Every finding on record at Villa Health Care East

Based on interview and record review, the facility failed to thoroughly conduct an abuse investigation for 1 (R7) of 5 residents reviewed for abuse in a sample of 7.Findings Include:R7's Undated Face Sheet documents R7 was admitted to the facility on [DATE].R7's Minimum Data Set, dated [DATE] documents R7 is severely cognitively impaired.The Facility's Final Investigation Dated 1/27/26 documents incident occurred on 1/23/26 at 4:30 PM. Summary: (R7) made allegations of sexual inappropriate behavior. Resident reported to son and hospice social worker. Son reports that he was told about this on Tuesday, 01.21.26 but didn't mention to anyone because he didn't believe there to be any truth to this, Son, administrator, and Director of Nursing (DON) interviewed resident. Resident answered yes/no questions and denied inappropriate care or being fearful. Conclusion: The allegations originated as sexual abuse. The findings were unfounded. Resident has diagnosis listed as dementia, unspecified severity, without behavioral disturbances, anxiety and depression.The Local Police Department Report dated 1/23/26 documents I spoke with (V24) about the situation before speaking with (R7). (V24) stated that the previous Wednesday, (R7) stated that a male climbed into her bed and shoved his penis in her mouth.On 7/28/26 at 2:13 PM V1, Administrator, stated she was informed by V25, Hospice Social Worker, that V25 heard R7 make the comment that R7 is not that type of girl. V1 stated V25 did not provide any type of information regarding the comment and the facility started an investigation.On 7/29/26 at 11:35 AM V23, Hospice Case Manager, stated she was informed by V25 that R7 made the comment of No, No, No, to V25 and that a male entered her room and laid on top of her, V23 stated she was informed that R7 made the comment I haven't done anything like that since I was married.On 7/29/26 at 11:48 AM V25, Hospice Social Worker, stated she was seeing R7 for a routine visit when V24, R7's Family, informed her that R7 stated a male came into her room and had gotten on top of her while she was in bed. V25 stated she spoke with R7 with V24 present, and R7 told her No, No, No, and that the male wouldn't get of her. V25 stated R7 stated she hadn't done anything like that since she was with her husband. V25 stated herself and V24 informed V1, Administrator, and V2, Director of Nursing (DON) of the statements R7 made and was informed an investigation would be conducted.On 7/29/26 at 12:44 PM V24, R7's Family, stated he walked into R7 rooms and R7 had informed her that someone came into her room one night and put something in her mouth. V24 stated she spoke to V25 regarding the statement R7 had made and V25 went with him into R7's room and R7 made the same statement to V25. V24 stated himself and V25 reported the statement to V1 and V2. V24 stated V2 came and spoke with R7 and R7 informed V2 that someone had come into her room and put something in her mouth.On 7/29/26 at 12:56 PM V2, DON, stated V24 came into the office and mentioned R7 made a comment. V2 stated she spoke with R7 and R7 made the comment that she was not that type of girl. V2 stated she was informed by V24 and V25 that R7 mentioned something was put in her mouth, but R7 did not mention that to her. V1 and V2 stated they were not made aware of any allegation made by R7 of a male coming into R7's room and lying on top of her.On 7/29/26 at 1:38 PM V1 stated the sexual inappropriate behavior she is referring to in the Facility's Final Investigation Report is the comment R7 made, which was she is not that kind of girl. V1 stated she was not aware of R7 stating something was shoved in her mouth. V1 stated she was unsure of the verbiage to use in the report because she did not know how to say the behavior.On 7/29/26 at 3:37 PM V26, Medical Doctor, stated she was the on-call physician and received a call from V2 stating R7 was claiming someone put their genitals in R7's mouth. V26 stated V2 informed her R7 does not believe the statement to be valid due to R7's dementia and history.The Facility's Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media Policy Last Revised Date 1/29/26 documents All residents have the right to be free of from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. After an initial report of suspected abuse or neglect is sent to Illinois Department of Public Health (IDPH), the Administrator or designee shall investigate all alleged incidents of abuse or neglect.

