist who made an order to send R8 to the hospital for an evaluation. A Nursing note dated [DATE] at 7:12 PM documents the ambulance arrived for transportation to the hospital, but R8 refused to go. The primary physician was notified. There is no documentation of the nephrologist being notified of R8's refusal to go to the hospital for an evaluation. A Nurse Practitioner note dated [DATE] documents R8 was seen today for the initial visit. R8 refused hemodialysis on Friday and discussed concerns. R8 is to resume hemodialysis on Monday. No further orders were put in place to monitor R8 before the next dialysis session. A Nursing note dated [DATE] at 4:19 PM documents R8 is receiving continuous oxygen at 3 L via nasal cannula. Vital signs are within normal limits but R8 complains of shortness of breath. R8 continuously requested to go to the hospital. The nurse and management educated R8 on breathing techniques and that vital signs are normal. A chest x-ray was ordered to rule out pneumonia. R8 was also counseled on refusing dialysis treatment and the adverse effects to overall health. R8's family member was notified and reported understanding. There is no documentation that an assessment was completed to listen to R8's lungs or that any vital signs were taken after this point to assess R8 for any further changes in condition or changes in vital signs. A Nursing note dated [DATE] at 5:10 PM documents R8 refused to go to the hospital. The nurse educated R8 that R8 should go to the hospital due to refusing dialysis treatments and missing two sessions. R8 voiced understanding after education was provided. A STAT order for labs were put in place. This note was not charted until 10:22PM which is after the time R8 expired. The x-ray company's Portable Service Requisition Sheet dated [DATE] documents the tech was performing the exam at 6:36PM. R8 was morbidly obese and bedbound. R8 was nonresponsive and physically unable to maintain the lateral position during the exam. A Nursing note dated [DATE] at 7:45 PM documents upon rounds, R8 was found without vital signs and was unresponsive. A code blue was called and CPR was initiated. 911 was called. EMS arrived at the bedside but was unable to resuscitate R8. Time of death was called at 8:23 PM. The Emergency Code Documentation dated [DATE] documents R8 was found around 7:45 PM by the nurse and had absent respirations, pulse, and blood pressure. CPR was started at this time. EMS arrived at 7:53 PM and took over. R8 expired in the facility at 8:23 PM. The Fire Department Record dated [DATE] documents the crew was dispatched to the facility for a full arrest. Upon entering our R8's room, staff from the nursing home were performing CPR and ventilating R8 with a bag valve mask. Staff also stated that R8 missed two dialysis treatments this week. Once placed on the cardiac monitor, it showed asystole for R8's heart rhythm. R8 was given three rounds of medications and CPR with no signs of improvement. The crew called medical control and relayed report. The crew was instructed by the physician to terminate resuscitation efforts with a time of death at 8:23 PM. On [DATE] at 1:52PM, V16 (Nurse) stated V16 was the nurse for R8 at the time R8 refused dialysis. V16 reported telling the dialysis company that R8 refused and an order was placed by the dialysis company to send R8 out to the hospital. V16 stated the nephrologist (V22) gave the order to send R8 to the hospital. V16 reported once the ambulance arrive to the facility R8 refused to go to the hospital. V16 reported telling V24 (Primary Physician) that R8 refused to go to the hospital but did not tell V22 (nephrologist). V16 stated V16 worked with R8 on [DATE] on the 3 PM to 11 PM shift. V16 reported the previous nurse told V16 a chest x-ray needed to be completed on R8 but V16 was not sure why the chest x-ray was ordered. V16 stated the chest x-ray was completed around 7:30 PM and about 15 minutes later, V16 went to go check on R8. V16 reported at this time R8 was unresponsive, did not have a pulse, and was not breathing. V16 stated a cold blue was called and CPR was started. V16 reported last seeing R8 around 5:30 PM and R8 was using R8's phone. V16 stated checking R8's vital signs around 4:30 PM when V16 arrived to the facility. V16 was unaware of what the x-ray results showed. V16 denied checking the x-ray report and stated it is the responsibility of the doctor. On [DATE] at 3:33PM, V18 (CNA) stated V18 came on at 3 PM on [DATE]. V18 reported this was the first time working with R8. V18 stated the only complaint R8 made was that R8 had a stomach ache and did not want to eat. V18 reported last seeing R8 around 6:30 or 7 PM (This is the time the x-ray was being completed and R8 was noted to be lethargic and unresponsive by V26 (Radiology Technician)) before V18 went on break. V18 stated the V18 was aware R8 skipped dialysis. V18 team reported as V18 was coming back from break, the paramedics were trying to resuscitate R8. V18 denied being aware R8 complained of shortness of breath earlier in the day. On [DATE] at 5:20PM, V19 (Nurse) stated V19 took care of R8 during the morning shift on ,d+[DATE]. V19 reported shortly after breakfast, R8 kept requesting to go to the hospital. V19 stated R8 appeared fine and had normal vitals. V19 denied remembering if R8 reported being short of breath. V19 reported being aware that R8 missed at least one dialysis session. V19 stated V19 did an assessment on R8 and listened to R8's lungs, which were clear. V19 reported V19 did not chart that part of the assessment. V19 stated if you don't chart what a nurse does then it is considered that it wasn't done. V19 reported last seeing R8 between 1:30 and 2:30 PM. V19 stated R8 was sleeping during this last set of rounds and V19 did not wake R8. V19 denied remembering why a chest x-ray was ordered. V19 reported R8 stated that R8 felt panicked and was getting anxious so V19 talked R8 through some breathing exercises to calm down. V19 stated a chest x-ray was put in STAT but does not know why the x-ray was not completed on V19's shift. V19 reported fluid builds up in the body when dialysis is missed. On [DATE] at 10:38AM, V20 (Dialysis Nurse) stated V20 was aware that R8 refused dialysis on ,d+[DATE]. V20 reported calling the nephrologist (V22) to notify of the refusal. V20 reported that V22 ordered to send R8 to the hospital for an evaluation. V20 stated it is the facilities responsibility to send R8 to the hospital. V20 denied being aware that R8 did not go to the hospital. V20 reported if V20 was made aware then V20 would have called the nephrologist to update V22 and get any further orders. V20 stated if a resident skips dialysis then they can become fluid overloaded. V20 reported fluid overload can begin anywhere from one day to three days after missing a treatment. On [DATE] at 11:43AM, V21 (Nurse Practitioner) stated V21 was aware that R8 refused dialysis on ,d+[DATE]. V21 reported telling R8 that if R8 became short of breath that R8 would need to go to the hospital to be dialyzed. V21 stated V21 did not follow up with R8 on ,d+[DATE] because when V21 saw R8 the day before, R8 was stable. V21 reported vital signs were being done each shift on R8 so no other orders needed to be put in. V21 stated V21 did not put in any further orders to monitor for fluid overload because R8 was stable the last time R8 was assessed by V21. On [DATE] at 12:03PM, V22 (Nephrologist) stated V22 had a very good rapport with R8 and followed R8 since R8 began dialysis at the hospital. V22 reported being aware that R8 refused dialysis on ,d+[DATE]. V22 stated that an order was put in to send R8 out to the hospital for an evaluation. V22 denied that any staff made the dialysis center or V22 aware that R8 refused to go to the hospital. V22 stated V22 was under the impression that R8 went to the hospital and got dialysis there. V22 reported R8 does not have a healthy heart or lungs to be skipping treatments without issues. V22 stated if a dialysis patient tells you they are short of breath then they need emergent dialysis. V22 reported V22 wanted to be involved if R8 was continuing to refuse care due to having a close relationship with R8. V22 stated V22 would have continued to speak with R8 or even come in to talk to R8 until R8 agreed to go to the hospital. V22 reported V22 would have gotten to the root of why R8 was refusing to go to dialysis. V22 stated that if V22 was aware that R8 did not go to the hospital that at a minimum labs and chest x-rays would have been ordered daily over the weekend. On [DATE] at 12:21PM, V23 (Nurse Manager) stated V23 was aware that R8 refused dialysis on ,d+[DATE]. V23 reported V23 began looking through orders and realize the facility had nothing going on for him. V23 suggested getting labs and a chest x-ray to get a baseline. V23 denied R8 received any dialysis since R8 was admitted on ,d+[DATE]. V23 reported vital signs were completed once a shift to monitor R8. V23 stated the facility staff communicate with a primary physician and dialysis staff communicates with the nephrologist. V23 reported if R8 was symptomatic then R8 would've been sent out to the hospital immediately. V23 stated all orders were put in STAT due to it being a weekend and it would have been a long wait if put in as a standard order. V23 reported they needed to be updated on R8's status on that day. V23 denied being aware that R8 complained of being short of breath. On [DATE] at 12:45PM, V1 (Asst. Administrator) stated V1 was at the facility but stepped out of the building at the time R8 was found unresponsive. V1 reported upon returning to the facility, V1 saw the paramedics and learned R8 expired. V1 stated V1 was made aware that R8 skipped dialysis on [DATE] and refused to go to the hospital. V1 reported the plan was to have a conversation with R8 on [DATE] to see if R8 wanted to continue dialysis or be put on hospice. V1 stated R8 had a chest x-ray and labs ordered on ,d+[DATE] because R8 refused dialysis. V1 reported V24 (Primary Physician) was made aware every time R8 refused dialysis or to go to the hospital. V1 stated only the dialysis nurses communicate with the nephrologist (V22). V1 reported it was portrayed that V22 put in the order for R8 to go to the hospital. V1 was not aware if V22 was called after R8 refused to go to the hospital. V1 reported the results to the x-rays are automatically uploaded to the computer system. V1 stated the nurse is responsible to read the results and notify the physician if there's any abnormalities. V1 reported if R8 was having any symptoms of fluid overload, R8 would have needed to go to the hospital and would not have had a choice at that point. V1 stated vital signs and head to toe assessments were performed each shift to monitor R8 for fluid overload. On [DATE] at 1:56PM, V24 (Primary Physician) stated R8 refused dialysis and refused to go to the hospital on ,d+[DATE]. V24 reported R8 asked to go to the hospital again on ,d+[DATE] due to a change in condition. V24 was unable to remember what the change of condition was. V24 stated if dialysis is refused or sessions are missed that the body can fill up with fluid. V24 reported the results of R8's chest x-ray indicate R8 would've had some kind of pneumonia and that the pleural fluid was meaning that R8's heart was filling up from fluid due to the kidneys, not working. On [DATE] at 12:40PM, V25 (Radiology Director of Operations) stated once the facility puts in order for an image to be taken, it gets electronically sent over to the radiology company. V25 reported the x-ray was ordered for R8 and assigned to a technician at 11:39 AM. V25 reported STAT orders are normally taken between 4 to 6 hours. V25 could not answer why the x-ray was not completed within 4 to 6 hours but reported the facilities are aware that if the STAT x-ray is not completed within this timeframe, they can decide what to do by calling the physician for notification. V25 stated the facility has bidirectional access which allows them to see results once they are uploaded into the computer system after being reviewed by radiologist. V25 reported the results to the chest x-ray for R8 were uploaded into the system at 6:52 PM. On [DATE] at 10:05AM, V1 stated STAT x-rays are usually done with in 4 to 6 hours. V1 reported sometimes the x-rays aren't taken in that time frame. V1 stated if a resident declines any further or shows symptoms of anything then they are sent out to the hospital immediately. On [DATE] at 11:10AM, V26 (Radiology Technician) stated V26 got to the facility and took the ordered chest x-ray around 6:30PM. V26 reported R8 was lethargic and would not respond to any questioning. V26 stated V26 exited the room before doing the exam to ask an unknown CNA if this was R8's normal state. V26 reported the CNA told V26 that it was normal for R8 to act unresponsive and did not go into the room to check on R8. V26 stated since R8 was not able to follow directions or move, V26 was only able to get a one view chest x-ray when a two view was ordered. V26 denied R8 being able to roll onto R8's side. V26 reported out of the 17 images, 11 of them were scheduled to be STAT that day. V26 denied the facility calling and checking on the status of when the x-ray would be taken. V26 reported normally if a resident cannot move staff will come in and assist, but no staff was available to help during the time of this x-ray. On [DATE] at 1:17PM, V19 stated V19 received an order to send R8 to the hospital on ,d+[DATE] but R8 changed R8's mind. V19 again denied remembering if R8 complained of being short of breath V19 was shown the note that was written by V19 on /,d+[DATE]. V19 said, Apparently he was complaining of shortness of breath after I read my note. V19 denied remembering what time R8 complained of shortness of breath. V19 reported checking R8's vital signs one time during that shift. V19 reported getting an order for a chest x-ray from V27 (Nurse Practitioner). V19 stated V24 (Primary Physician) gave the order to send R8 to the hospital. V19 reported an order should be put into the computer system as soon as they are received V19 denied remembering why the orders were put into the computer system by V19 after 10 PM. On [DATE] at 1:39PM, V27 (Nurse Practitioner) stated V27 was not called or notified about R8's change in condition. V27 reported at the time of R8's change in condition another physician's group covers for needs of the residents. V27 denied having any involvement in R8's care. On [DATE] at 2:13PM, V24 stated staff needs to call V24 to verify all orders before putting them in the computer system. V24 stated the order should be put into the computer system as soon as V24 agrees to it so it can be completed as soon as possible. V24 denied remembering what orders staff suggested for R8 on ,d+[DATE]. V24 denied remembering why the chest x-ray was ordered for R8 on ,d+[DATE]. V24 said, If the order says congestion, then I guess he was having some congestion. We have to put in a reason for every x-ray so the radiologist knows what they're looking for. V24 denied that staff ever called V24 to report a change in condition where R8 needed to be sent out via 911. V24 stated if a resident has a change then V24 must be notified, but if it is serious, then staff must send out the resident via 911 as soon as possible. The Admission Hospital Records dated [DATE] document R8 originally came to the hospital on [DATE] after being found hypoxic due to pneumonia. R8 suffered sepsis and multi organ failure. R8 began hemodialysis for acute renal failure, experienced cardiomegaly with congestive heart failure, respiratory failure, and needed a tracheostomy as well as gastrotomy tube placed. R8 received hemodialysis on Tuesdays, Thursdays, and Saturdays at the hospital. R8 received dialysis on [DATE] and had 3 L of fluid removed. R8 received dialysis again on [DATE] and had 3.4 L of fluid removed. R8 was given an extra session of dialysis before discharge and anticipation of being admitted to a new facility. Upon discharge, R8 had no significant volume overload. The Admission Evaluation dated [DATE] documents R8 is only able to urinate small amounts. Breath sounds upon admission are documented as clear bilaterally. The Physician Order Summary documents a STAT chest x-ray was ordered on [DATE] at 11:38 AM. An order was placed on [DATE] for R8 to receive hemodialysis on Mondays, Wednesdays, and Fridays. More orders were placed to send R8 to the hospital and or STAT CBC and CMP (laboratory work) on [DATE]. After reviewing the order details, the orders for the transfer to the hospital and laboratory work was put in on [DATE] at 10:10PM. These orders were placed almost 2.5 hours after R8 was found unresponsive. The Radiology Report dated [DATE] documents the results of the chest x-ray showed bilateral lung infiltrates, pericardial effusion, and pulmonary vascular congestion. The Order Information Sheet from the x-ray company documents the company was notified of the chest x-ray order at 11:39 AM on [DATE]. The order priority did come in as STAT. The technician arrived to the facility at 6:36 PM and completed the exam at 6:38 PM. The reason documented for ordering the exam is congestion. The results of the chest x-ray were read by the radiologist at 6:49 PM and uploaded into the computer system the facility could access at 6:52 PM. The chest x-ray did have a positive critical finding. The Care Plan dated [DATE] documents R8 is resistant to care related to anxiety and adjusting to the nursing home. R8 is currently on hemodialysis however R8 still eats food not listed on the renal diet and is resistant to care including dialysis and other care. There are no interventions or protocols on what to do when R8 refuses a dialysis treatment. The policy titled Refusal of Treatment, dated ,d+[DATE] documents, Policy Interpretation and Implementation: .3. If a resident/resident's clinical representative refuses treatment, the unit manager, charge nurse, director of nursing services, or designee will interview the resident to determine what and why the resident is not adherent to the plan of care in order to try to address the resident's concerns and explain the consequences. 4. The care plan team will assess the resident's needs and offer the resident alternative treatments, if available, while continuing to provide other services outlined in the care plan. 5. If the resident's refusal brings about a significant change, a reassessment will be made, and such information will be incorporated into the resident's care plan. 6. The attending physician must be notified of such refusal, consistent with facilities policy and accepted standard of practice. The policy titled, Notification of Change, dated [DATE] documents, Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and are reported to and consulted with the attending physician. The resident and/or the resident representative will be educated about treatment options and supported to make informed decision . Objective of the Notification of Change Guideline: The objective of the notification guideline is to ensure facilities staff make appropriate notification to the physician or delegated non-physician practitioner in immediate notification to the resident and/or the resident representative when there is a changing condition. Requirements for Notification of Resident, the Resident Representative, and their Physician: A significant change in the resident's physical, mental, or psychosocial status - A significant change includes deterioration and health, mental, or psychosocial status in either life-threatening conditions or clinical complications and/or a need to alter treatment significantly . Physician Notification and Consultation: Notification is provided to the physician to facilitate continuity of care and obtain guidance from the physician about changes or additions to or discontinuation of treatments . Procedure: 1. Obtain orders for appropriate treatment in monitoring and promote the residents right to make choices about treatment and care preferences 2. Document the notification and record any new orders in the resident's medical record. 3. Educate the resident and/or representative about the proposed plan to treat, manage, or monitor the resident's change in condition 4. Educate the resident and/or resident representative about the risks and benefits of the proposed treatment change and provide an opportunity for the resident to make an informed choice of treatment 5. Update the resident's care plan, transcribe, and implement the providers orders 6. Communicate the changes to the care team and pharmacy. The Facility Agreement with the x-ray company dated [DATE] documents, .Duties and Obligations of the Facility: .f. Facility agrees to provide a clinician/staff member to be present and assist when a service is performed. The facility in-services were reviewed. The In-service on [DATE] and [DATE] document the in-service was provided to nursing staff (CNAs and nurses) about changes in condition. Topics covered include: a change in condition must be reported to the RN or MD when first noted, STAT orders must be completed within 4 hours and if not then the MD must be notified, and nurses are expected to know abnormal lab values and diagnostic results - if the MD does not provide orders for the abnormal result then it must be questioned why. The Immediate Jeopardy that began on 1.5.25 was removed on 1.31.25 when the facility took the following actions to remove the immediacy. Abatement plan 698 R8 is no longer a resident in the facility. All current 22 dialysis residents were assessed for potential fluid overload, intervention in place as appropriate. There are no current dialysis residents refusing dialysis treatment currently. Licensed nurses were educated [DATE] by the Director of Nursing on the need to assess and implement interventions related to fluid volume overload when residents miss dialysis treatments. Dialysis assessment orders were updated per their physician. Their assessment order reads: Monitor for signs and symptoms of fluid volume overload, edema, bloating, headache, weight gain, shortness of breath, elevated blood pressure, JVD, lung sounds with crackles or wheezing, abdominal distention, or tachycardia. This assessment will be completed every shift and PRN. Licensed nurses were educated by the Director of Nursing on [DATE] on the importance of notifying the Attending physician and if unable to reach him/her notifying the resident's Nephrologist. Licensed nurses were educated [DATE] by the Director of Nursing if STAT radiology orders are not able to be completed within the recommended ,d+[DATE] hours the provider will be notified for additional instructions. Licensed Nurses will not work until they have been educated. Radiology company (All-Stat) has been notified of the expectation of timely notification of abnormal radiology results. Based on information from the radiology provider, x rays have an approximate read time of 90 minutes. Once the radiology company's quality controls has reviewed the results the results will be uploaded into the electronic health record. Nurses will obtain the information from the record at that time and notify physician accordingly. Licensed nurses were educated on [DATE] to review their electronic health records within 90 minutes to check and communicate the results of the radiology report. An additional email notification system has been implemented with the radiology company. This ensures all nursing managers receive results as they are uploaded into the electronic health record. All nursing managers were educated on [DATE] on the additional notification system. The Director of Nursing will audit weekly all residents who refused dialysis to ensure they have been assessed, appropriate interventions are implemented, and that the physician was made aware. In the event that the resident's physician was not made aware, she will ensure that the Nephrologist was. The Director of Nursing will complete weekly audits x 3 months to ensure any STAT radiology orders were completed within the recommended ,d+[DATE] hour timeframe, and if the physician was notified.