Based on interview and record review, the facility failed to ensure R3 was adequately supervised and respond in a timely manner to alarms to prevent elopement for 1 of 1 (R3) resident reviewed for supervision. This failure resulted in R3 who is confused, has a history of exit seeking and wandering at the facility eloped into unknown and unsafe conditions that include exiting the facility, falling onto the concrete, log rolling to a handicap parking sign then sitting up and scooting on her buttocks through the facility parking lot alone until two bystanders observed R3 laying in the facility parking lot and stopped to assist her. This failure resulted in Immediate Jeopardy on [DATE] when R3 eloped from the facility exit door at 7:12 PM and was found by two bystanders at 7:18 PM and was assessed at the local hospital and returned to the facility.On [DATE] at 10:55 AM V1 Administrator, V2 Director of Nurses (DON) and V13, [NAME] President of Operations were notified of the Immediate Jeopardy.The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on [DATE] but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R3's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnosis including unsteadiness on feet, history of falling, macular degeneration, depression, anxiety and diabetes. No diagnosis of dementia or Alzheimer's disease documented.R3's Baseline Care Plan, dated [DATE] documents she has some confusion, needs contact guard for transfer and bed mobility and staff dependent for assistance with personal care. Mobilizes with a wheelchair. Staff documented R3 was at risk for falls. R3's Care Plan Report, dated [DATE] documents resident was alert/oriented with much confusion and paranoid delusions and visual hallucinations. Resident sometimes wanders in/out of other residents' rooms due to confusion. Resident can be exit seeking when looking for family or dog. Goal: Resident will not leave the facility without staff or family supervision. No interventions documented to address resident's exit seeking or wandering behaviors.R3's admission Exit Seeking/Wandering Screener dated [DATE] documents score zero, staff documented no, resident not able to physically leave the facility on her own.R3's admission Minimum Data Set (MDS), dated [DATE] documents BIMS 9 and no behaviors exhibited including no wandering behaviors. R3's Health Status Note, dated [DATE] at 9:35 AM documents she was here for short term care.R3's Adv (Advanced) Skilled Evaluation dated [DATE] at 12:49 PM documents she is orientated to person and place and has mild cognitive impairment.R3's Social Service Note, dated [DATE] at 11:43 AM documents SSD (Social Services Director) CP (Care Plan) nurse met with resident and POA (Power of Attorney) today. Resident is alert/oriented with much confusion and forgetfulness. She has poor safety awareness and reasoning skills. She can be very anxious/restless and will sometimes attempt to get up by herself unsafely. 24-hour care recommended due to residents' confusion, cognition and poor safety awareness. Memory care facilities discussed in detail. SSD explained that if resident stays at facility and starts to become exit-seeking/elopement risk, alternative placement in a locked dementia facility would need to be considered. SSD explained that this facility was not equipped for memory care and exit seeking residents. This facility does NOT have locked doors, units, or wanderguard systems in place for dementia exit-seeking residents. R3's Health Status Note, dated [DATE] at 7:07 AM documents patient noted to be restless and attempted to self-ambulate (walk), she stated that she was to meet her son to get the kids. Patient adamant that she needs her shoes on because she has a ride coming so she can leave. R3's Behavior Note, dated [DATE] at 5:40 PM, V10, LPN (Licensed Practical Nurse) documented resident crying, seeking elopement, attempting to stand though wheelchair bound, speaking and saying she sees things that are not here. Cursing. Constant redirecting, walking the halls with the resident. Nurse sat resident at nursing station to keep her close and safe. Kept constant communication with resident. R3's Exit Seeking/Wandering Screener dated [DATE] documents yes, R3 is physically able to leave the building on her own. No score on this assessment was documented. R3's Exit Seeking/Wandering Screener dated [DATE] documents yes, R3 is physically able to leave the building on her own, resident is disoriented to place, has impaired decision making, makes statements about going home, and displays persistent anger. Staff documented resident didn't have a history of wandering. Staff documented yes, resident has a current behavior of wandering.R3's Care Plan