Based on interviews, and record reviews, the facility failed to follow its abuse prevention policy to prevent a resident-to-resident physical assault. This affected two of four residents (R1, R4) reviewed for physical abuse. This failure resulted in R4 entering R1's room and physically assaulting R1. R1 sustained a 3cm (centimeters) laceration to the center of forehead, a 4cm laceration of left upper eyelid, a 3cm laceration just distal to left lower eyelid, left eye swollen shut, left ear redness, and swelling, and a fracture of nasal bone. R1 was transported to the hospital to receive 10 sutures to repair facial lacerations. Findings include: R1's BIMS (Brief Interview of Mental Status), dated 3/2/24, R1's cognitive decision making skills are severely impaired. On 5/7/24 at 10:45 AM, there is signage observed in the men's village noting on no occasion during the shift should men's village be left with no staff, staff must be present all the time, if scheduled to work in men's village and you are going on break, charge must make sure a CNA (Certified Nurse Aide) is moved to stay in men's village until the assigned CNA returns. On 5/9/24 at 2:00 PM, R1 was observed to be pleasantly confused. R1 was unable to answer simple questions. On 5/7/24 at 1:30 PM, V2 DON (Director of Nursing) stated that at 5:30 AM on 5/3/24, V3 LPN (Licensed Practical Nurse) reported to V2 that R1 fell . V2 stated that V2 initiated a fall investigation. V2 stated that later that same day this investigation noted R1 did not fall, but rather R1 had a physical confrontation with R4. V2 stated that when R1 returned from the hospital with facial injuries, V1 and V2 determined these injuries were not possible from a fall. V2 stated that R1 communicated to V2 that R1 was in a fight. V2 stated that R1's story never changed with subsequent interviews. V2 stated that R5, R1's roommate, was able to communicate the same story as R1. V2 stated that R4 jumped R1. On 5/7/24 at 1:55 PM, V1 (Administrator) stated that staff that are assigned to the men's village are expected to remain in there to monitor residents at all times. V1 stated that there is signage that has been posted in the men's village since before she started at this facility in February 2024. On 5/7/24 at 2:00 PM, R5 stated that on Friday in the early morning R4 came into R5 and R1's room. R5 stated that he was in bed at the time. R5 stated that R4 approached him and wanted to hit R5 but he played ignorant so R4 did not hit him. R5 stated that R4 left his bedside and went into bathroom where R1 was and just started hitting R1. R5 stated that R1 was saying please, please, please. R5 stated that V3 LPN came in and separated the residents and removed R4 from the room. On 5/8/24 at 9:30 AM, V4 CNA (Certified Nurse Aide) stated that she worked 5/2/24, 11:00 PM until 7:00 AM on 5/3. V4 stated that V4 was sitting down in the men's village (dementia unit). V4 stated that she was getting ready to do her rounds at 4:00 AM. V4 stated that R4 came out of his room and was being combative towards V4. V4 stated that she tried to calm him down, tried to re-direct R4. V4 stated that R4 kept saying 'these B****** trying to kill me'. Then R4 put his hands up and walked towards V4, V4 told R4 again to go back to his room. V4 stated that at the same time, R5 started calling out to be changed. V4 stated that she went to R5's room and informed R5 she needed to get supplies and she would be right back. V4 stated that she closed R5's door because R4 was following behind her. V4 stated that there weren't any supplies in the men's village so she started walking towards the exit door. V4 stated that R4 was following her. R4 then began running after her so she started running to get away from R4 and exited the men's village. V4 stated that V3 LPN was sitting at the nurses' station when V4 informed V3 that R4 was being combative with her and that V3 needed to go check on R4. V4 stated that V3 did not look up from the computer. V4 stated that she said 'are you going to go check?' V4 stated that V3 still did not get up. V4 stated that she informed V3 that she was not going back into the men's village until V3 went there to address the situation. V4 stated that 10 minutes later, V3 and V4 heard screaming coming from the men's village. V4 stated that she and V3 ran into the men's village and saw R4 standing by R1's room and R1 was bleeding. V4 stated that V3 told her to get a sheet, we need to clean up this blood. V4 stated that R4 was still walking around talking crazy. V4 stated that she did not know she was supposed to call the abuse coordinator to report this incident. On 5/9/24 at 2:00 PM, V1 (Administrator) stated that she was not aware that V4 left the residents in the men's village unattended and did not return for 10 minutes until after R1 was injured by R4. On 5/10/24 at 9:30 AM, V2 DON stated that she was not aware that V4 left the residents in the men's village unattended and did not return for 10 minutes until after R1 was injured by R4. On 5/10/24 at 10:34 AM, V3 LPN stated that V4 CNA came to V3 and stated that she was going on break. V3 stated that he asked V4 if she had rounded on the residents in the men's village and if the residents were okay. V3 stated that V4 stated that all of the residents were okay and V4 left for break. V3 stated that after V3 administered medication to a resident, he returned to the nurses' station to continue charting on residents. V3 stated that he heard yelling from the men's village and found R1 sitting on the bathroom floor. V3 stated that R4 was near R1. V3 stated that he thought R4 was trying to help R1 get up from floor. V3 stated that he asked R1 what happened, R1 responded he fell . V3 stated that he could see that R1 hit his head on door frame when he fell . V3 stated that he went to another nursing floor to get assistance from another nurse. V3 stated that he called for an ambulance to transport R1 to the hospital for further treatment. V3 then stated that he witnessed R1 fall in the bathroom and that R1 kept repeating thank you. R1's care plan, dated 3/19/24, notes R1 is at risk for abuse due to language barrier, dementia, difficulty in communicating and understanding others. R1 was involved in an altercation with another peer on 5/3/24. Interventions identified on 3/19/24 include, but are not limited to, report all instances of alleged abuse to the abuse coordinator. On 5/7/24, 1:1 sitter. R4's pre-admission psychiatric evaluation, dated 7/27/2023, notes R4's judgement is fair, insight is fair to poor, thought processes - loosening of associations, visual delusions, and visual hallucinations. Diagnoses include, but not limited to, dementia with psychotic disturbances and visual hallucinations. R4's care plan, dated 2/8/24, notes R4 is at risk for abuse due to generalized weakness and being at a nursing facility. R4 displayed physical aggression towards peer on 5/3/24. Interventions identified on 2/8/24 include, but are not limited to, report all instances of alleged abuse to the abuse coordinator. R4's care plans, initiated 5/6/24, note R4 has a diagnosis of hallucinations and a mood problem due to dementia and severe mental illness. There is no documentation found in R4's medical record noting care plans related to R4's psychiatric diagnoses were initiated prior to 5/6/24. This facility's abuse prevention policy, undated, notes this facility is committed to protecting our residents from abuse by anyone including, but not limited to, residents. Abuse means any physical assault inflicted upon a resident other than by accidental means. Staff orientation and training and on an annual basis will include how to assess, prevent, and manage aggressive residents in a way that protects residents. As part of the resident's life history on the admission assessment and comprehensive care plan, staff will identify residents who have needs, triggers, and behaviors that might lead to conflict. Employees are required to report any incident, allegation, or suspicion of potential abuse to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator.

Based on interviews, and record review, the facility failed to effectively supervise/monitor a resident with a diagnosis of physical aggression, and dementia from physically assaulting a peer. This affected two of four (R1, R4) residents reviewed for supervision of aggressive residents. This failure to monitor and supervise resulted in R1 being physically assaulted by R4. R1 sustained a 3cm (centimeters) laceration to the center of forehead, a 4cm laceration of left upper eyelid, a 3cm laceration just distal to left lower eyelid requiring 10 sutures; left eye swollen shut; left ear redness and swelling; and a fracture of nasal bone. R1 was transported to the hospital to receive 10 sutures to repair facial lacerations. Findings include: On 5/7/24 at 10:45 AM, the nurses' station for the men's village is located on the adjacent nursing unit. The men's village is a locked unit. There is signage observed in the men's village noting on no occasion during the shift should men's village be left with no staff, staff must be present all the time, if scheduled to work in men's village and you are going on break, charge must make sure a CNA (Certified Nurse Aide) is moved to stay in men's village until the assigned CNA returns. On 5/9/24 at 2:00 PM, R1 was observed to be pleasantly confused. R1 was unable to answer simple questions. On 5/7/24 at 1:30 PM, V2 DON (Director of Nursing) stated that on the morning of 5/3/24, V3 LPN (Licensed Practical Nurse) reported to V2 that R1 fell and needed to go to the hospital. V2 stated that when R1 returned from the hospital with facial injuries, V1 and V2 determined these injuries were not possible from a fall. V2 stated that R1 communicated to V2 that R1 was in a fight. V2 stated that R1's story never changed with subsequent interviews. V2 stated that R5, R1's roommate, was able to communicate the same story as R1. V2 stated that R4 jumped R1. On 5/7/24 at 1:55 PM, V1 (Administrator) stated that there is signage posted in the men's village noting staff that are assigned to the men's village are expected to remain in there monitoring residents. V1 stated that this signage has been posted there since before she started at this facility in February 2024. On 5/7/24 at 2:00 PM, R5 stated that on Friday in the early morning, R4 came into R5 and R1's room. R5 stated that he was in bed at the time. R5 stated that R4 approached him and wanted to hit R5 but he played ignorant so R4 did not hit him. R5 stated that R4 left his bedside and went into bathroom where R1 was and just started hitting R1. R5 stated that R1 was saying please, please, please. R5 stated that V3 LPN came in and separated the residents and removed R4 from room. On 5/8/24 at 9:30 AM, V4 CNA (Certified Nurse Aide) stated that she worked 5/2/24, 11:00 PM until 7:00 AM on 5/3 on the men's village. V4 stated that she was getting ready to do her rounds at 4:00 AM. V4 stated that R4 came out of his room and was being combative towards V4. V4 stated that she tried to calm him down, tried to re-direct R4. V4 stated that R4 kept saying 'these B****** trying to kill me'. Then R4 put his hands up and walked towards V4, V4 told R4 again to go back to his room. V4 stated that at the same time, R5 started calling out to be changed. V4 stated that she went to R5's room and informed R5 she needed to get supplies and she would be right back. V4 stated that she closed R5's door because R4 was following behind her. V4 stated that there weren't any supplies in the men's village so she started walking towards the exit door for the mens village. V4 stated that R4 was following her. R4 then began running after her so she started running to get away from R4, she put code in to open the door and exited leaving R4 in the men's village. V4 stated that V3 LPN was sitting at the nurses' station. V4 stated that she informed V3 that R4 was being combative with her and that V3 needed to go check on R4. V4 stated that V3 did not look up from the computer. V4 stated that she said are you gonna go check? V4 stated that V3 still did not get up. V4 stated that she informed V4 that she was not going back into the men's village until V3 went there. V4 stated that 10 minutes later, V3 and V4 heard screaming coming from the men's village. V4 stated that she and V3 ran into the men's village and saw R4 standing by R1's room and R1 was bleeding. On 5/9/24 at 2:00 PM, V1 (Administrator) stated that she was not aware that V4 left the residents in the men's village unattended and did not return for 10 minutes until after R1 was injured by R4. On 5/10/24 at 9:30 AM, V2 DON stated that she was not aware that V4 left the residents in the men's village unattended and did not return for 10 minutes until after R1 was injured by R4. On 5/10/24 at 10:34 AM, V3 LPN stated that V4 CNA came to V3 and stated that she was going on break. V3 stated that he asked V4 if she had rounded on the residents in the men's village and if the residents were okay. V3 stated that V4 stated that all of the residents were okay and V4 left for break. V3 stated that after V3 administered medication to a resident, he returned to the nurses' station to continue charting on residents. V3 stated that he heard yelling from the men's village and found R1 sitting on the bathroom floor. V3 stated that R4 was near R1. V3 stated that he thought R4 was trying to help R1 get up from floor. V3 stated that he asked R1 what happened, R1 responded he fell . V3 stated that he could see that R1 hit his head on door frame when he fell . V3 stated that he went to the nursing unit on another floor to get assistance from another nurse. R1's BIMS (Brief Interview of Mental Status), dated 3/2/24, notes R1's cognitive skills for daily decision making is severely impaired. R4's pre-admission psychiatric evaluation, dated 7/27/2023, notes R4's judgement is fair, insight is fair to poor, thought processes - loosening of associations, visual delusions, and visual hallucinations. Diagnoses include, but not limited to, dementia with psychotic disturbances and visual hallucinations. R4's care plan, dated 2/8/24, notes R4 is at risk for abuse due to generalized weakness and being at a nursing facility. R4 displayed physical aggression towards peer on 5/3/24. Interventions identified on 3/19/24 include, but are not limited to, report all instances of alleged abuse to the abuse coordinator. R4's care plans, initiated 5/6/24, note R4 has a diagnosis of hallucinations and a mood problem due to dementia and severe mental illness.

Based on interview and record review, the facility failed to identify, assess, and treat a change in skin condition until it was an unstageable, necrotic pressure ulcer for 1 of 5 residents (R1) reviewed for wounds in the sample of 13. This failure resulted in R1's wound deteriorating, showing signs of possible infection, and requiring hospitalization . The findings include: R1's Admission Record (printed 3/15/24) shows he was admitted to the facility on [DATE]. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is dependent on staff for toileting hygiene and required maximal assistance to roll from lying on his back to left and right side, and return to lying on his back when in bed. The same MDS shows R1 has no rejection of care behaviors, R1 is always incontinent of bowel and bladder, and R1 has one unstageable pressure ulcer which was not present upon admission to the facility. R1's Braden skin risk assessment dated [DATE] shows he is at risk for developing pressure ulcers. R1's Progress Notes dated 12/6/23 at 12:22 PM shows that the wound doctor wants R1 sent to the hospital for an evaluation related to a wound on his backside. R1's Progress Notes dated 12/6/23 at 11:07 PM show R1 was admitted to the hospital with a diagnosis of unstageable pressure injury. R1's Care Plan initiated on 9/5/23 shows R1 has potential for impairment to his skin integrity and he should be monitored for any skin injury. R1's Wound Assessment and Plan shows V4, Wound Physician, saw R1 on 11/22/23. V4 documented an initial assessment of an unstageable (depth obscured) pressure injury of R1's sacrum measuring 9 cm (centimeters) length by 9.5 cm width with a wound onset date of 11/22/23. There was moderate exudate, 20% (percent) slough and 80% eschar with no signs or symptoms of infection. V4's Wound Assessment and Plan of R1's sacral pressure ulcer shows R1 was not seen on 11/29/23 as he was out of the facility for an appointment. On 12/6/23, V4's Wound Assessment and Plan shows R1's sacral pressure ulcer has declined and measures 11 cm length by 9 cm width with 100% eschar and signs and symptoms of infection include odor. V4's comments show R1 needs surgical debridement and recommends he be sent to the hospital for further evaluation and treatment. On 3/15/24 at 11:54 AM, V3, Wound Care Nurse/Coordinator, said if everyone is doing everything they should be doing, a wound should be identified before it becomes necrotic. V3 said R1 had wounds to his left and right heels and sacrum which were all acquired in the facility. V3 said R1's sacral pressure ulcer was first identified on 11/22/23 when it was a 9 cm by 9.5 cm unstageable pressure ulcer. V3 said unstageable means the skin on top of the wound was necrotic, so you could not see what was going on underneath. V3 said wounds should be identified long before becoming necrotic. V3 said it is important to identify wounds as soon as possible so they can put treatment measures in place and prevent the site from declining further. V3 said R1 was sent to the hospital on 12/6/23 and was admitted with a diagnosis including, but not limited to, unstageable pressure injury. On 3/15/24 at 3:18 PM, V4, Wound Care Physician, said she remembers sending R1 to the hospital the last time she saw him in the facility because his sacral wound looked worse and possibly looked infected. V4 said the phrase Healing Status Declined means the wound did not get better, but in fact, got worse, in comparison to the previous exam. V4 said odor can lead one to think of a possible wound infection, and R1's (sacral) wound odor triggered her to believe the wound was possibly infected V4 said because there was worsening of the sacral wound with 100% eschar, she felt R1 needed further evaluation to see if debridement was necessary as she is limited on what treatment she can do at the bedside. V4 said a wound would not become necrotic overnight. V4 said she did not see R1 again and does not know his outcome. On 3/15/24 at 2:28 PM, V8, Registered Nurse (RN), said the CNAs (certified nursing assistants) will report any redness or skin changes to the floor nurse and the nurse will assess the resident's skin and do a risk management report and send it to the wound care nurses so they can assess the area and implement wound care treatments right away. V8 said it is important to identify skin changes right away so it does not worsen and progress to a pressure ulcer. V8 said it is important to catch skin changes early to start the healing. V8 said if a pressure ulcer worsens, it gets more difficult and complicated to manage. If skin changes are found early, treatment can be more successful. On 3/15/24 at 2:29 PM, V9, CNA, said she knows to report any skin changes to the nurse right away. V9 said it is important so the resident can get treatment as soon as possible. V9 said a change in skin condition would go through so many stages before becoming black that finding a black wound which was not previously identified would be very unlikely. V9 said any skin changes should begin with documentation right from when redness is first noted.

Based on interview and record review the facility failed to follow their pressure ulcer prevention protocol for one of three residents (R263) reviewed for pressure ulcers in a sample of 36. This failure resulted in R263 developing a left hip skin tear and a right buttocks skin tear, a right and left heel deep tissue injury with eschar, and a stage three pressure ulcer to the right inferior buttocks. Findings include: On 2/2/2023 at 9:30am V35 (Wound care Manager) said that R263 was alert to name and could follow some commands, he was bed bound and incontinent of bowel and bladder and had no open skin areas. Record review documents that on 10/31/2023 R263 developed a skin tear to the right buttocks, on 11/1/2023 R263 developed a skin tear to left hip, on 11/10/2023 R263 developed a pressure ulcer with a deep tissue injury to his left and right heel, on 11/15/2023 R263 developed a pressure ulcer to the right inferior buttocks stage three with granulating tissue to the wound bed. V35 said the wound care team should have applied a pressure ulcer relieving low air loss mattress to R263's bed when he developed the skin tear to the left hip and the Braden score dropped to 14 indicating R263 was no longer at very limited risk, but had become a moderate risk for the development of pressure ulcers. On 2/2/2023 at 10:00am V36 (Wound care Nurse) said that R263 was alert and oriented to self only and that he was bed bound and was unsure of his ambulation status and that R263 did not have any skin issues upon admission. R263 developed wounds in the facility and the wound care manager is the one who makes the decision to place residents on pressure ulcer relieving mattresses. The Braden score did indicate that R263 was declining and had open wounds that required pressure ulcer prevention measures and a low air loss mattress should have been put in place. On 2/1/2023 at 3:30pm V2 (Director of Nursing-DON) said that R263 was admitted to the facility alert and oriented times one to two and was on the memory care unit, R263 was a fall risk and did not have any open areas on his skin. R263 started declining and developing skin issues, I expect my wound care team to know when to apply pressure ulcer prevention tools as needed. R263 had a stage three and he should've had a pressure ulcer relieving mattress in place. Record review documents that R263 was admitted to the facility on [DATE] alert to self, incontinent of bowel and bladder, chairbound and unable to ambulate but with skin intact. On 9/13/2023 a Braden score of 22 indicating R263 was a very limited risk for pressure ulcer development. On 10/3/2023 R263's Braden score was a 14 which indicates R263 was at moderate risk, on 10/31/2023 R263 developed a skin tear to the right buttocks measuring a 1.60 cm x 5.80 cm. On 11/1/2023 R263 developed a left hip skin tear measuring 2.40 cm x 1.70 cm. On 11/10/2023 R263 developed a left heel pressure ulcer deep tissue injury measuring 6.30 cm x 6.50 and a right heel pressure ulcer deep tissue injury measuring 5.80 cm x 7.00 cm. On 11/15/2023 R263 developed a right inferior buttocks pressure ulcer stage three measuring 0.70 cm x 1.50 cm x 0.10 cm. On 11/16/2023 R263 scored a 13 on the pressure ulcer Braden score which indicates Moderate risk for pressure ulcer development. A care plan dated 11/16/2023 indicates R263 had a pressure prevention intervention for a pressure relieving/reducing mattress device on the bed. Facility Policy: Pressure/Skin Breakdown-Clinical Protocol Effective date: January 2017 Policy Specifications. Document an individual significant risk factors for developing pressure ulcers sores, immobility, history of pressure wounds and recent weight loss. 3. Examine skin on new admission. 5. Identify factors contributing to skin breakdown. 7. The physician will authorize pertinent orders related to wound treatments, including pressure redistribution surfaces. Prevention of Pressure Wounds: January 2017 Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. General Guidelines: 2. The most common site of a pressure injury is where the bones are near the surface of the body including back of the head, around the ears, elbows shoulder blades, backbone, hips, knees, heels, ankles, and toes. Interventions and Preventive Measures: 2. for a person in bed, c. If a special mattress is needed, use one that contains foam, air, as indicated. The following equipment and supplies will be necessary when providing preventive skin care. 1. Tool for assessing skin and pressure injury risk. a. Braden Risk Assessment Form b. Intervention Preventive Measures