Report dated [DATE] additional interventions documented exit-seeking/attempting to exit facility without staff/family supervision: redirect resident away from facility exit doors. Wandering in/out of other residents' rooms: redirect resident out of the residents' room. Talk to resident in a calm and soothing manner. Offer resident a snack or something to drink. Take resident to the bathroom if needed. Redirect resident with group activities or other activities of interest. Listen to and address any worries or concerns. Provide reassurance and support as needed.R3's Social Service Note, dated [DATE] at 11:58 AM documents resident continues to be alert/oriented with much confusion and forgetfulness. She will sometimes wander in/out of other residents' rooms when confused, anxious, agitated, and looking for her family. She has potential to be exit seeking when anxious and looking for family. SS (Social Services) will add resident to elopement books for safety.R3's Social Service Note, dated [DATE] at 2:26 PM documents resident has been wandering up/down hallways and going in/out of other residents' rooms. Continuous redirection given. R3's Social Service Note, dated [DATE] at 2:45 PM documents SSD and Administrator contacted POA via phone early this afternoon. Resident has been wandering up/down hallways and wandering in/out of other residents' rooms. Due to her wandering, staff are having to provide 1:1 supervision for resident. SSD and Administrator told POA that due to resident's wandering and impulsive behaviors, facility will need family to search for alternative placement in a facility that can provide the dementia cares in a secured memory care unit. Administrator and SSD reminded POA that this facility does not have a secure memory care dementia unit. Administrator also informed POA that facility cannot continue to provide continuous 1:1 supervision with resident due to needing to meet the needs of other residents on their hallways in the facility. Resident is very restless this afternoon. She has been wandering up/down hallways, wandering in/out of other residents' rooms, exit seeking, and attempting to get up by herself unsafely.R3's Social Service Note, dated [DATE] at 4:30 PM documents SSD checked in on resident and stayed with resident until POA arrived this afternoon. She continued to be alert/oriented with much confusion. She was very anxious, restless, and agitated. She kept wheeling herself up/down hallways and going in/out of other residents' rooms and toward exit doors. She kept trying to get up by herself unsafely. She kept asking for her POA and family. She kept asking for a cigarette. Snacks, drinks, etc. offered. POA arrived to the facility around 3:30 pm. Resident continued to be very restless due to sundowning dementia. SSD talked to POA about discharge plans and alterative placements at great length. POA also voiced understanding to safety concerns regarding her exit-seeking and wandering behaviors. R3's Health Status Note, dated [DATE] at 10:21 AM documents received call from R3's PCP (Primary Care Provider), V11's office requesting an update on patient's behavior. Told office nurse that social services has had conversations with POA regarding patient needing placement in a memory unit. No new orders at this time.R3's Social Service Note, dated [DATE] at 9:50 AM documents SSD discussed with POA residents' wandering behaviors.R3's Social Service Note, dated [DATE] at 4:07 PM documents resident continues to have much confusion d/t (due to) dementia. Resident wanders in and out of other resident's room. Much redirection given.R3's Health Status Note, dated [DATE] at 11:26 PM V9, Registered Nurse documented Resident was noted with multiple behaviors this shift such as exit seeking. On call MD, POA, on-call manager and all appropriate parties notified.R3's Social Service Note, dated [DATE] at 3:17 PM SSD and staff have redirected resident multiple times. Resident is very confused due to dementia. She has been wandering up/down hallways and in/out of other residents' rooms. Continuous redirection given all day by CNA, nurse and therapy staff.R3's Health Status Note, dated [DATE] at 4:00 PM V7 documented resident was trying to elope through dining room door and main exit on her hall.R3's Social Service Note, dated [DATE] at 9:27 AM documents SSD, PT/OT, DON, and Administrator met with POA today. Resident is alert/oriented with much confusion and forgetfulness. She is easily distracted and has poor safety awareness. She needs assistance with all decision making. She is impulsive and frequently attempts to get up by herself unsafely. She will