Based on interview and record review, the facility failed to protect a resident from being sexually abused by another resident; the facility also failed to assess residents for abuse risk upon admission and failed to have effective interventions in place to keep residents free from abuse and/or abusing other residents. These failure applied to two (R1 and R2) of two residents reviewed for abuse and resulted in R1 being sexually assaulted by R2. R1 is not able to give consent for sexual activity due to cognitive impairment and was taken to local hospital and received prophylactic antibiotics. The Immediate Jeopardy began on 3/31/23 when R1 and R2 were found having non-consensual sex in R2's room. V1 (Administrator) was notified of the Immediate Jeopardy on 5/31/23 at 11:28 AM. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 6/01/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the resident monitoring and in-service training. Findings include: R1 is a [AGE] year-old female who has resided at the facility since 2020, with past medical history including, but not limited to history of falling, muscle weakness, adult sexual abuse, chronic kidney disease, unspecified dementia unspecified severity, essential primary hypertension, anxiety disorder, major depressive disorder, etc. During the complaint investigation on 5/24/2023 at 3:15 PM, R1 was observed in the dining room with peers and was taken to her room for private interview. At this time, R1 was alert and oriented to her name only. R1 did not recall the sexual assault incident and could only answer yes or no to questions. R1 was asked if she recalled having sex with a male resident and she said no, she is not in a relationship with anyone and does not recall having sex with anyone. R1 was asked if she would like to have sex if she had a boyfriend and she said, not exactly. Local police incident report dated 3/31/2023 titled criminal sexual assault incident at or about 1630 hour, reported 1804 hours, described the victim as R1. In the narrative, the report stated in part, on March 31, 2023, at 1804 hours, officers were dispatched to the facility in reference to a criminal sexual assault, upon arrival the officer met with a staff V5 (Nurse Manager) who related that a resident (R1) who is diagnosed with dementia was observed by staff having sex with another resident (R2). V5 added that he believed R2 may have lured R1 to his room due to her dementia. The report stated that the local fire department also arrived at the scene, while they were preparing to transport R1 to the hospital, V12 (Police Officer) asked R1 if she knew what happened today or why the police was in the facility and she stated that she did not know and that while trying to gather information from R1, she appears confused. Care plan initiated 9/04/2020 states that R1 has impaired cognitive function related to dementia, goal states that R1 will maintain current level of decision-making ability by the next review date. Interventions include but not limited to communicate with the resident/family/caregiver regarding resident's capabilities and needs, discuss concern about confusion, disease process, nursing home placement with resident/family/care giver, the resident needs supervision/assistance with all decision making. Abuse care plan dated 3/7/2023 stated that R1 is at risk for abuse due to severe cognitive impairment and being long term care at SNF. Interventions include to assess for abuse risk quarterly and as needed. R1 did not have any documented assessment for abuse risk since admission. Minimum data set assessment (MDS) dated [DATE], section C (Cognitive) coded R1 with brief interview for mental status (BIMS) score of 3, indicating severe impairment. Section G (functional status) of the same assessment coded R1 as requiring limited to extensive assistance with one-person physical assist for all activities of daily living (ADLs) including walking in room and corridor, as well as locomotion on and off unit. Another BIMS assessment dated [DATE] also coded R1's cognition as severe impairment. Hospital record for R1 dated 3/31/2023 documented the chief complaint as, reported sexual assault at a nursing home, patient with severe dementia. The same record documented in part, [AGE] year-old female from a nursing home due to reported sexual assault, patient has history of frontotemporal dementia, has been unable to recall any events that led her to the hospitalization . Patient was unable to name the place, year or even the date of her birthday, alert to self only and is unable to provide any meaningful information. The hospital record also stated that R1's dementia is severe, unlikely that she was able to consent to the act, resident complained of discomfort to the genital area and was treated with Ceftriaxone 500mg IM, doxycycline 100mg and metronidazole 500mg, resident to continue doxycycline and metronidazole pending genital culture result. R2 is a [AGE] year-old male who has resided at the facility since 2020, with past medical history of Unspecified psychosis, essential primary hypertension, hyperlipidemia, alcohol dependence, nicotine dependence, delusional disorder, other sexual dysfunction, unspecified dementia, etc. 5/24/2023 at 3:05 PM, R2 was observed in his room, alert and oriented with some confusion, did not recall R1 or being friends with any female resident. Stated that he does not recall having any sexual relationship with anyone and would not like to do so. Care plan initiated 12/13/2021 states that R2 has public displays of affection (holding hands, hugging, kissing, etc.) towards another peer, peer unable to reciprocate due to cognition, goal states that R2 will display affection in a safe and respectful manner. Interventions include allow family to be part of care plan meeting, involve R2 in activities, staff on duty to redirect as needed. Further review of R2's medical record did not show any abuse risk assessment since admission or abuse care plan for R2 prior to the incident. MDS assessment dated [DATE] coded R2 in section C (cognition) with a BIMS score of 10, section G (functional) of the same assessment coded R2 as requiring limited assistance with one-person physical assist for all ADLs except for eating. Another BIMS assessment for R2, dated 4/19/2023 coded him with a score of 13 (cognitively intact). 5/24/2023 at 12:18 PM, V4 (Social Service) said that none of the residents (R1 and R2) had any abuse risk assessment prior to the incident and added that assessment is supposed to be done on admission and when something happens. They both (R1 and R2) have an abuse care plan now, not sure if there is one prior to the incident. Facility reported incident dated 4/7/2023, presented by V1 (Administrator) documented that staff entered the room and observed R1 and R2 engaged in sexual activity, neither resident was in distress. The report continued that the local police was called, R1 was taken to the hospital per police protocol for further evaluation, R2 has been scheduled for a therapeutic home visit and was picked up by a family member. The report concluded that both residents willingly engaged in the sexual activity and abuse cannot be substantiated. On 5/24/2023 at 11:32 AM, V1 (Administrator) said that both residents were found engaging in a sexual activity by staff, the nurse was called, and the residents were separated. V1 said that he is not sure if it was abuse or consensual, staff who observed them said that they seem to have enjoyed it, none of them was in any distress. At 3:40 PM, V6 (LPN) said that she was informed by the resident assist (V7 / RA) that R1 and R2 were in the room getting busy, when she got to the room, she observed them lying down and R1's hands were around R2's neck, she asked them to stop, and they did. V6 said she had no idea how long the residents were gone before they were found, both residents are wanderers. 5/25/2023 at 10:38 AM, V7 (RA) said that she was making rounds after lunch around 1:00 PM and saw that the door to R2's room was closed and that was unusual because all the doors are normally left open. She knocked on the door and opened it, then saw R1 and R2 having sex and she told them to stop, and they both got up. 5/25/2024 at 11:35 AM, V8 (Medical Doctor) said that he is the attending physician for R1. V8 stated that he was told that (R1) had sex with another resident. He saw R1 on the 27th of May prior to the incident, she is only alert and oriented x1 and not capable of consenting to sex. 5/25/2023 at 2:09 PM, V12 (Police Officer) said that he is the officer in charge of the sexual assault allegation between R1 and R2 and when they responded to the facility for sexual assault, R1 was confused; did not know why the police were there or why she was going to the hospital, is unlikely that she consented to the act. 5/26/2023 at 12:54 PM, V3 (VP of Clinicals) said that she was very involved with the sexual assault allegation and that the facility conducted a full investigation and spoke to all nurses and CNAs. At first, they thought that R2 forced himself on R1, after the investigation it was clear that R1 was the one initiating the incident, V3 never spoke to R1 or R2 but said that R1's sister was very upset, and they think that race played a part in her anger. On 5/31/2023 at 9:56 AM, V1 (Administrator) said that during the abuse allegation investigation, he tried to speak to R2, but he really didn't want to talk to him, social services followed up with him later that day. V1 said that he did not speak to R1, when asked why not, he said that he speaks to the residents sometimes when investigating, not all the time, it depends on the nature of the investigation. V1 added that he relied on the interview of the social worker with R1 in drawing his conclusions. Facility abuse prevention policy dated 2/2017 stated in part that the facility affirms the right of residents to be free from abuse, neglect .or mistreatment. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The facility is committed to protecting residents from abuse, neglect .by anyone including, but not limited to facility staff, other residents, consultants, volunteers .friends or any other individuals. Under resident assessment, the document stated that as part of the resident's life history on the admission assessment, comprehensive care plan and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect .Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of abuse, neglect .for theses residents. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety as well as the safety of other residents and employees of the facility. The Immediate Jeopardy that began on 3/31/23 was removed on 6/1/23 when the facility took the following actions to remove the immediacy: R1 remains in the facility on the dementia unit. Her care plan has been updated to include need to monitor for her engagement with male peers on the unit. She remains at baseline functioning. Initiated on 3/31/23 and ongoing R2 remains at the facility, was removed from the dementia unit. His BIMs at the time of the event were noted to be 10 (moderately Impaired) on 01/19/2023. A repeat BIMs was completed following the event on 04/03/2023 and was noted to 9 (moderately impaired). His plan of care has been updated and includes a room change outside of the dementia unit, in the immediate view of the nursing staff. He has not exhibited any seeking out of female peers. Initiated 4/3/23 and ongoing Abuse risk assessments, wander/elopement risk assessments and sexuality assessments will be reviewed and updated accordingly on residents that reside in the dementia unit. The plan of care was reviewed/updated by social services or designee to reflect necessary supervision and staff assistance on the dementia unit based on the assessments. Completed on 6/01/23 The Social Service department has been educated to complete the abuse risk assessment upon admission and with any change in condition, and on updating the plan of care accordingly. Administrator completed on 6/01/23 All staff working the dementia unit will be educated prior to working their next shift regarding the need to provide supervision based on the resident's individualized plan of care. Monitoring will be increased to every 1 hour for residents who exhibit wandering or sexual behaviors. IDT has been educated by administrator/designee to review and update the list with any new admissions or any change in condition. Conducted by Administrator / Initiated on 6/01/23 and ongoing A list of residents that require increased monitoring related to sexual behavior or elopement/wandering based on the assessment of the resident was created. This list will be placed at the nursing station on the dementia unit for all staff on that unit to have access to it. Completed by Social Services on 6/1/23 Audits will be conducted by DON/designee 3 x per week x 4 weeks then weekly thereafter, audits will include monitoring to ensure supervision is being provided to residents based on their individualized plan of care. Initiated on 6/1/23 and ongoing.

Based on interview and record review, the facility failed to have adequate supervision and effective interventions in place to monitor residents with impaired judgement/decision making skills, assessed as requiring staff supervision for all Activities of Daily Living (ADLs) and assessed to have wandering behaviors, who resided on the dementia/locked unit of the facility. These failures affected two (R1 and R2) of two residents reviewed for supervision and resulted in R1 having non-consensual sex with R2. The Immediate Jeopardy began on 3/31/23 when R1 and R2 were found having non-consensual sex in R2's room. V1 (Administrator) was notified of the Immediate Jeopardy on 5/31/23 at 11:28 AM. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 6/01/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the resident monitoring and in-service training. Findings include: R1 is a [AGE] year-old female who has resided at the facility since 2020, with past medical history including, but not limited to history of falling, muscle weakness, adult sexual abuse, chronic kidney disease, unspecified dementia unspecified severity, essential primary hypertension, anxiety disorder, major depressive disorder, etc. On 5/24/2023 at 3:15 PM, R1 was observed in the dining room with peers and was taken to her room for private interview. R1 was alert and oriented to her name only and does not recall the sexual assault incident. R1 could only answer yes or no to questions. R1 was asked if she recalled having sex with a male resident and she said no, she is not in a relationship with anyone and does not recall having sex with anyone. R1 was asked if she would like to have sex if she had a boyfriend and she said, not exactly. Care plan initiated 9/04/2020 states that R1 has impaired cognitive function related to dementia, goal states that R1 will maintain current level of decision-making ability by the next review date. Interventions include but not limited to communicate with the resident/family/caregiver regarding resident's capabilities and needs, discuss concern about confusion, disease process, nursing home placement with resident/family/care giver, the resident needs supervision/assistance with all decision making. Care plan initiated 6/8/2021 stated that R1 is a wanderer as evidenced by history of attempts to leave facility unattended, impaired safety awareness, resident wanders aimlessly. Interventions include distract resident from wandering by offering pleasant diversions, structured activities, food, conversations, televisions, books resident prefers, monitor for fatigue and weight loss etc. Minimum data set assessment (MDS) dated [DATE], section C (Cognitive) coded R1 with brief interview for mental status (BIMS) score of 3, indicating severe impairment. Section G (functional status) of the same assessment coded R1 as requiring limited to extensive assistance with one-person physical assist for all activities of daily living (ADLs) including walking in room and corridor, as well as locomotion on and off unit. Another BIMS assessment dated [DATE] also coded R1's cognition as severe impairment. R2 is a [AGE] year-old male who has resided in the facility since 2020, with past medical history of Unspecified psychosis, essential primary hypertension, hyperlipidemia, alcohol dependence, nicotine dependence, delusional disorder, other sexual dysfunction, unspecified dementia, etc. 5/24/2023 at 3:05 PM, R2 was observed in his room, alert and oriented with some confusion. R2 did not recall R1 or being friends with any female resident and stated that he does not recall having any sexual relationship with any one and would not like to do so. Care plan initiated 12/13/2021 states that R2 has public displays of affection (holding hands, hugging, kissing, etc.) towards another peer who is unable to reciprocate due to cognition, goal states that R2 will display affection in a safe and respectful manner. Interventions include allow family to be part of care plan meeting, involve R2 in activities, staff on duty to redirect as needed. Care plan initiated 2/02/2020 states that R2 is an elopement risk/wanderer as evidenced by history of attempts to leave facility unattended and impaired safety awareness. Interventions included 1:1 monitoring, resident moved to a secured unit, monitor location every 60 minutes, monitor wandering behavior and document attempted diversional interventions in behavior log, etc. MDS assessment dated [DATE] coded R2 in section C (cognition) with a BIMS score of 13, section G (functional) of the same assessment coded R2 as requiring limited assistance with on-person physical assist for all ADLs except for eating. On 5/25/2023 at 3:40 PM, V6 (LPN) said that she was informed by the resident assist (V7/RA) that R1 and R2 were in the room getting busy and when she got to the room, she observed them lying down and R1's hands were around R2's neck. V6 said she asked them (R1 and R2) to stop, and they did. V6 said she had no idea how long the residents were gone before they were found. Both R1 and R2 are wanderers. R2 has an arm bracelet to prevent him from eloping and will trigger if R2 tries to enter the elevator. 5/25/2023 at 10:38 AM, V7 (RA) said that she was making rounds after lunch around 1:00 PM and saw that the door of R2's room was closed and that was unusual because all the doors are normally left open. She knocked on the door and opened it, then saw R1 and R2 having sex, she told them to stop, and they both got up. V7 added that she did not know that the residents were not in the dining room, she was not looking for them, just making rounds. 6/1/2023 at 10:32 AM, V18 (Medical Director) said that that the facility notified her immediately of the sexual assault incident between two residents, she is not clinical at the facility and not familiar with the residents but based on the information she was provided and after some research she is not sure if R2 should be labeled as a sexual abuser. The staff stated that R1 appears to be friendly with R2 and has expressed her desire to engage in sexual activity with him. Surveyor informed V18 that based on surveyors interview and record review, it's unlikely that R1 has the cognitive ability to consent to a sexual act. V18 said, well that changes everything, I was just going with the information I was provided. If a resident is not capable of consenting, then staff have to watch her closely and intervene when they see her entering another resident's room. This becomes obvious that the facility needs to up its game as far as supervision. A document provided by V2 (DON) titled resident supervision (undated) states in its policy statement states that routine resident checks shall be made to assure that resident's safety and wellbeing are maintained. Under policy interpretation and implementation, the policy states in part, to ensure the safety and well-being of our residents, resident checks will be made at least every 2 hours throughout each 24-hour shift by nursing service personnel. The Immediate Jeopardy that began on 3/31/23 was removed on 6/1/23 when the facility took the following actions to remove the immediacy: R1 remains in the facility on the dementia unit. Her care plan has been updated to include need to monitor for her engagement with male peers on the unit. She remains at baseline functioning. Initiated on 3/31/23 and ongoing R2 remains at the facility, was removed from the dementia unit. His BIMs at the time of the event were noted to be 10 (moderately Impaired) on 01/19/2023. A repeat BIMs was completed following the event on 04/03/2023 and was noted to 9 (moderately impaired). His plan of care has been updated and includes a room change outside of the dementia unit, in the immediate view of the nursing staff. He has not exhibited any seeking out of female peers. Initiated 4/3/23 and ongoing Wander risk assessments and sexuality assessments will be reviewed and updated by social services or designee on residents that reside in the dementia unit. The plan of care will be updated to reflect necessary supervision and staff assistance, especially on the dementia unit based off the reassessments. Completed on 6/01/23 The Social service department has been educated to complete the sexuality assessment upon admission and with any change in condition, and on updating the plan of care accordingly. Administrator completed on 6/1/23 All staff working the dementia unit will be educated prior to working their next shift regarding the need to provide supervision based on the resident's individualized plan of care. This was effective 6/1/23; in-servicing remains ongoing for staff who have not yet worked since initiation date, or for new hires. Monitoring will be increased to every 1 hour for residents who exhibit wandering or sexual behaviors. IDT has been educated by administrator/designee to review and update the list with any new admissions or any change in condition. Conducted by Administrator / Initiated on 6/01/23 and ongoing A list of residents that require increased monitoring related to sexual behavior or elopement/wandering based on the assessment of the resident was created. This list will be placed at the nursing station on the dementia unit for all staff on that unit to have access to it. Completed by social services on 6/1/23 Audits will be conducted by DON/designee 3 x per week x 4 weeks then weekly thereafter, audits will include monitoring to ensure supervision is being provided to residents based on their individualized plan of care. Initiated on 6/1/23 and ongoing

Based on observation, interview, and record review the facility failed to follow its policy for fall prevention program by failure to implement fall prevention interventions to resident (R40) on high risk for fall and has history of multiple falls. This failure caused R40 to have an unwitnessed fall after being readmitted within 4 hours from the hospital, sustaining a cut/laceration on right eyebrow which required a visit to hospital to control bleeding and suturing at the right eyebrow area. The facility failed to update resident's fall care plan after each fall occurrence. The facility failed to complete fall assessment after each fall incident. This deficiency affects all six (R19, R40, R63, R121, R128, and 154) residents in the sample of 34 reviewed for Fall prevention program. Findings include: R40 is readmitted on [DATE] after hospitalization last 2/25/23 due to fall evaluation and foot infection. R40 has diagnosis listed in part but not limited to Complete traumatic amputation of right lower leg, orthopedic aftercare following surgical amputation, Acute cystitis, Diabetes mellitus with foot ulcer, Polyneuropathy, Acquired absence of left great toe and right toe, Dementia, Urinary retention. Fall assessment indicated at high risk for falls. Care plan indicated at high risk for falls and fall injuries. R40's Facility reported incident initial dated 3/8/23 indicated R40 was observed laying on floor next to his bed. Upon assessment nurse noted open area to right eyebrow. Nurse cleaned and bandaged area. Physician made aware with order send to R40 to hospital for evaluation and treatment. R40's progress note indicated: 3/8/23 at 6:45pm, R40 readmitted from hospital. 3/8/23 at 10:50pm, incoming nurse reported that R40 observed on the floor at the bedside. R40 bleeding from the back of the head and above the eyebrow. R40 was sent out to hospital 3/9/23 at 4:14am, Returned from hospital. Sutures noted to the right side near eyebrow. 3/9/23 at 1:15pm, transferred to hospital for evaluation due to control bleeding at right eyebrow suture site. On 3/9/23 at 11:10am, Observed R40 lying in bed in slanted position, with half side rail up on the right side of the bed and no side rail on the left side of the bed. His head had a loose bandage soaked with blood positioned at the left corner of the headboard. The bed was not in the lowest position, its approximately 27 inches from the floor. R40 is lethargic but restless. Called V12 Agency nurse and V41 CNA to R40's room and showed observation. Both said that R40's bed cannot be lowered down. Observed also that the bed is not locked. V12 said that R40 was readmitted last night around 7pm and had an unwitnessed fall incident around 11pm. R40 was sent out to the hospital for suturing of the laceration on right eyebrow area. At 11:20am, V40 Nurse Practitioner (NP) came to the room with V42 NP to examine R40. Showed observation to both NPs. At 11:22am, V13 Restorative Nurse/Fall coordinator came and showed observation. Both NPs said that R40 should be on the low bed and have frequent monitoring. On 3/9/23 at 6:38pm, Telephone interview with V45 Agency Nurse . She said that she works on 11-7 shift on 3/8/23. She was just coming in, when she heard R40 calling for help and observed him lying on the floor on his back with blood coming from his head. She called the nurse and CNA. R40 was confused and unable to give details of what happened. His bed was not in the lowest position. (She said the bed height is above her knee and she is 5'7). No floor mats. She was not sure the location of his call light. His bed was locked. He is incontinent with feces and needed to be changed. He had indwelling catheter. R40 was sent out to the hospital to control bleeding and for suturing. He came back at 4am with 15 sutures covered with dressing. He returned to the same room. He was sleepy, lethargic. Floor mat was provided but the bed cannot be adjusted to lowest position. On 3/7/23 at 9:58am, V13 Restorative Nurse /Fall coordinator said that V3 DON does the root cause analysis after each fall and both of them update the fall care plan. She said that fall assessment done upon admission, quarterly, annual and after each fall incident. Review R40 's medical record with V13. R40 is initially admitted on [DATE]. V13 she does not have access of the record before 1/3/22 due to transition to PCC ( electronic medical record). Observed V13 changed and updated that fall care plan while reviewing with the surveyor. Surveyor informed V13 that she cannot update the care plan while being interviewed. V13 said that she just wants to reflect the most recent status of the resident care plan. R40 had fall incidents on 2/25/23, 2/4/23, 1/26/23, 1/23/23, 7/15/21, 11/20/20. Fall care plan was not updated after fall incident dated 1/26/23 and 2/4/23. No fall assessment after fall incident on 2/4/21. On 3/8/23 at 10:08am, V3 DON provided post investigation for fall incidents of 1/26/23, 2/4/23 and 2/25/23 in paper form. Informed V3 that post fall investigation for R40's fall incident for 2022 was documented in computer generated fall incident report form and asked V3 why she is providing paper post investigation forms. No copies of the fall incident report provided dated 2/25/23, 2/4/23, 1/26/23 and 1/23/23. No copy of post fall investigation provided for 1/23/23. She said, that's all I have. On 3/9/23 at 11:42am, V3 DON said that fall care plan should be updated after each fall incident and fall assessment should be completed after each fall. Fall intervention should be followed. Facility's policy on Managing falls and fall risk indicates: Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. Facility's policy on Clinical Fall protocol indicates: Monitoring and follow up: 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling ( besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. R19 is readmitted on [DATE] with diagnosis listed in part but not limited to Congenital hydrocephalus, Chronic Kidney disease, Cerebrovascular disease, Muscle atrophy, Muscle weakness, Dementia. Admission fall assessment dated [DATE] indicated high risk for fall. Care plan indicated at high risk for falls and fall injuries. Intervention: Fall mat when in bed. On 3/7/23 at 11:58am, Observed R19 with V15 Restorative aide and V16 CNA in her room eating lunch, no floor mat on the right side of her bed. Her bed is not in the lowest position. V15 said that she should have both floor mats on the sides of her bed. On 3/7/23 at 12:25pm, Reviewed R19's medical record with V13 Restorative nurse/Fall coordinator. R19 had following fall incidents: 5/8/21 and 9/23/21. Fall intervention indicated use of floor mats. Informed V13 that floor mat is not in place on the right side of her bed when I made rounds this morning. R63 is admitted on [DATE] with diagnosis listed in part but not limited to Acquired absence of bilateral leg below knee, Phantom limb pain, Acute respiratory failure, Diabetes Mellitus type 2. Admission fall assessment and fall care plan indicated he is at high risk for falls. Progress notes dated 3/2/23 indicated: R63 was observed on the floor by the patio door on the 1st floor face down. There is a cut to upper right face with bleeding. R63 explained that his envelope fell on the floor and he tried to pick it up and fell . R63 was sent to hospital for evaluation. On 3/7/23 at 9:38am, V5 LPN said that R63 has recently fallen on 3/2/23. Rounds made with V5 to R63's room. At 9:45am, Observed R63 lying in bed, he has bilateral below the knee amputation. His call light was on the floor, unable for him to reach. V5 pick up the call light and placed it within reach. V5 said that resident's call light should be within reach. R63 said that he has fallen recently, hit his head and cause abrasion on his right forehead. Both lower leg prosthesis on the floor. His wheelchair at his bedside, no Dycem (non-slid material) placed on wheelchair seat. On 3/7/23 at 9:58am, Review R63's medical record with V13 Restorative nurse/Fall coordinator. V13 said she is not aware that R63 had fall incident on 3/2/23. She said that the floor nurse should place the incident report in the risk management report for them to see and do the root cause analysis. The floor nurse should notify her and the DON if any resident has fallen. R63 is high risk for fall. R63 had the following fall incidents: 3/2/23,12/15/22, 1/15/22, 12/21/21, 9/9/21, 8/5/21 and 6/12/21. Informed V13 that R63 does not have dycem in his wheelchair seat. R121 is admitted on [DATE] with diagnosis listed in part but not limited to Dementia, History of falling, Alzheimer, Weakness, Malaise, Lack of coordination. On 3/7/23 at 12:11pm, Observed R121 with V15 Restorative aide and V16 CNA in her room with no floor mats on both sides of her bed. V32 CNA said that she is the assigned for R121 and she is not aware that she needs to have floor mats. V15 RA said that she should have floor mats. On 3/7/23 at 12:25pm, Review R121's medical record with V13 Restorative nurse/Fall coordinator. She said that R121's fall assessment indicated that she is at high risk for fall. V13 said fall care plan indicated that she is at high risk for falls and fall injuries with intervention: Floor mats. Informed V13 that no floor mats are in place around her bed when I made rounds this morning. R128 is admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and hemiparesis following traumatic intracerebral hemorrhage affecting left non-dominant side, Morbid obesity, Weakness, History of falling, Altered mental status. Fall assessment indicated she is at high risk for fall. Care plan indicated she is at high risk for falls and fall injuries. On 3/7/23 at 12:14pm, Observed R128 sitting on her bed. She said she had fallen three times in the facility. No floor mats and dycem (non-slid material) on her wheelchair seat. V17 CNA said that she is assigned to R128, but she is not aware not she needs to have floor mats and dycem on her wheelchair seat. On 3/7/23 at 12:25pm, Reviewed R128's medical record with V13 Restorative nurse/Fall coordinator. V13 said that a fall admission assessment was done on 3/17/22 indicating at high risk for falls. R128 had the following fall incidents: 4/11/22, 6/7/22, 7/13/22, 7/31/22 and 12/8/22. V13 said Fall interventions indicated use of floor mats and dycem. Informed V13 that floor mats and dycem are not in place when I made rounds this morning. 40001 A fall report indicates that R154 had an unwitnessed fall on 2/13/2023 resulting in a fractured clavicle, and an unwitnessed fall on 2/22/2023 resulting in neuro checks and resident refusing hospital visit. On 3/10/2023 at 11:00am V2 (Director of Nursing-DON) said a fall assessment should be completed after every fall a resident has with new care plan interventions. An Order Summary Report documents that R154 has a history of Displaced fracture of shaft of left clavicle, initial encounter for closed fracture, and a history of falling. R154 has an order to wear sling as ordered. A morse fall scale was done on 12/23/2022 with a score of 50 which indicates a high risk for falls. There was no fall assessment on 2/13/2023. A fall risk assessment on 2/22/2023 with a score of 19 indicates moderate risk for fall.

Based on interviews and record reviews, the facility failed to prevent an avoidable fall incident and failed to develop a plan to prevent or reduce the risk of falling. These failures affected 1 of 3 residents (R1) reviewed for fall prevention. These failures resulted in R1 having a unwitnessed fall after R1 was observed with a low oxygen saturation level of less than 90%. This fall resulted in R1 sustaining bilateral femur fractures. Findings include: On 11/18/22 at 10:45 am, V6 RT (respiratory therapist) stated that V6 does not recall R1. V6 stated that she sees all new admissions with diagnosis of heart failure. V6 stated that these residents are only followed for 30 days unless the resident's physician requests further visits from RT. V6 stated that she comes to this facility twice a week to see residents. This surveyor reviewed R1's notes with V6. V6 stated that she will double check pulse oximetry results with a different machine if results are low. V6 stated that she contacts the nurse and the NP (nurse practitioner), if NP available, and alerts them to her findings and recommendations. V6 stated that oxygen saturation levels in the low 80s could cause a resident to exhibit confusion. There is no documentation found in R1's medical record noting the nurse or nurse practitioner/physician were notified of V6's low oxygen levels. On 11/18/22 at 12:15 pm, V7 (nurse) stated that if RT (respiratory therapist) has any new orders/recommendations, she will let the nurse know. V7 stated that V7 does not recall being informed by V6 RT of R1 having low oxygen levels. V7 stated that R1's vital signs are assessed every shift. V7 stated that V7 checked R1's oxygen saturation level while R1 was receiving oxygen. V7 stated that V7 would have known if R1's oxygen saturation level was in the 80s during her shift. When questioned how V7 would know if R1's oxygen level was low on room air if V7 only checked oxygen level while on oxygen, V7 did not respond. On 11/22/22 at 10:40 am, V13 NP (nurse practitioner) denied being aware of R1's oxygen saturation level 81% - 88% on room air. V13 stated that nobody communicated to him what was going on with R1: elevated BNP (b-type natriuretic peptide-blood test that provides how the heart is working, high level is a sign the heart is not working as it should be) and the need for oxygen use. V13 stated that V13 did not see R1 using any oxygen during his visits. V13 stated that there had to be something going on medically with R1 for her oxygen levels to be in the 80's on room air. V13 stated that if V13 had been made aware, V13 would have come to facility to assess R1. Review of V6 RT's documentation notes the following: On 9/21/22, upon entering room, R1 was sitting in high fowler's position (upright position to help with breathing) in bed. R1's oxygen saturation level was 85% on room air, checked with two different pulse oximeters. R1 denies shortness of breath at this time, breath sounds are diminished bilaterally. R1 does have a non-productive cough. R1 was placed on 3 liters of oxygen via nasal cannula; oxygen saturation level gradually increased to 95% with oxygen. On 9/26/22, upon entering room, R1 was sitting in high Fowler ' s position in bed. R1 is slightly confused and will occasionally mumble her words. R1 was found off the oxygen. Oxygen saturation level on room air, checked with two different pulse oximeters, was 83-88%. R1 was placed back on 3 liters of oxygen via nasal cannula. R1's oxygen saturation level increased to 94%. On 9/28/22, upon entering room, R1 was sitting in high fowler's position in bed eating breakfast. R1 took her oxygen off to eat breakfast. Oxygen saturation level was 83% on room air. R1's breath sounds are diminished bilaterally. On 10/3/22, upon entering room, R1 was sitting in high fowler's position in bed. R1 was found off the oxygen. Oxygen saturation level was 81% on room air, checked by two different pulse oximeters. R1 was placed on 4 liters of oxygen via nasal cannula. R1's breath sounds are diminished bilaterally. Review of this facility's fall investigation report, dated 10/4/22, notes R1 was observed on her knees beside bed. R1 stated that R1 was trying to go to the bathroom unassisted but knees got wobbly and R1 fell to floor. R1 complained of moderate pain to both knees. X-rays were completed at facility noting bilateral distal femur fractures. Review of R1's hospital record, dated 10/4/22, notes R1 presented to the hospital after having an unwitnessed fall in the bathroom. R1 stated she is unsure if she hit her head. R1 complained of constant, moderate pain to both knees, headache, and posterior head tenderness. Chest x-ray noted right lung airspace disease consistent with pneumonia or edema. X-ray of R1's left femur noted a displaced oblique (bone breaks diagonally) fracture of the distal femur. X-ray of R1's right femur noted a displaced comminuted oblique fracture of the distal femur.

Based on interview and record review the facility failed to identify one resident and develop a plan with interventions to prevent drug seeking behaviors for a resident with a history of substance abuse. This failure affected 1 of 3 residents (R2) reviewed for psychosocial interventions for substance abuse. This failure resulted in R2 seeking medication/drugs from peer residents, causing R2 to overdose and treated with [MEDICATION(S)] (opioid antagonists). Findings include: On 4/19/2022 at 2:48 PM, R2 states regarding her hospitalization on [DATE] that the nurses would not give her any pain medication. R2 states, her pain is in her side, back and left leg and she takes [MEDICATION(S)] for pain. R2 states, I was in a lot of pain and I got pain medication from another lady (R1) here. R2 states, They don't give me pain medication when I ask, but (R1) can get whatever she wants from them. I know I made a mistake by getting the medication from her. R2 states that on 4/14/2022, (R1) saw I was in a lot of pain and she gave me this white powder, and I took some with my finger and sniffed it. She told me, be careful and not to take a lot. She said I have to be careful because it was the straight stuff. I thought it was heroine. R2 states, after taking the stuff (R1) gave me, I woke up the next day in the hospital . On 4/19/2022 at 2:56 PM, V11, (R2's Daughter), states, the staff find (R1) here high all the time. The nurses and CNA's say that. I don't know why (R1) is still here. V11 states, this is the second time this has happened where (R1) has given her mother drugs. V11 states, the night this happened (R5) told the nurse that (R1) told him to go check on my mother. R2 states about a month ago (3/5/22) she was in a lot of pain and (R1) gave R2 some medication, and she fell in R2's room and was sent to the hospital. On 4/20/22 at 1:25 PM, V3 LPN, said he was working on 4/14/22 when (R2) was unresponsive in her room. V3 said the paramedics had to give (R2) [MEDICATION(S)]. On 4/20/22 at 2:48 PM, V9 Social Service Director said, I was told R2 was given [MEDICATION(S)] when she went to the hospital on 4/14/22. V9 said if I know a resident has a drug abuse history I would care plan it. V9 said a resident with a drug abuse history can be referred to the Licensed Clinical Social Worker (LCSW). V9 said the facility has daily communication during morning meeting. V9 said she was told that (R2) went to the hospital and was given [MEDICATION(S)]. V9 said I don't hear that medication mentioned often. On 4/20/22 at 1:37 PM V2 Director of Nursing, said, in March (R2) was hospitalized for [CONDITION(S)]. (R2) was unresponsive and was sent to the hospital. V2 said prior to (R2)'s hospital transfer on 4/14/22, I did not know (R2) had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 said if she was notified that a resident used drugs while residing in the facility an investigation would be done. On 4/21/22 at 2:03 PM, V2 said she reviewed (R2)'s hospital records from 3/5/22 and saw they had given R2 [MEDICATION(S)]. On 4/21/22 at 2:12 PM, V12 LCSW, said she has seen R2 to discuss individual topics. V12 said (R2) is seen for Depression, Anxiety, and Grief. V12 said no groups are done in the facility and all programs are done on 1 to 1 basis. V12 said (R2) communicates and participates in her visits. V12 said asking if a resident has a drug abuse history is part of her intake documentation. V12 said she completed an intake on (R2) on 2/9/22. V12 said (R2) reported she had not used drugs in more than 12 months and was in remission. V12 said depending on responses to the intake and if there are 2 or more concerns on the intake then she would discuss it with the team and make it part of (R2)'s treatment plan. V12 said (R2) was seen on 2/23/22 and 3/11/22. V12 said on 3/11/12 (R2) discussed grief and anxiety. V12 said she was aware (R2) had been hospitalized before 3/11/22 but she did not know why (R2) was hospitalized . V12 said hospitalization s are discussed at morning meeting. V12 said if a resident is hospitalized for drug use she would prefer the facility notify her. While reviewing her notes V12 said during her intake (R2) reported she used to struggle with Heroin addiction. Review of the facility provided Online Referral documents for R2 dated 1/13/22 notes Substance Use Marijuana. Hospitalist Internal Medicine Progress Notes dated 1/9/22 note Patient admits to history of smoking crack, last use was 2 months ago. Review of V12's Intake document for R2 completed 2/29/22 notes Part B Substance Use Sustained remission (no symptoms for 12+ months). Severity Few/No symptoms reported. Details: The resident use to struggle with heroin addiction. She has been in remission for [AGE] years. Summary: The client struggles with feelings of anxiety and depression. Review of R2's hospital records admitted [DATE] note brought in secondary to being unresponsive. Provider notes state Differential Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is given [MEDICATION(S)] did get better. R2's progress notes dated 4/14/22 notes 911 was called and paramedics administered [MEDICATION(S)] and R2 started breathing. R2's hospital records from 4/14/22 note Chief Complaint Drug Overdose. Review of R2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's care plan initiated on 1/18/22 does not include a history of drug or Heroin abuse.

Based on interview, and records review, the facility failed to notify the physician of abnormal critical lab result for 1 (R1) of 3 residents reviewed physician notification of abnormal labs. This failure resulted in R1 having a change in condition, that required R1 to be transported to the local hospital assessed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of R1's face sheet documents an [AGE] year old admitted to the facility on [DATE]. R1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 9/17/2021: Enteral feed order Every shift enteral feeding: [MEDICATION(S)] 1.5 75ml until 1350 MS infuses/24hours. Up at 4 PM. R1's Tube feeding Care plan dated 9/16/2021 documents the following: Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of R1's order dated 9/17/2021 documents: Enteral feed order every 6 hours flush with 300 ML. Review of R1's Lab results dated 11/12/2021 include the following labs that were abnormally high as indicated by H or HH: Sodium 159 meq/L HH (136-147 mEq/L normal range) Potassium 5.4 mEq/L H(3.7-5.1 mEqL) BUN 96 mg/dL H( 8-28 mg/dl normal range) Creatinine 1.16 mg/dL (0.40 -1.60 normal range) Progress note dated 11/12/2021 by V4 (Nurse) documents the following: nurse reported labs to V16 (Primary Physician), and gave him the lab requisition. V16 stated, he would follow up. V4 (Nurse) was on vacation and would not return phone call during the investigation. On 12/10/2021 at 8:40 AM, V16 (Primary Physician) states, elevated BUN, can imply dehydration. Patient would need fluids. V16 states, if he had been given the 11/12/2021 lab values, he would have told the facility to push fluids and repeat the labs. I don't recall getting those lab results. R1's progress note dated 11/18/2021 at 13:52 by V19 (Nurse Practitioner) documentation includes the following: Appears weak. CMP reviewed, unclear if results communicated to MD. Stat CBC, CMP. Call V16 with results. Progress note dated 11/18/2021 at 15:23 V3 (Nurse Manger) documents R1 was sent to emergency room for Altered mental status and slow to respond. On 12/10/2021 at 2:30 PM, V17 (Infectious Disease APN) , V17 ordered the initial lab that resulted on 11/12/2021. V17 states, if he had seen the abnormal labs he would not have addressed it. V17 states, labs like the potassium levels, BUN, etc, he would have referred it to the Primary Doctor. V17 states, he would have ordered the labs routinely because the resident was Covid positive. R1's progress note dated 11/12/2021 by V17 documents: he reviewed the labs and there were no gross abnormalities. D-Dimer not found. V17 states he was referring to the D-Dimer had no gross abnormalities when he wrote the note on 11/12/2021. On 12/10/2021 at 3:53 PM V2 (DON) states the 11/12/2021 labs should have had some follow up. V2 states, she investigated this and once the nurse saw that V17 (ID APN) had reviewed the labs she thought V16 had been notified. V2 states, she did an in-service for the nurses to follow up with physician regarding abnormal lab results Review of R1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital emergency room notes document the following: 11/18/2021 Results: Sodium > 170 HH meq/L (134-149 mEq/L normal range, BUN 93 mg/dL H (7-20 mg/dL normal range), Creatinine 1.5 mg/dL H (0.5-1.4 mg/dL )

Based on interview and record review, the facility failed to meet professional standards of quality care for one resident (R19) with critical laboratory results out of three residents reviewed for an acute change in condition and timeliness of transport to the hospital, and failed to follow its skin care policy by not treating dry skin or lips with moisturizers as needed. This failure affected 2 of 2 (R27, R3) in a total sample size of 35. Findings include: 1. Review of the medical record notes R19 with [DIAGNOSES REDACTED]. Review of R19's BIMS (brief interview of mental status) score, dated [DATE], notes R19 scored 15 out of 15. R19 was able to make needs known. Review of infectious disease nurse practitioner note, dated [DATE], notes 3+ [MEDICAL CONDITION] (swelling) to both lower extremities (left more than right). Laboratory tests ordered for ,[DATE], call results to infectious disease. Continue to monitor for signs/symptoms of worsening infection [MEDICAL CONDITION]. Review of R19's laboratory test results, dated [DATE], notes white blood cell count 10.69 (normal range 4XXX,[DATE].8); sodium level 143 (normal range ,[DATE]); potassium 3.2 (normal range 3XXX,[DATE].1); CRP (C-reactive protein, a marker of inflammation/infection in blood) 13.6 (normal range 0XXX,[DATE].0); ESR (erythrocyte sedimentation rate, measures the degree of inflammation/infection in body) 25 (normal range ,[DATE]). The results of blood cultures drawn on [DATE] [MEDICAL CONDITIONS] on [DATE]. Review of R19's laboratory test results, collected on [DATE] at 8:20 AM, notes white blood cell count 18.5; sodium level 133; potassium level 2.7; C-reactive protein 236.5; and ESR 38. Results were called and faxed to V10, Licensed Practical Nurse (LPN) at this facility at 12:34 PM. There is no documentation found noting R19's critical laboratory test results were relayed to R19's physician or nurse practitioner by V10 (nurse). Review of R19's medical record notes the following: On [DATE] at 8:15 AM, R19 in bed with oxygen at 3 liters per nasal cannula. R19 stated R19 feels tired and short of breath, blood pressure ,[DATE], heart rate 100 beats/minute, respirations 22/minute, temperature 98.8, oxygen saturation level 96% on oxygen. V23 NP (Nurse Practitioner) notified, order received to transfer R19 to the PUI (persons under investigation) nursing unit. On ,[DATE], V23, NP, notes R19 seen for acute report of decreased oxygen saturation level and fever. R19 is acutely confused oriented only to self, which is drastically different than R19's baseline. R19 is tachypneic on exam and reports, I would feel better if I died 3 times. Due to R19's acute onset of symptoms, R19 was moved to PUI status. An infectious work-up was started. R19 reports fever, severe fatigue, shortness of breath, and weakness. Assessment notes generalized weakness, easy fatigue, nonproductive cough, shortness of breath. Temperature 101.7 degrees Fahrenheit, heart rate 131 beats/minute, respirations 22/minute, oxygen saturation level 95% on 3 liters of oxygen per nasal cannula. Diagnosis: [REDACTED]. Oxygen saturation level in the 80s on room air. On ,[DATE] at 1:00 AM, R19 was found wheezing. There is no intervention documented to treat R19's wheezing. On ,[DATE] at 2:00 AM, oxygen saturation level 93% on room air, heart rate 131 beats/minute, respirations 28/minute. Telehealth physician will be called. On ,[DATE] at 2:00 AM, telehealth physician note, physical exam noted R19 tachypneic, abdominal retractions. Diagnoses: [REDACTED]. R19 with respiratory decline, reviewed chest x-ray and had right lower lobe infiltrate, R19's clinical picture is much worse than the chest x-ray alone would explain. Very high C-reactive protein more likely reflective of severity of illness. Limited diagnosis/treatment capacity given R19's decline at facility, cannot do nebulizer treatments due to Covid-19. On ,[DATE] at 2:30 AM, EMS (emergency medical services) 911 called. R19 transported via ambulance to hospital at 3:00am. Review of R19's vital signs documentation notes the following: [DATE] at 6:41 AM, BP (blood pressure) ,[DATE] ,[DATE] at 10:11 AM, BP ,[DATE], heart rate 110 beats/minute ,[DATE] at 12:55 AM, BP ,[DATE], heart rate 131 beats/minute ,[DATE] at 9:36 PM, BP ,[DATE], heart rate 100 beats/minute ,[DATE] at 00:27 AM, BP ,[DATE] ,[DATE] at 2:00 AM, heart rate 131 beats/minute, respirations 28/minute, and oxygen saturation level 93%. Review of R19's hospital records, dated [DATE], notes R19 presented to the emergency room at 3:38 AM. Vital signs: temperature 101.2 degrees Fahrenheit, heart rate 112 beats/minute, respirations 31/minute. emergency room physician noted R19 presented to the emergency room for evaluation of shortness of breath, onset prior to arrival 3 hours. Per this facility's report, R19 has been in respiratory distress for 3 hours. Oxygen at 4 liters per nasal cannula. Respiratory assessment noted labored breathing, difficulty speaking short phrase; ,[DATE] word labored breathing. On [DATE] at 2:45 PM, V23, NP (Nurse Practitioner) stated V23 was not notified of R19's oxygen level dropping into the 80s. V23 stated that R19 appeared ill when V23 saw R19 on the morning of [DATE], asked the nurse to obtain vital signs, ordered oxygen and to transfer R19 to the PUI (persons under investigation for Covid-19) unit. V23 stated that V23 ordered laboratory tests, chest x-ray, and Covid-19 rapid test, which was negative for Covid-19. V23 stated if we can treat resident in facility, we will keep him/her here. V23 stated that R19's oxygen saturation level improved with 2 liters of oxygen. V23 stated that R19's breathing was not labored when V23 saw R19. V23 stated that V23 was not notified of R19's critical laboratory test results; V23 is available for staff to call until 7:00pm daily. V23 stated that after 7:00pm, telehealth providers are called with any resident concerns. On [DATE] at 9:00 AM, V10, Licensed Practical Nurse (LPC), stated the outside laboratory service will call and fax critical laboratory results. V10 stated the resident's physician/nurse practitioner needs to be notified of all critical lab results. Review of this facility's change in resident's condition policy, dated ,[DATE], notes nursing will notify the resident's physician or nurse practitioner when there is a significant change in the resident's status or when necessary or appropriate in the best interest of the resident. The communication with the physician/nurse practitioner will be documented in the resident's medical record. Review of this facility's Covid-19 policy, revised ,[DATE], notes resident monitoring protocol: fever, shortness of breath, cough, sore throat, chills, muscle pain, headache, and/or new loss of taste or smell. Contact clinical supervisor for any of the following: new-onset fever, shortness of breath, cough, sore throat, or for any decrease in pulse oximetry from resident baseline or any pulse oximetry reading less than 92%. Providers should strongly consider transfer to a higher level of care. Monitoring every 4 hours is appropriate for residents with evidence of clinical deterioration. 2. On [DATE] at 4:01 PM, R3's skin was observed dry and flakey. Small rolled up brown and dried yellow-beige particle/ flakes was observed on R3's bed sheets from R3's shoulders area to R3's feet. The dried particle/flakes was consisted with dried detached skin. R3 who is alert and oriented said, I scratch all day and night related to the dirt on my body. I am itching, because I have not had water to run over my body to wash off the dirty. That is dried dead skin all over my sheet. The certified nursing assistance won't put lotion on me. V6 (nurse) said, R3's skin is dry because he is not getting lotion applied daily. That is dried skin on R3's sheets. R3's physician orders [REDACTED]. Apply lotion to whole body topically one time a day for itching. On [DATE] at 10:55a AM, R27 was observed with dry cracked lips and feet. R27, who is alert and oriented, said he doesn't get lotion applied to his feet or moisturizer to his lips. On [DATE] at 11:51 AM, V2 (Director of Nursing) said, I would expect my nursing staff to apply lip balm and lotion as needed/prescribed. Skin Care Prevention Policy, dated ,[DATE], #8 Treat dry skin with moisturizers as needed.