wander to exit doors and in/out of other residents' rooms. Due to her wandering behaviors alternative placement or discharge will need to be sought. SSD discussed memory care again with POA. R3's Health Status Note, dated [DATE] at 9:15 PM V8, Registered Nurse (RN) documents resident was found outside of back door on her bottom. Assessment done. Skin tear on right hand. EMS (Emergency Medical Services) dressed the skin tear. VS (vital signs) stable. Confused to all spheres, she did know her name. POA and PCP notified of incident. R3's Health Status Note, dated [DATE] at 11:00 PM V8 documents resident transported to local hospital for evaluation. On [DATE] at 10:15 AM V1, Administrator and Illinois Department of Public Health (IDPH) Surveyor went to the door that R3 eloped from. V1 put a code in on the keypad and exited the double doors to the parking lot. V1 showed the IDPH surveyor where the resident was when the bystanders found her in the parking lot. Straight ahead was a very busy four lane highway with heavy traffic. V1 stated that four lane highway is the main highway through this town and it's busy all day and night. On [DATE] at 12:25 PM the surveyor opened the exit door that R3 eloped from which was next to the nurse's station and the door alarm sounded. Staff turned the door alarm off shortly after. On [DATE] at 10:35 AM the facility's wander/elopement book was reviewed and R3 was documented on the list. On [DATE] at 12:11 PM V7, LPN stated she was assigned to R3 on [DATE] from 2:00 PM to 6:00 PM. V7 recalled R3 was very confused and wandered a lot during that shift. V7 stated R3 was yelling out and was sundowning that shift and was wandering into other residents' rooms trying to find her dog. V7 stated R3 pushed on the exit door in the dining room and set the exit door alarm off near the nurse's station during that shift. V7 stated she continued to redirect R3 away from the exit doors and she didn't report to staff that R3 was attempting to get out exit doors because she didn't get out and she didn't get hurt and she didn't see what the importance of reporting those behaviors to management was. V7 stated she documented R3's exit seeking behavior in her nurse's notes and assumed management read over the nurse's notes so they'd know R3 was exit seeking. On [DATE] at 1:02 PM V10, LPN stated she was assigned to R3 on [DATE] from 2:00 PM to 6:30 PM. V10 stated she picked up the four-hour shift to help the facility out. V10 stated she got nurse report that R3 was very confused and was a wander and shortly after the day shift nurse left R3 started wandering down the hall by self-propelling in her wheelchair. V10 stated she recalled R3 telling her that she wanted to go home and that her husband was going to pick her up. V10 stated she observed R3 self-propelled to the exit door by the nurse's station and looked out. V10 stated she and the CNA redirected R3 away from the exit door often because she didn't want R3 to attempt to leave the facility. V10 stated her and the CNA kept a constant eye on R3 that shift because they were concerned for R3's safety and wanted to ensure she was going to leave the facility or attempt to leave the facility by herself. V10 stated she didn't report R3 was looking out the exit door or that she stated her husband was going to pick her up because she didn't feel that was important to report to management. On [DATE] at 10:27 AM V9, RN stated he is an agency nurse and worked night shift from 6:00 PM to 6:00 AM on [DATE] and was assigned to R3. V9 stated R3 had multiple behaviors that shift, and he wasn't familiar with her. V9 stated R3 was alert to name only and she was really confused. V9 stated R3 wandered around the halls self-propelling in her wheelchair up and down the hall. V9 stated he didn't know if R3 was an elopement risk because he is an agency nurse but stated he noted R3 was staring out of the exit doors on her hall including the exit door located at the nurse's station. V9 stated he kept redirecting R3 from the exit door because he didn't want her to get out of the facility by herself. V9 stated he didn't feel R3 had safety awareness because she attempted to stand up on her own and she wasn't steady on her feet and was a fall risk. V9 stated he called the on-call nurse (name unknown) and let the on-call nurse know R3 was having a lot of behaviors and was looking out the exit doors and he was concerned R3 would try to leave the facility if he hadn't redirected her away from the exit doors that shift. V9 stated he documented R3 was exit seeking but wanted to clarify that R3 didn't set the exit door alarms off because