Based on interviews and record reviews, the facility failed to consistently and accurately assess and monitor a resident's clinical condition, implement interventions that are consistent with a resident's needs, goals, and professional standards of practice, and evaluate the effectiveness of the interventions to prevent a sacral pressure ulcer from worsening for one resident (R11) in a sample of 9 reviewed for pressure ulcers. This failure resulted in R11 developing a stage 4 sacral pressure ulcer requiring surgical debridement. R11 was also found to have osteo[DIAGNOSES REDACTED] (bone infection) of the sacrum and coccyx. Findings include: Review of R11's medical record notes R11 with [DIAGNOSES REDACTED]. Review of R11's hospital record, dated 10/19/20 - 10/28/20, the Wound Physician notes R11's sacral wound is just excoriations, measuring 6cm (centimeters) x 7cm, at this time that are superficial will dress with a medicated cream and a large foam dressing. R11 needs a stage 4 mattress and should turn every two hours. Review of R11's re-admission clinical evaluation, dated 10/28/20, V35, LPN,(Licensed Practical Nurse) noted R11's skin observation: coccyx full thickness skin loss with grey yellow slough; right buttock partial thickness skin loss; and left buttock partial thickness skin loss. Review of R11's Braden score, dated 10/28/20, notes R11's score is 11; score notes R11 is at high risk for skin breakdown. Review of R11's POS (Physician order [REDACTED]. A Braden score of 13-18 requires daily skin check two times a week. If a skin issue is identified complete the risk management, which will trigger a skin event form every night shift on Mondays and Thursdays. Review of R11's medical record from re-admission on 10/29 until re-hospitalization on ,[DATE] does not note any documentation regarding R11's sacral/buttocks ulcers. Review of R11's MDS (Minimum Data Set), dated 11/5/2020, notes R11 is totally dependent on two staff members for bed mobility; R11 requires extensive assistance of one staff member for eating, toileting, dressing, hygiene, and bathing. Review of R11's hospital record, dated 11/10/20 - 11/21/20, notes R11 with a sacral pressure ulcer which is more demarcating and necrotic (dead tissue). R11 underwent debridement on 11/16 and found to have osteo[DIAGNOSES REDACTED] of the sacrum and coccyx. Sacral ulcer measures 10cm x 12cm, exposed bone, with some excoriations around the edges. On 12/9/2020 at 1:40 PM, V43 (family member) stated V43 was not aware R11 had a sacral pressure ulcer. V43 stated when R11 went to the hospital in November, the nurse at the hospital informed V43 of the sacral pressure ulcer R11 was admitted with. On 12/15/2020 at 10:12 AM, V4 (Wound Care Coordinator) stated the Braden scale is used to determine a resident's risk for skin breakdown. V4 stated R11 is high risk for skin breakdown. V4 stated residents at high risk should have skin assessed daily. V4 stated upon R11's re-admission to this facility on 11/23/20, R11 was noted to have a stage 4 sacral pressure ulcer. V4 denied being informed R11 had skin breakdown on sacrum upon re-admission on 10/28/20. V4 stated prior to 11/23/20, R11 was only being seen for bilateral heel wounds due to [MEDICAL CONDITION]. On 12/15/2020 at 2:50 PM, V24 NP (Nurse Practitioner) stated after reviewing R11's progress notes, R11 did have ulcers on both heels in October. V24 stated V24 is unable to find documentation of sacral pressure ulcer prior to R11's re-admission on 11/21/2020. V24 stated V24 would expect the Nurse Practitioner to order wound care treatments if she had been made aware of sacral wound when R11 was readmitted to this facility on 10/28/2020. On 12/16/2020 at 11:50 AM, V2, DON (Director of Nursing), stated the nurse documents skin events in risk management in the resident's electronic medical record. V2 stated V2 did not note any documentation in risk management related to skin events noted upon re-admission to this facility on 10/28/20 or 11/21/2020. On 12/17/2020 at 9:00 AM, V10, LPN (Licensed Practical Nurse), stated after reviewing R11's re-admission clinical evaluation, dated 10/28/20, V35, LPN, should have alerted the wound care team of new wounds identified on R11's sacrum/buttocks. V10 stated the wound care team would have measured and staged R11's wounds, received treatment orders from the wound care physician, notified R11's family member, and updated R11's care plan. Review of this facility's skin care prevention policy, revised 12/2019, notes the Wound Care Coordinator will review all new admissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment, and other pertinent information. All resident will be observed daily for changes in their skin condition. Residents will be assessed during care for any changes in skin condition including redness or any other alteration in skin integrity, and this will be reported to the nurse. Review of this facility's wound evaluation and documentation policy, reviewed 12/2020, notes wounds will be evaluated and the following areas documented every 7 days: location, classification/stage, size, depth, presence and location of any undermining, drainage, pain, wound bed color and type of tissue, description of wound edges and surrounding tissue. If a wound is present, the resident and/or resident representative and physician will be notified. The licensed staff will notify the wound care team in a timely manner upon identification of skin impairment. The licensed staff should document the open area, risk management, skin event form, and pain evaluation. Notify the physician for treatment orders. When the wound care team assesses the resident, they will complete braden scale, measure the wound, review physician orders, and update any notes and care plans as appropriate. A member of the wound care team will complete braden scale, wound characteristics and appropriate notes within 24 hours of admission.

Failures at this level require more than 1 deficient practice statement A. Based on interview and record review, the facility failed to follow the plan of care for high risk for falls, failed to implement individualized safety interventions of a soft helmet, and failed to provide supervision when the resident is up in the chair. This failure resulted in R6 falling forward out the wheelchair, sustaining a laceration to the head. R6 was sent to the hospital and received 7 sutures. This affects 1 of 9 resident reviewed for falls in sample of 36. B. Based on interview and record review, the facility failed to prevent an avoidable fall incident by not reassessing the effectiveness of a medication given for lower back pain, and notify the physician of the ineffectiveness of the current pain management for 1 of 1 residents (R14) reviewed for avoidable accidents. This failure resulted in R14 complaining of persistent lower back pain for over 3 hours and subsequently standing up to get pain relief, losing her balance, and falling to the floor, and being transported to the hospital. R14 was assessed to have an acute comminuted avulsion [MEDICAL CONDITION] ischial tuberosity. C. Based on interview and record review, the facility failed to implement interventions consistent with a resident's needs, goals, care plan, and current professional standards of practice to reduce the risk of a fall, analyze the resident's fall to determine the root cause, and develop interventions to reduce the potential for further falls for one resident (R2) out of three reviewed for risk of avoidable falls in a sample of 35. Findings Include: A. R6 physician order [REDACTED]. R6 plan of care, with initial date of 4/18/2013 and target date of 7/3/2020, shows R6 is high risk for falls related to unaware of safety need. R6 noted with fall incident. Goals will be for R6 not to sustain serious injury through the next review date. Interventions are to have floor mat on the side of the bed while in the bed. Educate the family about safety reminders and what to do if fall occurs. R6 bed in lowest position. Resident transfer to an acute facility for further evaluation. Soft helmet on at all times, may remove during meals, continue to re-educate husband with the risks and benefits of helmet use, Husband continue to remove helmet when he is around despite education. Staff to ensure resident is in high visualized are for monitoring when not in bed. The resident has a chair/ bed alarm and motion pad alarm on bed, ensure the device is in place as needed. The resident will have helmet on while ambulating, per family request to prevent head injuries. Therapy department to screen for appropriate ambulatory assistive device. R6 care plan, with initiated dated of 11/13/2017, shows R6 had an actual fall on 11/13/17 r/t (related to) poor safety awareness / impulsiveness, pt (patient). was sent to ER for an evaluation. Goals are to decrease incident of fall through the next review. Interventions: Resident not to be alone in the room while sitting on the chair unsupervised due to poor trunk control. Mattress on the floor for safety. Place call light within reach. R6 Plan of care, with initiated date of 5/15/2020, shows R24 has potential for falls, resident at risk for injury from falls Poor Balance, and Poor safety awareness/impulsiveness. Goals: The facility will reduce the likelihood of the resident experiencing an injury related to a fall through next review target date 07/03/2020. Interventions are to maintain bed in the lowest position, lock wheels to prevent the bed from moving. Check on resident frequently and place resident in visible view of staff when up in chair as resident will allow. PT/OT evaluation and treat per MD order. Call light within resident's reach when in room. R6 facility incident report, dated 5/15/2020 at 8:15 AM, shows incident location, resident's room. Incident description observed resident laying on the floor. Leaf huddle called nursing staff responded. Resident assisted from floor put to bed per mechanical lift. Noted laceration of forehead with small amount of bleeding pressure dressing applied bleeding stopped. Neuro checks initiated no change in LOC. Full body check done no visible injuries or bruises noted PROM within normal limits. Resident's nonverbal no s/s - (signs/symptoms) of pain noted, no facial grimacing noted. Resident unable to give description. Assessed by nurse. Resident assisted from the floor to the bed per mechanical lift x2 staff members. Noted laceration to forehead with small amount of bleeding pressure dressing applied bleeding stopped. Neuro checks initiated no change in LOC. Full body check done no visible injuries or bruises noted PROM within normal limits. Resident's nonverbal no s/s of pain noted, no facial grimacing noted. Head to toes check done, vital signs taken, pressure dressing applied, neuro checks initiated, scheduled pain medication given. Resident sent to hospital. N. injury type, laceration injury location, face. Level of pain 0. Mental status unable to determine. Injuries report post incident, no injuries observed post incident. Predisposing environmental factors, other. Predisposing physiological factors, gait imbalance. Predisposing situation factors, leaning. Witness V20 (Nurse) fall unwitnessed. V37, CNA-(Certified Nursing Assistant) informed me that she got the resident up and stepped away to get her tray. Resident leaned forward and fell . She was unable to catch her in time. Patient had a laceration to her forehead. V37 witness statement shows I got the resident up as usual. I stepped away to get her tray and she fell I could not reach her in time to prevent her fall. Agencies / People notified. Nurse Practitioner at 5/15/2020 at 1:42 PM and Family member on 5/15/2020 at 8:40 AM. Notes RCA (Root Cause Analysis): poor sitting balance r/t weakness. Resident left facility via stretcher accompanied two attendants. Gauze dressing to forehead dry no change in status. Neuro checks pearl, no decrease in LOC. Resident transported to ER for evaluation. Resident left facility via stretcher accompanied two attendants. Gauze dressing to forehead dry no change in status. Neuro checks pearl, no decrease in LOC. Resident transported to ER for evaluation. [AGE] year-old female here for long term care. Past medical history hypertension, [MEDICAL CONDITION] reflux disease, dysphagia, [MEDICAL CONDITION], Alzheimer's, dementia, chronic [MEDICAL CONDITION], chronic rhinitis, ulcerative [MEDICAL CONDITION]/ chron's disease, [MEDICAL CONDITION]. Patient was observed on the floor with laceration to forehead and small amount of bleeding. Pressure dressing applied bleeding stopped. Neuro checks initiated no change in LOC. Full body check done no visible injuries or bruises noted PROM within normal limits. Residents' nonverbal no s/s of pain noted, no facial grimacing noted. Resident transported to ER for Evaluation. Resident left facility via stretcher accompanied two attendants. Gauze dressing to forehead dry no change in status. Neuro checks pearl, no decrease in LOC. Returned to facility with sutures to forehead. R6 progress note, dated 5/15/2020 at 1:33 PM, completed by V20 (Nurse) shows Writer called to this resident room per assigned CNA noted resident laying on the floor face down. Leaf huddle called nursing staff responded. Resident R6 assisted from the floor put to bed per mechanical lift. Noted laceration to forehead with small amount of bleeding pressure dressing applied bleeding stopped. Neuro checks initiated no change in LOC- loss of consciousness. Full body check done no visible injuries or bruises noted. PROM (Passive Range of motion) within normal limits. Resident nonverbal no s/s (signs/symptoms) of pain noted no facial grimace noted. NP (Nurse Practitioner) notified states I will be in the facility by 10 am to see her. Daughter notified. R6 hospital records, dated 5/15/2020 at 12:00 PM, shows in part history of present illness, the patient presents with head injury. The onset was just prior to arrival. Type of injury fall with laceration. The course /duration of symptoms is improving. The location of incident occurred was at the nursing home. Risk factors consist of Alzheimer's. Prior episodes: none. Therapy today. Associated symptoms: denies vomiting. [DIAGNOSES REDACTED]. Laceration repair shows in part 3 cm in length, irregular shape depth multiple layers, anesthesia 5ml 2% [MEDICATION NAME], skin closure 5-0 nylon (7 sutures) simple technique. Complexity 2 layers. On 12/11/2020 at 3:28 PM, V20 (Nurse) said she was notified by the aide that R6 had a fall on 5/15/2020. V20 said when she went to R6's room to complete her assessment, R6 was on the floor face down in front of her wheelchair. V20 said R6 was noted with a laceration to her forehead. V20 said she observed R6 high back wheelchair was in the upright position. V20 said she rendered first aide and applied a gauze dressing to the area. V20 said the aide told her she stepped away from R6 to get something, V20 said she wasn't sure. Facility incident report reviewed with V20. V20 said the documentation showing no visible injuries or bruises noted was typed in error, R6 did sustain and injury from the fall. V20 said R6 was sent to the hospital and received sutures to her forehead. V20 said she was unable to determine R6 mental status because R6 was nonverbal. V20 said although she checked the box for predisposing environmental factors, there were no predisposing environmental factors related to R6 fall. V20 said R6 had predisposing physiological factors that contributed to her fall of gait balance. V20said R6 could not come to a standing position independently, she required assist. V20 said R6 had predisposing situational factors of leaning that contributed to her fall. V20 said R6 had poor trunk control which caused her to lean from side to side. V20 said R6 should not be left sitting in high back wheelchair in an upright position alone. V20 said the staff should not step away too far from the resident who has poor trunk control a couple steps are okay. V20 said she does not know how far or how long V20 stepped away from R6. V20 said R6 did not need her helmet on the day of the fall. V20 said if she documented that the fall occurred in R6 room then that's where the fall occurred. On 12/15/2020 at 2:45 PM, V2 (Director of Nursing) said she conducted the fall investigation for R6 for the fall on 5/15/2020. V2 said although both witness statements show V20's name, one statement is from V20 and the other statement is from V37. V2 said that's why she specifically put V37's name in the statement so that it could be recognized as V37 statement. V2 said the program did not have V37 name listed and she had to list any name in order to document the interview. V2 said the root cause for R6 fall was poor sitting balance. V2 said if R6 plan of care intervention show that R6 should have a soft helmet on at all times and may remove during meals then R6 should have had a helmet on the day of the fall. V2 said the helmet is used to prevent head injuries in the event of a fall or [MEDICAL CONDITION]. V2 said R6 plan of care shows R6 should not be alone in the room while sitting up on the wheelchair unsupervised due to poor trunk control. V2 said R6 could potentially fall from the chair when she is unsupervised due to poor trunk control, R6 did not have the ability to maintain a proper sitting balance. V2 said R6 should have not been left sitting in the high back wheelchair while V37 stepped away to retrieve the food tray. V2 said R6 sustained a laceration to the forehead and was sent to the hospital where she received sutures. Several calls were made to interview V37, no answer. Care Plan policy, dated 10/03 with last review date of 9/20, shows each resident will have a care plan that is current, individualized, and consistent with their medical regimen. Care plan consist of the flowing problems identified by reviewing the medical records and discussion with the resident and /or significant others. Goals are set in conjunction with the family and resident. Goals are realistic, measurable, behaviorally stated and may be longer or shorter term. Goals should prevent decline or maintain resident function if realistic and appropriate based on the diagnosis. Interventions are actions taken to achieve the goals. These interventions should build on the resident's strengths, be realistic and identify those responsible for the interventions. Evaluation of the care plan should occur at least every90 days or with a significate change of the resident. If the goal is continued, a new date of completion should be identified. If the goal has been achieved it should be discontinued and a new goal, if appropriate, written. If the goal is now unachievable, it should be discontinued, and a care plan update as to why. Fall Management and Prevention Program policy, dated 9/2020, shows in-part, it is the intent of this facility to provide residents with assistance and supervision to minimize the risk of falls and falls related to injuries. A comprehensive care plan will be implemented based on fall risk screen score with an individual goal and interventions specific to each patient. B. R14 was admitted in the facility on 8/19/20 with primary admitting [DIAGNOSES REDACTED]. R14 care plan reviewed. R14 has a care plan for at risk for alteration of comfort initiated on 8/19/20 with an intervention that reads: Notify physician if current pain medication management is not effective. R14 care plan indicates potential for falls, at risk for injury from falls, with start date of 8/19/20. Goals: The facility will reduce the likelihood of the resident experiencing a fa;; through next review, initiated on 8/19/20 and with target date of 11/17/20. Medication Administration Record [REDACTED]. [MEDICATION NAME] pain medication was given on 12/21/20 at 0150 for a pain level of 8 on a scale of (0-10). V40's Notes on 8/21/20 at 2:03 AM reads: R14 rang call light, requested pain meds. R14 given 2 [MEDICATION NAME] as ordered. On 8/21/20 at 3:00 AM, V40's note reads: R14 rang call light, stated R14 is still waiting for her [MEDICATION NAME]. Nurse informed R14 she had taken her [MEDICATION NAME] an hour ago. R14 stated she don't remember. On 8/21/20 at 4:00 AM,V40's note reads: R14 rang call light again asking for more pain meds, reviewed medication with R14 and what time she could have more [MEDICATION NAME]. On 8/21/20 at 4:27 AM, V40's note reads: rang call light again asking for her pain meds. On 8/21/20 at 5:05 AM, V40's incident follow up note reads: R14 alert and oriented stated she was in pain and got up to look through her purse in the closet to see if she had stronger pain meds. Stated she lost her balance and fell backward landing on her left side, however she was observed laying on her right side. On 8/21/20, R14 was sent to hospital and Emergency department Chief Complaint was Back Pain, reads in part: patient states I had corrective back surgery and I have not been getting anything for pain. Patient alert and oriented x 4, patient states pain of 10/10. X-ray of Pelvis and Bilateral hips with an impression of acute comminuted avulsion [MEDICAL CONDITION] ischial tuberosity On 12/17/20 at 2 PM, surveyor interviewed V40 (Nurse) who stated R14 is able to reposition herself and resident was repositioning herself. I gave her [MEDICATION NAME] as ordered one time and did not do any new interventions from 2 AM to 5 AM. R14 was the one who keeps putting her light on and telling me she is still in pain. I told her she already had her medicine. I did not call the doctor and I don't recall why I did not call. Pain is subjective, usually if the pain medication is not working, I would notify the doctor to let them know that resident been complaining of pain and already medicated, maybe get a new order to relieve pain. On 12/15/20 at 1 PM, surveyor interviewed V2 (Director of Nursing) who stated, R14 had a fall. It was on a night shift. R14 had medication that she wanted sooner and that it was not able to be given. Nurse explained that she could not give pain medication to R14 because it was too soon. When V40 told R14 no and did not give medication, R14 called her Neurologist. I cannot remember the details but I know the nurse informed me of the fall. 911 came after the fall. It was R14 that called 911 per her neurologist instruction. R14 was transferred to hospital and she was discharge from the hospital back to R14's home. On 12/17/20 at 2:15 PM, R14's attending physician (V38) I do not remember R14, she was only in the facility for a short period of time. R14 gets two [MEDICATION NAME] 50mg for pain every 6 hours as needed. I did not receive a call from the nurse, but in general, if the medication is ineffective and resident is still in pain and pain medication is too soon to be given, the nurses sometimes calls and informs me and maybe after our discussion I could order another pain medication. Fall management and prevention program, with date created 9/2020, reads, in part: All residents will have a comprehensive fall risk screens on admission, quarterly and with significant change of condition and appropriate care plan intervention will be implemented and evaluated as indicated by assessment. Pain management policy, with revision date 7/14, reads in part: To facilitate and provide guidance on pain observation and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence and enhance dignity and life involvement. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Monitoring for effectiveness of interventions. Licensed nursing may notify Health Care Provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on individual's pain factors. If the pain has not been managed consistent with the resident's goal and needs the interdisciplinary team may need to reconsider current interventions and revise those interventions as needed. C. Review of R2's medical record notes R2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of R2's fall risk screen, dated 12/31/2019, notes R2 is at high risk for falls. Review of R2's falls care plan, dated 12/31/2019, notes R2 is at risk for injury from falls. Interventions identified include: provide adequate lighting, check on R2 frequently and place in visible view of staff when up in chair, toilet in a timely manner, encourage R2 to transfer and change position slowly, and orient to environment. R2's care plan was not updated after a fall on 1/6/2020. Review of R2's PT (Physical Therapy) evaluation, dated 1/1/2020, R2's functional assessment notes R2 requires maximum assistance of two staff for bed mobility, rolling, and supine to sitting position. R2 requires total assistance with transfers. Assessment summary notes R2 demonstrates decreased bilateral lower extremity muscle strength/muscle performance, impaired balance and functional activity tolerance, all of which impact R2's safety and independence with functional activity tolerance and requires skilled PT services in order to help R2 reach R2's prior level of functioning with increased safety awareness. Review of R2's nurse practitioner's progress note, dated 1/6/2020, notes reason for visit: fall and pain. R2 alert and oriented x 3. R2 seen today for report of fall over night as well as pain associated from the fall. R2 reported R2 was being transferred from bed to [MEDICAL TREATMENT] chair when R2 fell . R2 reported R2's legs went behind R2. R2 reported pain in lower back, left hip, and left leg. X-rays ordered of left hip, left leg, and lower back; results showed no acute injury. As needed narcotic [MEDICATION NAME] and [MEDICATION NAME] to lower back ordered. R2 with significant muscle weakness. Fall precautions, safety awareness discussed with nursing and R2. R2 instructed R2 must be transferred with a mechanical lift device. There is no documentation found in R2's medical record noting the fall event on 1/6/2020, or that the interdisciplinary team met to determine the root cause of R2's fall and develop interventions to prevent future falls from occurring. Review of R2's BIMS (Brief Interview of Mental Status), dated 1/7/2020, notes R2's score is 15 out of 15. R2 is able to make needs known. Review of R2's MDS (Minimum Data Set), dated 1/7/2020, notes R2 is totally dependent on two staff persons for bed mobility and transfers. On 12/11/2020 at 1:00 PM, V12 (Rehabilitation Director) stated R2 was non-ambulatory. V12 stated it was recommend staff use a mechanical lift device for all transfers for R2. On 12/11/2020 at 1:27 PM, V10, LPN (Licensed Practical Nurse) stated the fall protocol includes: performing a pain assessment, notifying the physician, and completing the fall risk assessment. V10 stated fall screening is completed upon admission and quarterly. V10 stated residents are monitored for 72 hours post fall. V10 stated the IDT (Interdisciplinary Team) meets post fall to determine root cause, review interventions, and document in the resident's care plan. V10 stated the care card at the nurses' station is used to inform CNAs (Certified Nurse Aides) of resident's fall interventions. On 12/15/2020 at 1:30 PM, V2, DON (Director of Nursing) stated V2 was not made aware R2 had a fall while residing at this facility. V2 stated V2 reviewed R2's medical record and did not note any fall event documentation by the nurse on duty at the time of the fall. V2 stated nurse expectations include: notify family, physician, and V2; document fall event in risk management; and complete a fall event. V2 stated IDT (Interdisciplinary Team) would meet to determine root cause and high risk, and determine interventions to prevent further falls. Review of this facility's fall management and prevention program, dated 9/2/2020, notes all residents will have a comprehensive fall risk screen on admission and with significant change of condition and appropriate care plan interventions will be implemented and evaluated as indicated by assessment. A comprehensive care plan will be implemented based on fall risk screen score with an individual gal and interventions specific to each resident. The care plan will be reviewed following each fall. Interventions are to be revised as indicated by screen. If a fall occurs, the following actions will be taken: assess resident including neurological checks, pain, range of motion, skin, joints, extremities, vital signs; assess resident each shift for 72 hours; pain will be assessed every shift for 72 hours; notify physician/family member; document assessment, pertinent facts, and incident in risk management; complete a fall event; begin investigation; IDT to determine root cause of fall; update care plan.

Based on interview and record review, the facility failed to follow their comprehensive pain management protocol and reassess the effectiveness of an administered pain medication for 1 of 1 resident (R14) reviewed for comprehensive pain assessment. This failure resulted in R14 complaining of persistent lower back pain for over 3 hours and subsequently standing up to get pain relief, losing her balance, falling to the floor, and being transported to the hospital. R14 was assessed to have an acute comminuted avulsion [MEDICAL CONDITION] ischial tuberosity. Findings Include: R14 admitted in the facility on 8/19/20 with primary admitting [DIAGNOSES REDACTED]. Medication Administration Record [REDACTED]. [MEDICATION NAME] pain medication was given on 8/21/20 at 0150 for a pain level of 8 on a scale of (0-10). R14 care plan indicates R14 is at risk for alteration of comfort initiated on 8/19/20 with an intervention that reads: Notify physician if current pain medication management is not effective. V40's Notes on 8/21/20 at 2:03 AM reads: R14 rang call light, requested pain meds. R14 given 2 [MEDICATION NAME] as ordered. On 8/21/20 at 3:00 AM, V40's note reads: R14 rang call light, stated R14 is still waiting for her [MEDICATION NAME]. Nurse informed R14 she had taken her [MEDICATION NAME] an hour ago. R14 stated she don't remember. On 8/21/20 at 4:00 AM, V40's note reads: R14 rang call light again asking for more pain meds, reviewed medication with R14 and what time she could have more [MEDICATION NAME]. On 8/21/20 at 4:27 AM, V40's note reads: rang call light again asking for her pain meds. On 8/21/20 at 5:05 AM, V40's incident follow up note reads: R14 alert and oriented stated she was in pain and got up to look through her purse in the closet to see if she had stronger pain meds. Stated she lost her balance and fell backward landing on her left side, however she was observed laying on her right side. On 8/21/20, R14 was sent to hospital and Emergency department Chief Complaint was Back Pain, reads in part: patient states I had corrective back surgery and I have not been getting anything for pain. Patient alert and oriented x 4, patient states pain of 10/10. X-ray of Pelvis and Bilateral hips with an impression of acute comminuted avulsion [MEDICAL CONDITION] ischial tuberosity On 12/17/20 at 2 PM, surveyor interviewed V40 (Nurse) who stated, R14 is able to reposition herself and resident was repositioning herself. I gave her [MEDICATION NAME] as ordered one time and did not do any new interventions from 2am to 5am. R14 was the one who keeps putting her light on and telling me she is still in pain. I told her she already had her medicine. I did not call the doctor and I don't recall why I did not call. Pain is subjective, usually if the pain medication is not working, I would notify the doctor to let them know that resident been complaining of pain and already medicated, maybe get a new order to relieve pain. On 12/15/20 at 1 PM, surveyor interviewed V2 (Director of Nursing) who stated, R14 had a fall. It was on a night shift. R14 had medication that she wanted sooner and that it was not able to be given. Nurse explained that she could not give pain medication to R14 because it was too soon. When V40 told R14 no and did not give medication, R14 called her Neurologist. I cannot remember the details but I know the nurse informed me of the fall. 911 came after the fall. It was R14 that called 911 per her neurologist instruction. R14 was transferred to hospital and she was discharge from the hospital back to R14's home. On 12/17/20 at 2:15 PM, R14's attending physician (V38) stated, I do not remember R14, she was only in the facility for a short period of time. R14 gets two [MEDICATION NAME] 50mg for pain every 6 hours as needed. I did not receive a call from the nurse, but in general, if the medication is ineffective and resident is still in pain and pain medication is too soon to be given, the nurses sometimes calls and informs me and maybe after our discussion I could order another pain medication. Pain management policy, with revision date of 7/14, reads in part: To facilitate and provide guidance on pain observation and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence and enhance dignity and life involvement. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Monitoring for effectiveness of interventions. Licensed nursing may notify Health Care Provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on individual's pain factors. If the pain has not been managed consistent with the resident's goal and needs the interdisciplinary team may need to reconsider current interventions and revise those interventions as needed.

Based on interview and record review the facility failed to have two staff present for transfer of one resident (R1), who was coded for two assist on the Minimum Data Set (MDS). This failure applied to one (R1) of three rsidents reviewed for falls and resulted in R1 sustaining a fall that resulted in a closed head injury. Findings include: 2/20/19 3:20 PM V5 (LPN-Licensed Practical Nurse) said that, I heard the (V6) CNA- Certified Nursing assistant calling out from R1's room. V6 said that as R1 sat in the wheelchair it collapsed. R1 was on the left side, there was some swelling in the back of the head. There was no loss of consciousness. R1 was sent to the hospital for assessment. The wheelchair was sent to maintenance to be checked. R1 recieved a different wheelchair from (hospice) when R1 returned from the hospital. 2/20/19 3:50 PM V6 said that, I was transferring R1 from the bed to the wheelchair. I was transferring R1 alone with a gait belt. The chair move with us toward the other bed. I lost my balance when the chair moved and I fell with R1. The brakes were locked on the wheelchair, it moved with the brakes locked. When maintenance came they checked the wheelchair. R1's progress note dated 2/6/19 11:15 by V5 reads; called to room by V6, noted lying on the floor on the left side. (V6) was transferring resident to the manual w/c (wheelchair) and the chair collapsed, resident immediately assessed for any injuries, protocol Leaf Huddle called, resident transferre to bed by mechanical life, no visible discoloration, or complaints of pain at this time, able to move extremities as prior to fall, upon assessment of resident's scalp area, a samll raised area noted, resident denies any pain or discomfort or nausea at this time, no blurred vision reported. The MDS (Mininum Data Set) dated 1/23/19 indicates that R1 uses a wheelchair. The MDS is coded 3/3 for transfer which means that R1 requires extensive assistance of two or two plus persons. A progress not dated 2/6/19 22:53 by V9 (LPN) reads; Resident admitted to (Hospital) with [DIAGNOSES REDACTED]. A CT (computerized tomography) scan report dated 2/6/19 by V11 (Physician) reads, impression: There is no evidence of acute intracranial abnormality. Mild age-related atrophic changes are identified. Soft tissue swelling overlying the left parietal region is noted. Minimal sinus disease is suspected. Emergency Documentation dated 2/6/19 by V12(Physician) reads, Diagnosis: [REDACTED]. Emergency Documentation Discharge Instructions dated 2/6/19 by R13 (Physcian) reads, Discharge Diagnosis: [REDACTED].

Based on interview and record review facility failed to provide toileting assistance for 1 of 3 residents (R1) reviewed for falls. This failure resulted in the facility not assisting R1 to use the washroom after she (R1) requested to go and subsequently R1 sustained a left shoulder and left knee fracture after attempting to get up on her own. Findings Include: R1 ' s minimum (MDS) data set [DATE] toilet use extensive assist one person; incontinent of bowel and bladder. E5 (Certified Nurse Aide) stated on 11-13-14 at 2:00 pm works regularly on the unit where R1 once resided and was assigned to took care of R1 on a regular basis. E5 stated R1 would urinate on herself but sometimes would let the staff know when she had to use the washroom and they would assist her to the toilet to urinate. E5 stated if a resident or R1 asks to use the washroom that she helps her go immediately or if she is helping another resident would ask another staff member to assist that resident to the washroom. E5 stated would not make a resident or R1 wait longer than 10 minutes to take them to the washroom. E4 (Licensed Practical Nurse) stated on 11-13-14 at 1:30 pm R1 was one of the residents she took care of on a daily basis. E4 stated R1 wanted to have her independence but had to remind frequently of what she couldn't do. E4 stated R1 was able to express to staff her needs or what she wanted. E4 stated R1 was incontinent and would be found wet at times. E4 stated on some occasions R1 would ask staff to help her use the washroom. E4 stated R1 had to be monitored because she was high risk for fall. E4 stated if R1 or any resident asked her to assist to the washroom would do it help that resident or get a staff member right away to assist that resident to the toilet. E4 stated because R1 liked her independence R1 needed constant to be reminding to wait for help to come because she would try to go to the washroom on her own. R1's care plan initiated 9-25-14 denotes R1 has an ADL self care performance deficit related to cognitive deficits, requires extensive assistance with ADL ' s transfers. Resident ambulates with staff assist. Incontinent bowel and bladder. Toilet use the resident requires extensive (1) staff participation to use toilet. E2 (Licensed Practical Nurse) stated on 11-13-14 was the nurse on duty for the fourth floor when R1 was discovered in her room on the floor on 10-30-14 at 6:45 am. E2 stated the fall occurred at approximately 6:45 am on 10-30-14 but prior to R1 ' s fall incident R1 had tried to get out of her bed without assistance wanting to go to the washroom at around 6:00 am. E2 stated she repositioned R1 back in the bed checked the bed alarm, floor mat and instructed R1 to wait for the CNA to come to help her use the washroom. E2 stated she gave R1 her six o ' clock medication at 6am then told R1 to wait that the CNA would be in to help her use the washroom. E2 stated she walked out of R1 ' s room and saw the CNA (E3) in another room giving care to another resident and told E3 that R1 needed toileting. E2 stated finished her morning medication pass and went back to the dining room to monitor the residents that were sitting there. E2 stated she did not take R1 to the washroom because she had to monitor the dayroom. E2 stated was sitting in the dining room at about 6:45 am when E3 called for help that R1 had fallen. E2 stated she went to R1's room and saw R1 on the floor on her left side. E2 stated R1 was assessed, doctor notified and X-ray ordered. E3 (Certified Nurse Aide) stated on 11-13-14 at 10:20 am was assigned to the fourth floor on 10-30-14 and was on E2 ' s team with her residents including R1. E3 stated normally works the third floor and was new and not familiar with the fourth floor residents. E3 stated while she was in R1's room in the washroom with R1's roommate she heard R1's alarm go off and stepped out of the washroom and observed R1 on the floor. E3 stated she called for assistance and E2 came to the room and assessed R1. E3 stated she was never told by E2 that R1 had to use the washroom prior to the fall because if she had knew that R1 neeed to use the washroom would have not gotten R1 ' s roommate up but instead would have assisted R1 to the washroom first. E3 denied that E2 told her that R1 needed to be toileted between 6:00- 6:45 am on 10-30-14. R1 ' s incident report dated 10-30-14 denotes type-fall, location resident ' s room, laying face down on the floor. Care prior to fall 6:00am. Time of fall 6:45 am. R1 ' s medication sheet denotes R1 received heparin 5000 unit injection subcutaneously. R1 ' s nurse note dated 10-30-14 denotes fall at 6:45 am with complaints of pain to left shoulder, arm and knee; X-ray ordered. R1 ' s nurse note dated 10-30-14 written at 12:50 pm denotes doctor notified X-ray results mid left patella suspect an acute nondisplaced fracture. Received orders to send R1 to hospital as direct admit. R1 ' s hospital record dated 10-31-4 denotes impression the X-rays revealed the patient (R1) status [REDACTED]. She (R1) also has left knee patellar fracture with minimal displacement. Will proceed with close management of left shoulder with immobilization sling. A knee immobilizer was applied to the left extremity for close management. Z2 (Doctor) stated on 11-14-14 at 9:00 am does not know what happened prior to fall but believes the fall caused the fracture to the left knee and shoulder. E1 (Director of Nursing) stated on 11-13-14 at 3:00 pm all residents should be toileted as soon as they call/request to go to the washroom. E1 stated no resident should have to wait no longer than ten minutes to use the washroom if they inform staff that they need to go. Facility ' s Activities Of Daily Living guidelines denotes activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. The ability of each resident to meet the demands of daily living is determined by a Licensed Nurse. A program of assistance and instructions in ADL skills is care planned and implemented. Procedure: Elimination assistance and instruction are given as required. R1 ' s [DIAGNOSES REDACTED].