he redirected her away from the doors multiple times that shift and wanted to ensure R3 stays safe in the facility.On [DATE] at 2:15 PM V6, Certified Nurse Assistant (CNA) stated she worked night shift starting at 6:00 PM on [DATE] and was assigned to R3 that shift. V6 stated she and R3 were close, and she was very familiar with R3. V6 stated R3 had multiple behaviors including wandering up and down the hall and into other residents' rooms. V6 stated she always knew to keep a close eye on R3 because she wandered so much, and she was very confused. V6 stated R3 was alert to name only and recalled R3 told her one time that her husband was deceased then another day R3 had a bag of her belongings packed and stated her husband was going to pick her up to go get the kids. V6 stated R3 packed her belongings at the facility four times, one time in a reuseable tote bag, another shift a grocery bag, another shift collecting her belongings on her bed and another shift R3 put all her belongings in her lap and was heading to the exit door by the nurse's station, but she redirected her prior to R3 getting to the exit door. V6 stated when she got to the facility on [DATE], she recalled R3 was sleeping sitting up in her wheelchair at the nurse's station on her hall. V6 stated she stayed up there and charted a while then another resident put their call light on to get a shower. V6 stated she was the only CNA on the hall and was assigned ten residents, including R3 so she thought she'd go and shower the other resident while R3 slept at the nurse's station. V6 stated she was done showering the resident within 15 minutes and when she opened the resident's door, she heard an alarm. V6 stated she ran to the nurse's station and didn't see R3 at the nurse's station then she ran outside the exit door located right next to the nurse's station and noted R3 was outside with two people she didn't know and a police officer. V6 stated she ran inside and reported to the charge nurse, V8, that R3 was outside sitting on the ground and she was bleeding. V6 stated V8 immediately followed her outside and assessed R3 at that time. V6 stated she didn't know R3 was outside while she was showering another resident and didn't know how R3 got outside and didn't know how long she'd been outside before the bystanders came to assist her. V6 was very upset that R3 got outside by herself because she was so confused and she could have gotten really hurt. On [DATE] at 11:00 AM V8, RN stated she worked with R3 often and was assigned to her on night shift on [DATE] starting at 6:00 PM. V8 stated R3 was very confused and didn't have safety awareness, R3 often wandered up and down the hall and in and out of other resident's rooms. V8 recalled when she got to the facility that evening R3 was at the nurse's station dozing in her wheelchair. V8 stated R3 was a resident you had to keep your eyes on at all times because she was very confused. V8 stated she was assigned two halls that shift, as always and she got report on R3's hall at 6:00 PM then went and got nurse report on the other hall and started administering medications to the other hall. At one-point (time unknown) V6 ran to her while she was on the other hall and reported R3 was outside, and she was hurt. V8 stated she followed V6 to the exit door near the nurse's station where R3 was initially sleeping at and observed R3 was sitting on the ground with 2 unknown people at her side and a police officer was there as well. V8 asked R3 what happened pointing to her hands and knee that were bleeding and stated R3 looked up at her and said I don't remember. V8 stated she didn't understand why the police were at the facility with R3. V8 stated she assessed R3 and took her vital signs at that time which were within normal limits. V8 stated R3 was very confused and didn't have safety awareness. V8 stated she knew R3 was a wander but didn't think R3 would attempt to leave the facility on her own. V8 stated R3 should never have been left alone at the nurse's station, even if she was sleeping because she has a history of wandering. V8 stated she didn't know V6 was going to leave R3 at the nurse's station alone while she showered another resident and if she told her that she would have taken R3 with her to keep an eye on her while she administered medications on the other hall until V6 was done showering the other resident. V8 stated she didn't observe R3 set exit door alarms off and didn't see R3 attempting to open an exit door because she told night shift staff to keep R3 away from exit doors because she was a wander and she wanted to ensure R3 was safe.On [DATE] at 9:02 AM V4, SSD stated R3 was admitted to the facility for short term rehabilitation after falling at home and she had a diagnosis of dementia. V4 stated when R3 was admitted to the facility late February 2026 she immediately knew this was not an appropriate facility for the resident to reside at because of her behaviors, including wandering into other residents' rooms and up and down the hall. V4 stated she documented R3 was not an appropriate resident for this facility throughout R3's medical record because she was really concerned about her safety regarding wandering behaviors. V4 stated she didn't see, and no staff told her that R3 touched an exit door or set an exit door alarm off, but she would self-propel in her wheelchair to the exit doors and staff redirected her throughout the shift. V4 stated she documented R3 on the wander/elopement list mid-[DATE] because she was wandering into other resident rooms, not because she was attempting to elope the facility. V4 stated she documented that because she wanted to ensure staff knew she wandered, V4 stated she didn't think R3 had the physical capacity to get exit doors open, so she wasn't concerned R3 was going to elope or attempt to elope from the facility. On [DATE] at 10:02 AM V3, Assistant Director of Nurses (ADON) stated she was very familiar with R3 and stated she had many behaviors, including wandering about the facility. V3 stated R3 was very confused and was alert to name only and R3 had no safety awareness. V3 stated these wandering behaviors got worse at night, and she would often stay late and sit with R3 so staff could take care of other residents. V3 stated she was assigned to R3 on [DATE] day shift and recalled she was her usual self that day, anxious, restless and wandering throughout the halls. V3 stated she wasn't at the facility at the time R3 eloped.On [DATE] at 10:55 AM V2, Director of Nurses (DON) stated her understanding when R3 was admitted to the facility was she was being taken care of by family at home then she had a fall, and she was admitted to the facility for short term rehabilitation. V2 stated upon admission she didn't know R3 had behaviors including wandering. V2 stated shortly after R3 was admitted to the facility staff reported that R3 was very confused and wandered in and out of other resident rooms and staff had to redirect R3 often. V3 stated R3 needed alternative placement because she needed a locked memory care unit due to her wandering behaviors, and this facility isn't a locked facility and doesn't offer memory care. V2 stated she reviewed R3's medical records and she does not have a diagnosis of dementia or Alzheimer's disease, but she thinks R3 needs to be assessed due to her very confused cognitive state. V2 stated no staff reported to her that R3 packed up her belongings four times or that R3 told staff to help put her shoes on because her family was going to pick her up. V2 stated no staff reported to her that R3 set off exit door alarms or that R3 was attempting to open exit doors. V2 stated she expected staff to report that to her or other management immediately so they can put interventions in place to prevent R3 from eloping the facility. V2 stated if she knew R3 was pushing on exit doors and attempting to elope the facility she would have placed R3 on 15 or 30 minute checks and called R3's family to come sit with her. V2 stated she could have also assigned 1:1 staff to sit with R3 to ensure her safety if that was needed. V2 stated she wasn't aware of R3 ever being a 1:1 while at the facility. V2 stated after staff were aware of R3's wandering behaviors staff documented her name on the wander/elopement list, but it was more for wandering because V2 stated she wasn't aware R3 was an elopement risk. V2 stated R3 did not have safety awareness and if she would have go to the busy four lane highway in front of the facility she could have got hit by a car and could have died. On [DATE] at 10:45 V1, Administrator and V17, Maintenance Director showed the surveillance camera of R3 eloping from the facility. V1 stated this occurred on [DATE] and the surveillance footage recording started at 7:00 PM which showed R3 was sitting up in her wheelchair at the nurse's station asleep. At 7:06 PM R3 woke up and took a drink. At 7:12 PM R3 self-propelled in her wheelchair from behind the nurse's station and saw the exit door which was right next to the nurse's station. R3 pushed on the door and was out the first door at 7:12 PM. R3 then self-propelled to the second exit door and got the exit door open but had difficulty getting her wheelchair through the second exit