Based on observation, record review and interviews, the facility failed to provide incontinence care to minimize exposure of skin to moisture; reposition residents who require total staff assist with bed mobility; follow manufacturer's recommendations for use of low air loss mattress; have pressure reducing devices in place, provide nutritional assessment went weight changes or new pressure ulcers are identified, encourage and assist residents at meal time for adequate protein and calorie intake to promote wound healing, provide wound treatments as order by the physician, apply wound medication according to it's intended use and inform the physician of a resident's newly identified pressure ulcer for treatment or a decline status (worsening) of an existing pressure ulcers. In addition, the wound treatment nurses did not demonstrate knowledge for treating wounds according to physician's orders [REDACTED]. These failures apply 12 to 12 residents (R1, R2, R3, R4, R5, R6, R23, R24, R25, R26, R27 and R48) identified with either a pressure ulcer or high risk for the development of a pressure ulcer in the sample of 47 residents. As a result of these failures R1, R2, R3, R4, and R6's existing acquired pressure ulcers increased in size and R4 developed a new pressure ulcer. On 8/22/14 an Immediate Jeopardy was identified to have begun on 8/21/14 when R1, R2, R3, R4, R6 were observed incontinent of bowel and bladder without being change over a two hour period, not being turned and/or repositioned within a two hour period, not having pressure relieving measures for bony pressure areas and while in bed as care planned or directed and wound treatment not performed as ordered. On 8/22/14 at 11:10am, E1 (Administrator) and E2 (Director of Nursing) were informed of the immediate jeopardy. While it was determined by the team the immediacy was removed on 8/22/14 at 5:45pm, the facility remains out of compliance at a severity level two. The facility needs to implement care intervention, monitor the intervention and evaluate the effectiveness of the facility's staff education and develop and revise policies and procedures and monitor their implementation. Findings include: 1. During initial observation of R1 on 8/20/14 at approximately 11:45am, R1 was in bed, awake and non-verbal. Z3 (Family) was present and stated she's visiting with R1 today because she received a call from the facility regarding development of sores on R1's back side which is draining and infected. Pressure sore risk assessment dated 8/18/14 shows R1 at high risk for pressure sore development with a risk score of 12, related to completely limited sensory perception, limited bed mobility, bedfast and very moist skin. R1 required 2 persons physical assist with bed mobility. -On 8/21/14 at approximately 5:20pm, R1 was in bed with a foul body odor. E3 (Wound Care Coordinator) was present, preparing to conduct wound assessment. R1 was lying on a regular mattress, not an low air loss mattress. R1 was soiled with urine and feces. E25 (Certified Nurses Aid) was present and provided incontinent care for R1. R1 was wearing foam padded boots and when removed by E3, a pressure sore was observed on the left plantar foot. There was no dressing in place to which E3 stated "it must have fallen off." E3 assessed this wound as a Stage 2. There was minimal drainage noted at the wound site. The wound was measured at 1cm x 1.2cm. Wound assessment documentation dated 8/18/14 shows this wound was initially assessed on 8/18/14 with measurements of 0.8cm x 1.0cm. The assessment identified this wound as a facility acquired skin tear. R1's right heel was noted to have a distinct area of redness. This site was assessed to be healed on 7/14/14 and treatment orders were discontinued. E3 acknowledged the redness and stated the site will be monitored. E3 stated that "the redness is non-blanchable which is not a concern." E2 (Director of Nursing) was unable to provide pressure sore staging guidelines upon request. The National Pressure Ulcer Advisory Panel's (NPUAP) literature on non-blanchable skin states this would be classified as a Stage I pressure ulcer. There was an open wound on R1's Right Iliac Crest which measures 1.8cm x 2.1cm. Wound assessment documentation dated 8/18/14 identifies this wound as a facility acquired skin tear measuring 1.3cm x 1.8cm. R1 is not listed on the facility's wound report dated 8/21/14. -Z2 (Wound Physician) stated on 8/22/14 at 11:35am she has never assessed R1 and was not aware that R1 has wounds. R1 was added to her referral list today (8/22/14) and she (Z2) plans to assess R1 today if time permits. Z2 stated she depends on staff to inform her of which residents are to be evaluated. -E26 (Registered dietitian) stated on 8/22/14 at approximately 10:45am that she assessed R1 nutritional status today in response to new Stage 2 wound on right Illiac Crest and R1 protein intake needed to be increased promote healing of newly acquired wounds. E26 stated prior to today she did not recognize the need for additional protein intake for R1. 2. R2 was admitted to facility with [DIAGNOSES REDACTED]. -Wound Assessment Report dated 6/19/14 shows the facility identified R2 with a stage 2 pressure ulcer to left heel was present on admission. Another report dated 6/27/14 shows R2 acquired an unstageable pressure ulcer to right outer ankle. On 8/14/14, R2 was identified with a stage 2 pressure ulcer on sacrum and a moisture associated skin damage behind R2's scrotum that were present on re-admission 8/13/14. -On 8/21/14 at 11:16am, E11 (wound care nurse) performed wound care to R2's wounds and E21 CNA (Certified Nurse Aide/ CNA) assisted with positioning R2. R2 was incontinent of stool. E21 stated R2's was last checked and incontinence care provided at 8:30am. Facility's skin protection policy states residents are to be checked for incontinence at least every two hours. R2's the left heel pressure ulcer measurement was 1.8cm(centimeters) length x 2cm width. Review of Wound Assessment Details Report dated 8/18/14 indicates wound measurement was 1.10cm x 1.10cm which indicates a deterioration of wound. E11 stated R2's right outer ankle dressing was not due to be changed today. Review of physician orders [REDACTED]. Review of the TAR (Treatment Administration Record), indicates right outer ankle dressing was last changed on 8/16/14, 5 days prior. It was noted by surveyor that R2's sacral wound dressing had brown discoloration and was not securely attached to R2's skin. E11 stated the sacral wound was not due to be treated today because it was just changed. Review of physician orders [REDACTED]. R2's treatment administration record (TAR) indicated the sacral dressing was last changed on 8/16/14, 5 days prior. Treatment to this site was not done according to physician's orders [REDACTED]. According to E11, the excoriated area behind R2's scrotum is moisture related. Measurements were not obtained for this area prior to applying [MEDICATION NAME] ointment. Review of physician orders [REDACTED]. Review of TAR indicates R2 did not receive this treatment on 8/19/14. -On 8/20/14 at 10:55am, R2 was lying in bed and stated it has been mush more that two hours since he has been repositioned. R2 also stated he does not know the last time he was transferred out of bed. -On 8/22/14 at 11:50am, E4 (Certified Nurses Aid- CNA)stated music is played over the intercom to indicate when it is time to turn residents. On 8/22/14 at 12:30pm, E5 (Nurse) stated she has a reference card attached to her name badge noting times residents are to be turned and music is played over intercom to notify staff to turn residents. E5 also stated she last heard music between 10:00am and 10:30am, more than two hours prior. E5 stated R2 was transferred to current room in July, 2014, and has been on bedrest since then. E5 said at that time, the wound team instructed nursing staff not to get R2 out of bed until further notice. -Review of physician orders [REDACTED]. E26's (Registered Dietitian) dietary notes dated 8/19/14 states R2's tube feeding is adequate to promote wound healing and weight gain. On 8/22/14 at approximately 11:45am, E26 stated she re-assessed R2 and recommended increasing R2's protein intake based on wound healing concerns. 3. On 8/20/14 at 10:15am, R3 was observed in bed lying on her left side, awake, alert with inaudible speech, poor oral hygiene and an odor of feces near R3's bed. E21 (Nurse) was present and stated that R3 has a history of Cerebro-vascular Accident ([MEDICAL CONDITION]), is aphasic and has contractures in all four extremities. E21 also stated that R3 is totally dependent on staff for all activities of daily living (ADL's) including toileting and bed mobility, and requires hourly monitoring by staff and has a pressure sore. R3 was lying on an adjustable low air loss mattress at maximum pressure distribution at a setting of 800 - 1000 pounds. R3 weighs 90 pounds. R3's foam boots were observed on the window ledge to which E21 stated that R3 requires off-loading of the heels and should be wearing the boots at all times while in bed. E21 proceeded to check R3 for incontinence and noted R3 was incontinent of bladder and bowel. E21 asked E22 (Certified Nurses' Aid - CNA) and E23 (CNA) to provide incontinent care for R3. At approximately 10:40am, while receiving incontinent care, R3 was noted to have a dressing on the sacrum which was soiled with urine and feces. R3's perineum was observed to be red and excoriated. E11 (Wound Treatment Nurse ) was present in R3's room to perform wound treatment. E11 removed R3's sacral wound dressing to reveal a Stage 4 ulcer with gauze packing, copious amount of sero-sanguineous drainage and a foul odor. R3's wound was not clearly visible because there was very poor lighting near R3's bed. E11 was observed to apply Santyl to healthy tissue surrounding the wound and [MEDICATION NAME] using a wooden spatula. E11 then used several dry gauze pads to pack the Stage 4 wound. E11 stated R3 has large amount of drainage and she (E11) decided it best to use the gauze packing. E11 could not recall if the application of the gauze packing is part of the physician's treatment order. R3's physician's orders [REDACTED]." There was no order for use of packing to the wound. Upon completion of wound treatment, E11 and E23 changed R3's disposable incontinent brief and quilted pad by pulling these items under R3 exposing R3's skin to possible friction. R3 was left on her left side. -On 8/21/14 at 4:15pm E3 (Wound Treatment Coordinator) was observed performing wound assessment and treatment for [REDACTED]. R3's buttocks and perineum was again noted to be red and excoriated to which E3 stated R3 has [MEDICAL CONDITION] as a result of incontinence. R3's gauze packing was noted to be saturated and there was large amount of necrotic tissue and slough in the wound bed. The perimeter of the wound was red. E3 attempted to obtain wound measurements in poor lighting. Surveyor illuminated the wound site using a flash light to provide better view of the wound. E3 obtained measurements of 6.5cm (centimeters) X 9.0cm X 2.5cm with 3.0cm - 3.5cm undermining. R3's previous wound measurements dated 8/13/14 shows measurements of 7.5cm x 7.7cm x 3.0cm. E3 applied a large amount of Santyl mixed with [MEDICATION NAME] preparation filling the wound cavity, applied gauze packing to the wound, dispersing Santyl to the healthy surrounding tissue and covered the wound with an abdominal pad. E3 then applied barrier cream to the excoriated areas of buttocks and perineum stating the CNAs will be monitoring the redness. -On 8/20/14 and 8/21/14, R3's adjustable low air flow mattress was observed to be at a setting of 800 - 1000 pounds. Manufacturer's recommendation for use of this mattress states "adjust the support surface pressure using the patient weight buttons on the control panel to the appropriate weight. This facilitates blood circulation and provides maximum body tissue redistribution for treating and prevention pressure ulcers" The recommendations also state it is recommended to limit bed linens to one sheet in order to maximize the system's performance. R3's weight measurement obtained 8/19/14 shows a weight of 90.4 pounds. -R3's Care Plan dated 6/16/14 stated: R3 was admitted on [DATE] with deep tissue injury to the sacrum. Interventions included daily skin treatment, reduce sacral pressure, maintain low air loss mattress while in bed to prevent further deterioration. Care Plan 6/30/14 states R3 is at high risk for impairment of skin integrity due to contractures and decreased mobility. The care plan does not address R3 needs for total assist with bed mobility, need for frequent turning and repositioning and incontinent care. -During an interview with Z2 (Wound Physician) on 8/22/14 at approximately 11:35am, Z2 stated R3 was recently treated with antibiotics for an infection at the pressure ulcer site. Z2 stated she was not made aware of R3's further deteriorating wound. Z2 also stated that Santyl is used for [MEDICATION NAME] wounds and should not be applied to R3's healthy skin and R3's wound requires a wet gauze packing, not a dry packing. 4. R4 is an seventy six year (76) old resident admitted to the facility on [DATE] with intact skin, [DIAGNOSES REDACTED]. Braden scale: 15 or 16 = low risk, 13 or 14 = moderate risk, 12 or 15 = high risk -On 8/20/2014, at 10:15 am, R4 was observed laying on a regular mattress, with a deflated air mattress under the regular mattress. In addition, R4's heel protectors were noted on the floor under R4's bed. There was no off-loading of R4's heels during this same observation. R4 was observed from 10:15 am through 1:00 pm, during 15 minute intervals while she remained in the room. The staff did not enter R4's room to provide turning, repositioning and toileting. -On 8/20/2014 at 1:10 pm, E18 ( CNA) was asked to assess R4 for incontinence. R4 was incontinent of stool which appeared dry. R4 has a urinary catheter. R4's disposable brief was overly saturated with urine. E18 was asked how often should R4 be repositioned. E18 stated all residents should be turned and repositioned every two hours. E18 was also asked why was R4 laying on a regular mattress with a deflated air mattress underneath the regular mattress. E18 stated " I have no idea." -On 8/21/2014 at 9:45 am, R4 was observed still laying on a regular mattress with the deflated air mattress underneath the regular mattress. R4 was observed laying on right side?. It was also noted there was no off loading of R4's heels. E3 (Wound Treatment coordinator) was present and stated R4 should have an air mattress. -On 8/21/2014 at approximately 12:00 pm 1: 30 pm , during initial wound treatment observations, R4 was incontinent of stool which covered the urinary catheter, and sacral wound. E3 (Wound care coordinator) and E11 (Wound Treatment nurse) provided incontinence care and then proceeded with dressing changes for R4. The wounds were noted as follows: R4's Sacrum healing Stage 3 with measurements at 1.5cm centimeters length x 1.5 width, exudates was noted on old dressing. The facility's wound assessment report dated 8/18/2014, classified wound as a pressure ulcer. Measurements on 8/18/2014 reflect 1.50 cm length x 1.00 width, and a 0.20 depth. The facility's wound assessment report denotes the pressure ulcer was facility acquired. R4's right trochanter (hip), Stage 3 healing wound. There were no measurements obtained. The facility's wound report dated 8/18/2014, classify the wound as a pressure ulcer. The facility's wound report denotes the pressure ulcer was facility acquired. R4's left lateral foot- Stage 2 pressure ulcer showed measurements of 1.0cm length x 1.5cm width. The dressing was saturated with blood. The facility's treatment record dated 8/18/2014, did not document the fact that there was a left lateral foot pressure ulcer. E3 cleansed this wound with normal saline and applied santyl to the wound and covered the wound with a dry dressing. The physician's orders [REDACTED]. E3 and E11 could not contest to the development of the left lateral foot pressure ulcer. E3 and E11 could not confirm if Z2 (wound care physician) was aware of the left lateral foot pressure ulcer. Wound report dated 8/20/14 stated this pressure ulcer was facility acquired. R4's left heel pressure ulcer shows measurements of 5.5cm length x 4.4cm (width) x 0.3cm (depth) - Stage 3. Left heel pressure ulcer with measurements of 1.5 cm length x 1.5 cm width. The facility's wound report dated 8/18/2014, classifies the wound as a pressure related ulcers. Measurements on 8/18/2014 reflect 3.50 cm length x 5.30 cm width. The facility's wound assessment report denotes that the Left heel pressure ulcer was facility acquired. R4's right medial foot pressure ulcer measures of 2.6 cm length x 2.8 width, with a depth of 0.3 cm- Stage 2- Beefy red appearance. The facility's wound report dated 8/18/2014, classify the wound as a pressure ulcer. Measurements on 8/18/2014 reflect 3.0 cm length x 2.50 width, and 0.20 cm depth. The facilities wound assessment report denotes the pressure ulcer was facility acquired. R4's care plan dated 4/17/13 denotes R4 has limited ability to move upper and lower extremities through full range of motion related to weakness. Pressure risk score reflects 12, showing high risk for developing pressure ulcers. Care plan denotes R4 to be turned every two hours, kept clean and dry, off loading of heels, and apply pressure reduction or low air loss mattress therapy and pressure relieving cushion when up in wheel chair. -On 8/20/2014 and 8/21/2014, at approximately 12:45 pm, R4's lunch (mechanical soft diet) tray was sitting on his bedside table. R4 did not receive assistance with his lunch meal. At least 90% of R4's lunch meal was not consumed. E27 (CNA) was present during this observation and was asked if R4 required assistance with meals. E27 stated "he feeds himself." -E26's ( registered dietician) progress notes dated 8/20/14 denotes R4 requires assistance with meals. E26 (Registered Dietitian) stated on 8/22/14 at 11:45am residents with pressure sores require a higher intake of calories and protein in their diet to promote wound healing. On 8/22/14 at approximately 10:45am, E26 stated she assesses R4's nutritional status on a monthly basis. E26 stated at the time of her 8/20/14 assessment, there were no updated wound report for R4 and she (E26) based her recommendations on wound report of 8/13/14. E26 also stated she was not made aware of R4's recent weight loss. Over what time period was this weight loss? R4 care plan dated 7/10 2014 denotes R4 has the potential for alteration in nutrition related to chewing difficulty requires encouragement and assistance with meals to ensure proper nutritional intake. R4's weight tracking record denotes R4 has lost a total of 10 pounds in one month (7.5%). 5. Closed record review denotes R5 was admitted to facility on 4/22/2014. R5 is a [AGE] year old diagnosed with [REDACTED]. -The facility's weekly wound assessment report dated 5/12/14 denotes R5 acquired a " superficial sacrum wound, due to moisture associated skin damage". On 5/12/2014, the wound was measured at 7.50 cm length x 1.50 cm width. The facility's weekly wound report dated 7/21/2014 denotes, R5 acquired a " buttock wound. " The facility classified the wound as full thickness, and related the wound to incontinence. On 7/21/2014 the wound was measured at 8.00 centimeters x 5.50 width. There were no documented clinical records that addressed the onset and progression of this wound. In addition, there were no daily skin assessments provided by the facility upon request. -The facility's weekly wound report dated 7/25/2014 denotes, R5's buttock wound measured 6.00 cm length x 7.50 cm width x 4.00 cm depth. The wound report further detailed that the wound had a foul odor with a large amount of exudates. Z2(wound physician) referred R5 to a surgeon for debridement. -R5's care plan dated 4/24/24 states R5's Braden scale was 13, which put R5 at moderate risk for skin breakdown. Care plan further stated that, R5 required assistance to turn and reposition every two hours. The facility did not provide a care plan for R5's buttock wound nor a wound prevention protocol. -R5's hospital medical records denotes, R5 presented to the hospital on [DATE], febrile, and with a 2-3 centimeter severe sacral pressure ulcer that look like there was communication between the skin and the rectum, with drainage that look and smelled liked feces. R5 was also diagnosed with [REDACTED]. On 7/26 /2014, R5 was admitted to local hospital due to the infected buttock wound, R5 was placed under the supervision of an infectious disease physician. 6. R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6's Weekly wound report dated 8/17/14 indicates the facility identified R6 with an acquired Stage 2 sacral pressure ulcer (10 days after admission). This report dated 8/18/14 showed R6 also acquired a right heel deep tissue injury (11 days after admission). R6's pressure sore risk assessment dated [DATE] shows R6 scored at "12" which signifies high risk for developing pressure sore. Facility's Skin Prevention policy dated 5/14 states "skin checks will be completed daily for at risk residents." After several requests for skin check documentation for R6, none was provided. -On 8/21/14 at 9:40am R6 was observed in bed, incontinent of bowel. E3 was present to perform wound care with E9 (Nurse) assisting with positioning of R6. A sacral dressing was noted to not be securely attached to R6's skin. E3 removed the sacral dressing and there was feces present in wound. Wound measurement obtained as 5cm length x 4.2cm width. Wound Assessment Details Report dated 8/17/14 indicates wound measurement was 4.5cm length x 2cm width. R6's right heel dressing was removed and wound measured 2.4cm length x 3.4cm width. Wound Assessment Details Report dated 8/18/14 indicates wound measurement was 2cm length x 3.3cm width. E3 was observed to apply skin preparation solution to entire wound and surrounding tissue. On 8/21/14 at 11:23am, E11 stated skin prep is applied to surrounding tissue; it goes on the outside of wound not on the wound. 7. On 8/20/2014 from 10:00 am to 12:40 pm every fifteen interval observations were made while residents were in the dining room area. During this time period, R23, R24, R25, R26, and R27 were not turned, repositioned, or assessed for incontinence while in this area. These residents remained in their wheel chairs over this time period and all require staff assist for mobility and toileting and at risk for skin breakdown. E18 (CNA) was monitoring the dinning room and was asked what was the facility's policy regarding turning and repositioning residents who are compromised, and unable to independently turn and reposition themselves in bed, or when up in a chair. E18 stated "we're suppose to check them every two hours and before lunch." E18 was also asked who was responsible for assessing the residents' for incontinence when the residents are in the dining room area. E18 stated, when a CNA monitors the dining room, they are responsible for checking the residents' for incontinence. According to E18; R23, R24, R25, R26, and R27 had not been assessed for incontinence since 9:00 am (more than 3 hours prior). -R23 care plan dated 8/7/14 shows [DIAGNOSES REDACTED]. R23 cannot independently perform activities of daily living. R23 was noted to be sitting in a reclining chair and wearing an incontinent brief due to incontinence. Care plan denotes R23 is incontinent of bowel and bladder related to decreased mobility. Intervention denotes assessment for incontinence every two hours, provide total assistance when necessary, check skin daily, and to keep skin clean and dry. 8/20/14 at 12:50 pm E18 was asked to escort R23 to their assigned room to assess for incontinence. R23's diaper was saturated with urine. During this same observation Z5 (family member) was present and stated "my sister is always soaking wet; this happens all the time." R23's care plan dated shows R23 is at risk for impaired skin integrity. Braden score reflects 14 which puts R23 at moderate risk for developing pressure ulcers. 8. 8/20/14 at 12:57 pm, E18 was asked to escort R24 to the assigned room. R24 is prescribed a wheel chair. R24's incontinent brief was saturated with urine. R24 is diagnosed with [REDACTED]. Care plan dated 7/21/2014, denotes R24 is incontinent of bowel and bladder and is unable to inform staff of need to void. Interventions reflect turning and repositioning every two hours, assess for incontinence every two hours, skin checks daily and R24 to be kept clean and dry. R24 is at risk for impaired skin integrity. Braden score reflects 12 which puts R24 at high risk for developing a pressure ulcer. 9. R25 is diagnosed with [REDACTED]. R25 is prescribed a wheel chair. Care plan dated 4/22/2014, denotes R25 is incontinent of bowel and bladder and is unable to inform staff of need to void. Interventions reflect turning and repositioning every two hours, assess for incontinence every two hours, skin checks daily and R25 to be kept clean and dry. R25 is at risk for impaired skin integrity. Braden score reflects 19. 8/20/14 at 1:10 pm, E18 ( CNA) was asked to escort R25 to the assigned room. R25's incontinent brief was saturated with urine. 10. R26 is diagnosed with [REDACTED]. R26's care plan dated 8/25/2014, denotes R26 is incontinent of bowel and bladder and is unable to inform staff of need to void. Interventions reflect turning and repositioning every two hours, assess for incontinence every two hours, skin checks daily, and R26 to be kept clean and dry. R26 is at high risk for impaired skin integrity. Braden score reflects 17. 8/20/14 at approximately 1:30 pm E18 was asked to escort R26 to the assigned room. R26's incontinent brief to be saturated with urine. 11. R27 is diagnosed with [REDACTED]. Care plan dated 5/28/2014, denotes R27 is incontinent of bowel and bladder and is unable to inform staff of need to void. Interventions reflect turning and repositioning every two hours, assess for incontinence every two hours, skin checks daily, and R27 to be kept clean and dry. R27 is at high risk for impaired skin integrity. Braden score reflects 11. 8/20/14 at 1:30 pm E18 was asked to escort R27 to the assigned room. R27's incontinent brief to be saturated with urine. 12. R48 ' s closed record review of R48 ' s wound assessments shows R48 was admitted to the facility on [DATE] pressure sores to the left ear (Stage 2), right ear (Deep tissue injury), right shoulder (unstagable), left below knee amputation (BKA) stump (unstagable), right BKA stump (unstagable), sacrum (Stage 4), right ischial tuberosity (Stage 3). On 4/18/14 a new unstagable right elbow wound was identified. The right BKA stump wound increased in size on 5/8/14. There was gradual deterioration of this wound from unstagable to Stage 4, the left BKA stump wound from unstagable to Stage 3 and sacral wound which increased in size. R48 received ultra sound therapy to the sacral wound and required the use of a [DEVICE]. There was documented on 6/21/14 regarding odor to the wound. Nursing notes dated 6/27/14 states R48 developed a change in condition and sent out to the hospital for evaluation. emergency room notes states R48 ' s wounds were mal-odorous and R48 required antibiotic regimen. E34 (Wound treatment Nurse) stated on 9/25/14 she provided wound treatments for R48 throughout her stay in the facility. E34 ' s most recent skin assessment and wound treatment was conducted on 6/27/14, the day of R48 ' s discharge. Regarding her assessments of R48 ' s wounds E34 stated she never noted any foul odor to the wounds. E34 went on to say that R48 was receiving " mist therapy " by physical therapy department to the wounds which was done prior to her assessments. E34 stated may be the reason why she did not detect any odors because the mist therapy washed out the wound. E34 admitted to not assessing R48 ' s right ear wound on 6/9/14; not identifying the left Ischium wound as facility acquired and documented it was present on admission; did not identify the specific location of a " posterior knee " wound and did not identify a Stage 2 wound to R48 ' s left upper back which was noted in the emergency room records. 13. On 8/22/14 at approximately 11:35am, Z2 (Wound physician) stated the timely turning and repositioning of residents, minimizing skin exposure to moisture, utilizing pressure relieving measures and providing adequate nutritional intake are necessary factors to prevent development of and worsening of pressure sores. Z2 further stated that she has been working at the facility for approximately one month and is present in the facility 2 days each week. Nursing personnel provides a list of the residents to be seen during the wound rounds. Wound assessments are performed upon nursing recommendation. Z2 stated that she is available by phone and expects nursing personnel to contact her if there are signs of new skin breakdown or deterioration of wounds. There has been no reports of newly acquired nor deterioration of wounds from facility staff. Z2 went on to say that she had no knowledge of the high prevalence of facility acquired wounds and stated she has no opinion of the amount of acquired pressure in the facility because she is new and has not yet identified an interdisciplinary wound management team. E1 (Administrator) stated during an interview on 8/22/14 at approximately 11:30am that she is new to the facility (less than 1 month) and is not knowledgeable about the facility's quality of care concerns. E1 stated that the Quality Assurance committee identified wound management as an area of concern in the facility. The Committee also identified a concern regarding staff's failure to implement recommendations to improve wound management. The Committee also recommended the use of "Shake, Rattle and Roll" music to be played over the intercom to indicate and remind staff to reposition residents. The Committee, in June 2014, decided that the facility's wound care team will work with the new wound physician to ensure that all are on the same page for documentation and care/treatment routines. The Committee has focus on the development of heel wounds and staff will monitoring the compliance with off-loading of residents' heels. During observation, on 8/20/14, 8/21/14, 8/22/14 the music for repositioning residents could be heard over the intercom approximately 1-2 times during 8 hour period. The facility's Turning and Repositioning Program policy dated 11/03 does not