door. R3 attempted to stand and fell out of the second exit door, onto the concrete outside of the second door at 7:13 PM. R3's wheelchair was left between the two doors. R3 then did three log rolls to the parking lot where she reached out and held onto the handicap sign to sit up. At 7:16 PM R3 scooted on her buttocks and hands in a forward motion in the parking lot. At 7:18 PM two bystanders stopped by to check on R3 and the resident scooted out of view of the surveillance camera at that time. On [DATE] at 7:41 PM V17, V18, Bystander #1 stated she was the passenger in a vehicle on [DATE] around 7:10 PM and saw an elderly woman sitting in the parking lot of a nursing home from the highway and she told the driver (V19, Bystander #2) that he needs to pull over and they need to help that lady. V18 stated when she got to the resident, she was bleeding from both hands and from her knee and she only knew her name. V18 stated when they pulled up, she noted no staff were outside with the resident and the resident was really confused and screaming, HELP, HELP, HELP. V18 stated she directed V19 to go find nursing home staff and let them know she's outside by herself and she's injured. V18 stated she sat with the resident while V19 went to get help from nursing home staff. V18 stated the resident only knew her name and she was very scared and kept screaming for help even though she was sitting with her and reassured her they were getting her help. V18 stated a few minutes later V19 came back and stated he initially couldn't find any staff but then he found one (staff name unknown) and reported that there was an elderly woman outside sitting in the parking lot and was injured and needed assistance and the staff shrugged their shoulders and didn't follow him out of the facility. V18 stated when V19 came back to her and the resident sitting outside without staff they called 911 and reported the resident was outside sitting in the parking lot and she was bleeding and very confused. V18 stated the police arrived very fast to the facility and they took over and a few minutes later nursing home staff ran out and asked how the resident got outside in the first place and V18 told them she saw the resident sitting outside in the parking lot by herself and she knew something was wrong so that's why she stopped to assist. V18 stated they left after EMS took the resident to the local hospital. On [DATE] at 8:40 PM V19 stated he was driving down a four lane very busy highway that was located next to a nursing home on [DATE] at approximately 7:13 PM and V18 told him to pull into the parking lot because there was a nursing home resident sitting in the parking lot by herself. When they arrived to the parking lot V18 opened the door and he heard the resident yelling/screaming, HELP! HELP! HELP! V18 told him she'd go sit with the resident and he should go tell staff she's outside alone and she's bleeding. V19 stated she drove to the main entrance of the facility and looked for staff after finding a staff member (name unknown) he reported an elderly resident was outside and she was bleeding and needed staff assistance. V19 stated the staff member didn't follow him to go assist the resident so he drove back to where the resident and V18 were. V19 told V18 staff didn't follow him, and they decided to call 911 and the police arrived to the facility a minute later to assist the resident. V19 stated it was for several more minutes that facility staff came outside to assist the resident. V19 stated he knows staff weren't aware the resident was outside, and he was really concerned because the resident was very confused, and the busy 4 lane highway was located right in front of the facility and the resident could have really got hurt if she attempted to cross the highway. On [DATE] at 9:51 AM V1, Administrator stated a resident (R3) recently eloped from the facility and bystanders saw her in the parking lot and stopped to assist. V1 stated R3 was on the wanderer/elopement list because she wandered into other residents' rooms but that R3 didn't exit seek while she resided at the facility. V1 stated R3 was admitted to the facility at the end of February 2026 for short term rehabilitation and she wasn't aware that R3 had wandering behaviors prior to admission. V1 stated no staff reported that R3 packed up her belongings, that R3 stated her husband was going to pick her up or that R3 attempted to get out of an exit door or that R3 had set an exit door alarm off before. V1 stated if R3 was doing those things she expected staff to report that to her or the DON so they could put interventions in place