Based on observation, interviews and record reviews, the facility neglected to follow and implement care plan interventions and established policies governing the care and treatment for [REDACTED]. This failure applies to 6 of 6 residents (R1, R2, R3, R4, R5 and R6) reviewed for pressure ulcer, in a sample of 47. As a result, R1, R2, R3, R4, R6 experienced a decline (worsening) of pressure sores. Findings include: E1(administrator) presented to the surveyor the following policy for pressure ulcer treatment. Facility's undated Skin and Wound Care Protocol statest for "All residents considered at high risk, pressure reducing beds and cushions are implemented regardless of the site of the lesion." The Skin Prevention policy dated 5/14 states "Interventions will be put into place based on risks identified and to include turning and repositioning every 2 hours; level 2 support surfaces; preventive foot care; overlays or wheelchair cushions; incontinent care at least every two hours. In addition, the facility's policy for Change In The Resident's Condition dated 7/08 states "should there be a change in the resident's physical, mental or emotional status, the attending physician should be notified. If the attending physician does not respond within 30 minutes, contact the medical director. -R1 was admitted to the facility on [DATE]. Care plan dated 7/30/14 states R1 has cognitive, physical and communication deficit, incontinent of bowel and bladder, factors that put her at risk for skin breakdown. On 8/21/14 at approximately 5:20pm, R1 was in bed with a foul body odor. R1 was lying on a quilted pad, wearing a disposable diaper and incontinent of bowel and bladder. R1 was lying on a regular mattress. R1's care plan shows R1 has skin breakdown to her right illiac crest, right hand and left plantar foot. Interventions includes use of low air loss mattress while in bed. During 8/20/ 8/21 and 8/22/2014, R1 remianed in bed with no low air loss mattress in place. E3 (Wound Treatment Coordinator) was present during these observation and assessed the facility acquired wound on R1's left plantar foot. The wound was measure at 1cm(centimeters) lenght x 1.2cm width. The wound assessment documentation dated 8/18/14 shows this wound has increased in size from 0.8cm x 1.0cm. There was no evidence found to demostrate the physician was notified. R1's right heel was also noted to have a distinct area of redness. E3 acknowledged the redness and stated the site will be monitored. E3 did notdobtain measurements of this wound. There was an open wound on R1's Right Illiac Crest which measures 1.8cm x 2.1cm. Wound assessment documentation dated 8/18/14 identifies this wound as a facility acquired skin tear measuring 1.3cm x 1.8cm. E3 also stated R1 should have been provided a low air loss mattress. - R2 was admitted to facility with [DIAGNOSES REDACTED]. On 8/21/14 at 11:16am, R2 was lying in bed incontinent of stool. E21 (Certified Nurses Aide) was present and stated R2's incontinent brief was last changed at 8:30am (more than 2 hours prior). E11 (wound care nurse- LPN) was also present and performed wound assessment and treatment to R2 ' s left heel wound. This wound showed a measurement of 1.8cm (centimeters) x 2cm. This was a deterioration according to the wound assessment dated [DATE] which shows measurement of 1.10cm x 1.10cm. Wound Assessment Report dated 6/27/14 showed R2 acquired an unstageable pressure ulcer to right outer ankle. On 8/14/14, R2 was identified with a stage 2 pressure ulcer on sacrum and a wound behind R2's scrotum that were present on readmission 8/13/14. R2 was noted to have an large area of excoriation behind the scrotum. E11 acknowledged this excoriated and failed to conduct an assessment and stated the redenned area is moisture related. On 8/20/14 at 10:55am, R2 was lying in bed and stated he has not been turned in a long time. R2 also stated he does not know the last time he was transfered out of bed. - On 8/21/14 at approximately 10:15am, R3 was observed in bed lying on her left side, awake, alert with inaudible speech, poor oral hygiene and an odor of feces near R3's bed. R3's care plan dated 6/16/14 states R3 has impaired skin integrity, decreased mobility, incontinent of bowel and bladder and has contractures. On 6/16/14 R3 was assessed with [REDACTED]. R3 was lying on an adjustable low air loss mattress set at maximum pressure required for residents' weighing 800 - 1000 pounds. Manufacturer's recommendation for use of this mattress states "adjust the support surface pressure using the patient weight buttons on the control panel to the appropriate weight. This facilitates blood circulation and provides maximum body tissue redistribution for treating and prevention pressure ulcers" R3's weight measurement obtained 8/19/14 shows a weight of 90.4 pounds. R3's foam boots were observed on the window ledge to which E21 (Nurse) stated R3 requires off-loading of the heels and should be wearing the boots at all times. R3 was noted to be incontinent of bladder and bowel and the perineum was observed to be red and excoriated. E11 (nurse) and E23 (Certified Nurses Aid) changed R3's disposable diaper and quilted pad by pulling these items under R3 exposing R3's skin to friction. R3 was left on her left side. On 8/21/14 at approximately 4:15pm R3 was found to be incontinent of both bowel and bladder and sacral dressing soiled. R3's buttocks and perineum was again noted to be red and excoriated to which E3 stated R3 has [MEDICAL CONDITION] as a result of incontinence. R3's deep tissue injury identified on 6/16/14 was now a Stage IV pressure ulcer. Based on new measurements obtained at the time of observation, R3's wound has further deteriorated over 7 days. - R4's face sheet states R4 is an seventy six year (76) old resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 8/20/2014 at approximately 10:15 am, R4 was observed laying on a regular mattress, with a deflated air loss mattress under the regular mattress. In addition, R4's heel protectors were noted on the floor under R4's bed. There was no off-loading of R4's heels. Based on direct observation from 10:15am through 1:00pm, R4 remained on his left side without turning and repositioning from nursing staff. On 8/20/2014 at approximately 1:10 pm E18 (CNA)) was asked to assess R4 for incontinence. R4 was incontinent of urine and stool. R4's incontinent brief was overly saturated with urine and dried stool. E18 was asked how often should R4 be repositioned. E18 stated all residents should be turned and repositioned every two hours. E18 was also asked why was R4 laying on a regular mattress with deflated air mattress underneath the regular mattress. E18 stated," I have no idea. " On 8/21/2014 at 9:45 am, R4 was observed still laying on a regular mattress on his right side. It was also noted there was no off loading of R4s heels. E3 (Wound Treatment coordinator) was present and stated R4 should have an air mattress. On 8/21/2014 at approximately 12:00 pm, during wound care observations, R4 was incontinent of stool. R4 has a urinary catheter which was covered with dried stool. In addition R4 was observed laying on right side. Wound assessment reports shows R4 has wounds to left heel, right medial foot. right trochanter and sacrum, all acquired in the facility R4's care plan dated 7/10 2014 states R4'S Braden score reflects 12, to be turned every two hours, kept clean and dry, off loading of heels, and apply pressure reduction or low air loss mattress therapy and pressure relieving cushion when up in wheel chair. -On 8/21/14 at 9:40am R6 was observed in bed, incontinent of bowel. R6's [DIAGNOSES REDACTED]. R6 also has an acquired a stage 2 sacral pressure ulcer and an acquired right heel deep tissue injury. R6 has limited bed mobility and is incontinent of bowel and bladder. R6 also has an acquired a stage 2 sacral pressure ulcer and an acquired right heel deep tissue injury. R6 has limited bed mobility and is incontinent of bowel and bladder. -According to R5's closed record, R5 was admitted to facility on 4/22/2014. R5 is a [AGE] year old diagnosed with [REDACTED]. The facility's weekly wound assessment report dated 5/12/14 denotes R5 acquired a " superficial sacrum wound, due to moisture associated skin damage ." On 5/12/2014, the wound was measured at 7.50 centimeters x 1.50 width. The facility's weekly wound report dated 7/21/2014 denotes, R5 acquired a " buttock wound " which is classified as a full thickness, and related the wound development due to incontinence. On 7/21/2014 the wound was measured at 8.00 centimeters x 5.50 width. The facility's weekly wound report dated 7/25/2014 denotes, R5's buttock wound measured 6.00 centimeters x 7.50 width x 4.00 depth. The wound report further detailed that the wound had a foul odor with a large amount of exudates. Z2(wound physician) referred R5 to a surgeon for debridement. R5 was admitted to local hospital due to the infected buttock wound and under the supervision of an infectious disease physician. The facility documented the wound as facility acquired. There were no documented clinical records that addressed the onset and progression of this wound. In addition, there were no daily skin assessments provided by the facility. A review of R5's care plan dated 4/24/24 states R5's Braden scale was 13, which put R5 at moderate risk for skin breakdown. Care plan further stated that, R5 required assistance to turn and reposition every two hours. The facility did not provide a care plan for R5's buttock wound nor a wound prevention protocol. A review of R5's hospital medical records denotes, R5 presented to the hospital on [DATE], febrile, and 2-3 centimeter severe sacral decubitus ulcer that look like there was communication between the skin and the rectum, with drainage that look and smelled liked feces. R5 was also diagnosed with [REDACTED]. On 7/26 /2014, R 5 was full admitted to local hospital due to the infected buttock wound, R5 was placed under the supervision of an infectious disease physician.

Based on observations, record reviews and interviews the facility failed to provide care to an unresponsive resident for over one hour and failed to monitor blood glucose levels for 1 of 3 residents (R1) who are insulin dependent in of a total sample size of 20. R1 was transferred to the hospital unresponsive with a severe low blood glucose level of 18 and noted to suffer permanent [MEDICAL CONDITION] from prolonged [DIAGNOSES REDACTED]. Findings Include: R1 was observed in bed starring directly up at the ceiling. R1 does not respond to the staff for verbal or tactile stimuli. R1 is incontinent of stool and has a sacral pressure sore along with being in isolation from an acquired infection. R1 also has a [MEDICAL TREATMENT] catheter (AV fistula) in her right arm. R1 is an [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R1 ' s emergency room records dated 8-31-13 at 9:38AM notes the following " patient with decelerated rigidity and clonic activity ([MEDICAL CONDITION]) during exam. Suspect patient has suffered permanent [MEDICAL CONDITION] from prolonged [DIAGNOSES REDACTED]. " Review of the nursing notes from 8-31-13 at 8:00AM denotes; " R1 was unresponsive to verbal and tactile stimuli. Notified Z2 (R1's physician) and he ordered to send her out. " E14 (Staff Nurse) explained on 10-3-13 at 1:30PM, "she assess R1 sleeping in bed at the beginning of the shift at 7:00AM. E14 stated she returned to R1 ' s room and made an assessment around 8:00AM of R1 ' s unresponsiveness. E14 stated after she obtain an order from the physician to sent R1 out to the hospital she than call to the family. E14 stated the family member decided not to send R1 out to the hospital because they were afraid of the hospital putting R1 on life support system or a on a ventilator. Then the family member called back a few minutes later and agreed to have R1 to go to the hospital. E14 stated the family was the reasons why there was a delay, they did not want her to go to the hospital. E14 had no comments as to why the physician orders were not implemented immediately based upon the physical assessment of R1 being unresponsive. Z4 (Ambulance Company) stated on 10-7-13 at 9:30AM the following; " The call came in at 8:50AM, the paramedics arrived at 9:03AM and departed from facility 9:31AM and arrived at the emergency room at 9:39AM. The paramedics found R1 unresponsive and blood glucose was 40 (normal level 80 to 120). There was an attempt to start an intravenous line but failed twice. Glycogen 1 mg given intramuscularly, but no results while in facility. R1 ' s normal behavior is alert and oriented to person and self at times and verbal. In route blood glucose (sugar) was re-assess and the result was " Low. " Patients remain unresponsive and no change while in route to hospital. R1 has physician orders of blood glucose monitoring twice a day, at 6:00AM and then again at 5:00PM. The physician orders for frequent blood glucose monitoring are to help manage R1 ' s chronic decease process of insulin dependent diabetes mellitus along with the other co-morbidities of [MEDICAL CONDITION] and [MEDICAL TREATMENT]. Review of R1 ' s medication administration records notes the following: The last blood glucose results were on 8-30-13 at 9:00PM. The results were 283. On 8-31-13 at 6:00AM there are no results of any blood glucose monitoring, there is no documentation on the medications administrations records (MAR), it is a blank space. Review of the nursing notes from 8-31-13 at 8:00AM notes; " R1 was unresponsive to verbal and tactile stimuli. Notified Z2 (R1's physician) and he ordered to send her out. " E13 (Staff Nurse/Night Nurse) stated on 10-7-13 that she could not clearly remember the (R1) patient/resident. E13 could not say what condition R1 was in or if a glucose monitor was done. The nursing notes along with the MAR and the 24 hour nurse to nurse report does not report R1's blood glucose on 8-31-13 at 6:00AM and anytime during the morning until the paramedics arrived. E1(Director of Nursing) had no comments on 10-7-13 at 4:30PM as to why R1 was in the bed one plus hours after the initial assessments of being unresponsive to verbal and tactile stimuli. Review of the facility policy name " Diabetes Mellitus: Nursing Care of the Resident " indicates the following in taking care of a resident: The purpose is to: Recognize, manage, and document the treatment of [REDACTED]. Management of [DIAGNOSES REDACTED]: for symptomatic and unresponsive resident with [DIAGNOSES REDACTED] a). immediately administer oral glucose b). if resident remains unresponsive call 911 c). remain with resident d). monitor vital signs Glucose monitoring for the reasons to: management of individual with diabetes mellitus should follow relevant protocols and guidelines. Mild [DIAGNOSES REDACTED], 55-70, moderate [DIAGNOSES REDACTED] 40-55 and severe [DIAGNOSES REDACTED] less than 40 mg/dl. This policy was not followed in the care and treatment for [REDACTED]. Z3 (Nurse Practitioner) explained on 10-3-13 at 4:00PM that it is very important that R1 ' s blood glucose be monitor according to physician orders because R1 had many co-morbidities. These morbidities are possible dehydration relate to the infection, [MEDICAL CONDITION] and [MEDICAL TREATMENT] to prevent further complications. The nurses should follow the protocols for the treatment of [REDACTED]. Z3 (Nurse Practitioner) stated on 10-7-13 at 2:00PM, "after review of the clinical records, there does no understand as to why the nursing staff does not follow the Diabetic protocol. R1 has much co-morbidity, such as infection, [MEDICAL TREATMENT] and dehydration. I do not see the documentation of blood glucose monitoring on 8-31-13, the day R1 was transferred to the hospital. I do not have any comments as to why R1 was not transferred to the hospital immediately after the physician order was given considering R1 was unresponsive." E12 (Assistant Director of Nursing) stated on 10-7-13 at 11:50AM, " after she reviewed the clinical records and the nurse to nurse report, there are no blood glucose documented on the 8-31-13 and gave no reasons to why there was a delay in urgent medical treatment.

Based on record review and interview, the Facility failed to develop a Plan of Care with effective interventions to prevent pressure ulcers for 1 of 7 (R8) residents reviewed for skin breakdown in the sample of 26. This failure resulted in R8 developing Pressure Ulcers/Deep-Tissue Injuries to his left buttock and left heel. Findings include: R8 was originally admitted to the facility on [DATE] with diagnoses, in part, of [MEDICAL CONDITION], Diabetes Mellitus and [MEDICAL CONDITION]. R8's Admission Minimum Data Set (MDS), dated [DATE], documents that he had disorganized thinking; was dependent on the extensive assistance of two or more persons for physical assistance during transfers; required the extensive assistance of one person for ambulation, dressing and personal care; had functional limitations in range of motion on one side for both his upper and lower extremities; and was occasionally incontinent of urine and bowel. The Facility "Patient Risk Profile, Risk Assessment History", dated [DATE], documents that R8 was assessed as having a Braden Score of 16. The form documents that a score of ,[DATE] puts and individual "At Risk" of developing a pressure ulcer. This form includes the following documented "Preventive Interventions-Recommendations: Turning Schedule, observe and assess regularly, use commercial moisture barrier and consult dietitian". R8's plan of care documents no interventions for prevention of skin breakdown until he developed a pressure sore on his left heel on [DATE]. On [DATE], the Facility implemented a care plan for "Deep Tissue Injury" for R8 which documents a Problem of "Impaired skin integrity related to; deep tissue injury; Goal-promote healing and prevent further deterioration; Approach-Completely relieve pressure, assess and observe every shift, Do Not massage, rinse and pat dry, Apply protective dressing is necessary using sponge dressing, change every 3 days and as needed, heel protectors as tolerated. The following documentation is handwritten onto the Care Plan: "Problem: [DATE], Left Buttock". There are undated Approaches documented on the bottom of the Care Plan which state: Low Air Loss Mattress, Turn and Reposition every 1XXX,[DATE] hours while in bed, Overlay for [MEDICAL TREATMENT] Chair". Facility nurses notes document "[DATE], 10:30 AM, Certified Nurses Aide (CNA) made writer aware that resident had an open area on buttock. Writer called wound care nurse to assess. Resident denies pain or discomfort at this time". R8's "Wound Assessment Details Reports" document the following for the pressure ulcer on his left buttock: "[DATE]-Size: 10 x 2 x unknown (LxWxD), Area: 20 centimeters squared (cm2), Volume: unknown, Undermining: None, Tunneling: None. Facility acquired Suspected Deep Tissue Injury. Current Plan: Resident was noted with a Deep Tissue Injury (DTI) to the buttock irregular shaped. He is incontinent of bowel and bladder and requires assistance with turning and repositioning. He is currently on turning and repositioning program and has a low air loss mattress and heel protectors in place. [DATE]-Size: 11 x 3.3 x unknown (LxWxD), Area; 36.3 cm2, Volume: unknown, Undermining: None, Tunneling: None. Was seen on rounds by wound physician. Continue with current treatment orders for the left buttock. Turn and reposition program in place. Noted an open area at the sacral 1.3 x 0.6 with 30% granulated and 70% slough. It was debrided. Left heel remains dry and intact. [DATE]-Size: 14 x 6.5 x unknown (LxWxD), Area 91 cm2, Volume: unknown, Undermining: None, Tunneling: None. Turning and repositioning program in place. Treatment to include Santyl, cover with dry dressing daily: On [DATE] it was also documented, "Noted an open area at the sacral 1.3 x ,[DATE] with 30% granulated and 70% slough. It was debrided." This was the only documentaion in R8's clinical record or in the wound reports, concerning the open area on R8's Sacrum which was documented on [DATE]. R8's "Wound Assessment Details Reports" document the following for the pressure ulcer on his left foot: [DATE]-Size: 2 x 1.6 x 0 (LxWxD), Area: 3.2 cm2, Volume: 0, Undermining: None, Tunneling: None. Facility Acquired Suspected Deep-Tissue Injury. [DATE]-Size: 2 x 2 x Unknown (LxWxD), Area 4.0 cm2, Volume: Unknown, Undermining: None, Tunneling: None. Treatment appears to be beneficial to the wound. Noted no open areas, wound appears as stable eschar. Pedal pulse palpable. [DATE]-Size: 2 x 2 x unknown (LxWxD), Area 4.0 cm2, Volume: Unknown, Undermining: None, Tunneling: None. Skin dry and intact, no drainage, continue dry dressing, offload heels when in bed. [DATE]-Size: 2 x 2 x unknown (LxWxD), Area 4.0 cm2, Volume: Unknown, Undermining: None, Tunneling: None. Wound at this time appears to be unstageable. Has 80% of hard necrotic tissue with 20% soft necrotic tissue with the periwound having yellow adherent slough. Physician notified and treatment order changed. Resident co-morbidities are Diabetes Mellitus, Left sided [MEDICAL CONDITION] [MEDICAL CONDITION], [MEDICAL CONDITIONS]. [DATE]-Size: 1.5 x 1.5 x unknown (LxWxD), Area: 2.25 cm2, Volume: Unknown, Undermining: None, Tunneling: None. Decreasing in size. No drainage. [DATE]-Size: 2 x 2 x unknown (LxWxD), Area 4.0 cm2, Volume: Unknown, Undermining: None, Tunneling: None. Continue with current treatment plan. Area presents with stable escarp. Unable to palpate pedal pulse at this time. (The box on the bottom of the form indicating "Physician Notified" is not checked). [DATE]-Size: 2 x 2 x unknown (LxWxD), Area 4.0 cm2, Volume: Unknown, Undermining: None, Tunneling: None. Continue treatment until healed/resolved. Heel protectors in place." In an interview with E2, Director of Nursing, and E12, Clinical Risk Manager, on [DATE] at 11:10 AM, it was confirmed that the Facility failed to develop a plan of care to prevent the development of unstageable pressure sores for R8. Both E2 and E12 are unaware when the Approaches stating "Low Air Loss Mattress, Turn and Reposition every 1XXX,[DATE] hours while in bed, Overlay for [MEDICAL TREATMENT] Chair", were added to R8's plan of care however, they think it was after he developed the open area on his left buttock. They could not confirm that R8 had a low air loss mattress or an overlay for his [MEDICAL TREATMENT] chair. R8's clinical record documents that he was sent to the hospital on [DATE] [MEDICAL CONDITION]. R8 expired at the hospital on [DATE]. The History from the hospital, dated [DATE], documents that R8 had "[MEDICAL CONDITION] -there is concern for possible blood stream infection, source uncertain". The Facility "Skin Care Prevention Protocol; documents "All resident's will receive appropriate care to decrease the risk of skin breakdown. The Skin Care Coordinator or person designated by the Director of Nursing will review all new admissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information".

Based on interview and record review, the facility failed to provide the required assistance during transfer of 1 of 3 residents (R1). The facility also failed to implement the physician orders for skilled therapy to decrease the potential risk for falls for 1 of 3 residents (R2.) R1 and R2 were reviewed for falls in a total sample of 3. These failures resulted in both R1 and R2 being involved in fall incidents and both sustaining fractures. Findings include: 1. R1 is [AGE] years old with left sided weakness related to a history of CVA (Cerebral Vascular Accident). R1 also has a history of osteoarthritis in the right knee. Per nurse's notes, R1 complained of right leg / knee pain and swelling off and on. On 8/03/12, a venous Doppler study was done of the right lower leg which was negative for deep vein thrombosis. The indication for the study was pain and swelling in the right knee. Then, on 8/06/12, an X-ray of the right knee showed osteoarthritis and the physician ordered warm compresses to the right knee daily. On 8/14/12, 12:30 PM, E6, R1's nurse stated that she was not sure if R1 was having problems with her knees. E6 stated that R1 requires one - person assist for transfer on /off the toilet. Review of the quarterly restorative / mobility screen dated 6/28/12, said that R1 requires extensive assist to transfer on / off the toilet. On 8/14/12 at 2:55 PM, E4, Nurse (Care Plan Coordinator) stated that extensive assist would require that at least two persons assist R1 on / off the toilet. The annual MDS (Minimum Data Set) dated 3/26/12 and the quarterly MDS, dated [DATE], showed R1 to have impairment on both lower extremities and requiring extensive assistance for transferring. Review of incident reports showed that R1 fell on [DATE] when her right foot slipped as she transferred herself from the wheel chair to the toilet. Then, on 8/08/12 at 12:20 PM, R 1 sustained a fracture of her left lower leg while being assisted by one person, E5, CNA (Certified Nurse Assistant) from the toilet to the wheel chair. On 8/14/12 at 12:00 PM, E5, CNA stated that she (E5) was the only person assisting R1 from the toilet to the wheelchair on 8/8/12 when she (R1) fractured her left leg. E5 stated that R1 ' s "good leg" (right leg) gave out and R1 was lowered to the floor. On 8/14/12 at 11:20 AM, E7, CNA stated that previous to R1's fall on 8/08/12; one person assist was used to assist R1 on / off the toilet. On 8/14/12 at 2:35 PM, E8, Restorative Nurse stated that R1 requires extensive assistance with transferring on / off the toilet. E8 defined extensive assist as requiring the assistance of 2 persons. 2. R2 is an [AGE] year old who was admitted to the facility on [DATE]. According to the nurse's admission notes, R2 had bruising to the right side of her face as a result of multiple falls and had a very unsteady gait. Other admitting [DIAGNOSES REDACTED]. On 6/07/12, the admitting physician orders included an order for [REDACTED]. Per review of the nurse's notes, on 6/12/12 at 9:45 PM, R2 was found on the floor of her room with a large hematoma to the forehead. R2 was sent to the hospital and returned after emergency treatment. Rehabilitative therapy had not been initiated at that time. On 6/21/12 at 1:55 AM, R2 was found lying on the floor at bedside in a large pool of blood underneath her face. There was a laceration to the right forehead and bleeding from the nose. R2 was sent to the hospital and treated for [REDACTED]. R2 returned to the facility that day. At this point, R2 still had not been evaluated for physical / occupational therapy. On 6/22/12, another telephone order was written stating, "PT to evaluate and treat as indicated. Skilled PT 5 times per week for 30 days for therapeutic exercises, neuromuscular reeducation, gait training and therapeutic activities." R2 did not receive the initial evaluation for physical and occupational therapy until three days later, on 6/25/12. On 8/15/12, 2:00 PM, E2, DON (Director of Nursing) stated that both the nursing and rehab departments were responsible for the delay of R1's therapy. On 8/15/12, 1:30 PM, E9, Director of a new rehabilitation company contracted by the facility stated that they took over on 7/02/12. Review of the facility policy of "Physician / Telephone Orders", presented on 8/15/12 by E2, DON showed that the unit nurse, Nursing Unit Manager and the Rehab Unit Manager should have been aware of the orders if the protocol was followed.