to keep R3 safe. V1 stated it was clear to her that shortly after R3 was admitted to the facility the facility was not proper placement for her because she had behaviors including wandering and they were not a memory unit nor a locked unit which is what R3 needed due to confusion and wandering behaviors. V1 stated when staff documented R3 on the wander/elopement sheet it was only due to R3's wandering behavior, not that she was an elopement risk. V1 stated she reviewed the surveillance camera and noted when R3 eloped at approximately 7:13 PM on [DATE] she was at the nurse's station sleeping prior to and then and when R3 woke up she went directly to the exit door next to the nurse's station and got out of the facility. V1 stated as she watched the surveillance camera two people pulled up in a vehicle at some point and assisted R3. They called the police and R3 was transported to the local emergency room. V1 stated she arrived at the facility shortly after R3 was taken to the hospital and staff reported to her that R3's hands and knee were bleeding. V1 stated when R3 was getting out the exit doors the CNA was showering another resident, and the assigned nurse was administering medication on another hall. V1 stated she interviewed both staff and they stated they didn't know R3 was outside, how she got outside or how long she was outside by herself. V1 stated stuff like this doesn't happen at this facility and she was actively working with R3's POA to get her the proper care she needed at a memory care locked unit because this facility wasn't appropriate for her.On [DATE] at 3:43 PM V12, Deputy Chief of Police stated a police officer was called to the facility by a passerby and stated an elderly resident was sitting in the facility parking lot by herself yelling for help. V12 stated the responding police officer was a block away when he received the call on [DATE] at 7:19 PM and the officer was on scene within 30 seconds. V12 stated the police officer noted the resident was very confused and was bleeding from both wrists/hands area. V12 stated the police officer interviewed the resident but she was really confused and only knew her first name. V12 stated the officer asked the resident how she got outside, and the resident didn't know how she got outside. V12 stated no nursing home staff were outside with the resident when the officer arrived to the scene, they started coming out of the facility a few minutes later. The officer stated nursing home staff didn't know how the resident got out of the facility but that she shouldn't be outside by herself due to her confusion. V12 stated there wasn't a police report documented for this 911 call because no laws were broken.On [DATE] at 10:32 AM V11, R3's PCP stated he has been R3's PCP for over 20 years. V11 stated he assessed R3 in his office last on [DATE] and R3 was alert and seemed oriented with bouts of confusion. V11 stated R3 had not been diagnosed with dementia but it was questionable due to over the last year he could tell R3 had declined cognitively. V11 stated R3 had no insight and no safety awareness and due to being confused she wouldn't be able to cross a busy four lane highway and be cognizant to look both ways for cars. V11 stated when R3 eloped from the facility she could have got severely hurt including getting hit but a car on the busy four lane highway that is directly out front of the facility, and she could have died. V11 stated when R3 attempted to elope from the facility and set exit door alarms of prior to eloping staff should have reported that to management and they should have implemented interventions to prevent R3 from eloping. V11 stated no facility staff called his office to report R3 was exhibiting exit seeking behaviors and if she was exhibiting exit seeking behaviors, he expected staff to document the behaviors and to also assess and document interventions to prevent R3 from eloping from the facility and keeping R3 safe. R3's ED (Emergency Department) Physician Notes, dated [DATE] documents the patient presents with [AGE] year-old with PMH (previous medical history) of dementia (close to baseline per EMS) presents after fall. The patient reportedly eloped from her nursing home and was found outside the building. Patient is complaining of right knee and right hip pain, she denies LOC (loss of consciousness), she is awake, alert and orientated to self and place. Medical history: neurological: dementia. Physical e[TRUNCATED]

Based on observation, interview, and record review, the facility failed to prepare and provide food according to physician orders for 1 of 3 residents (R3) reviewed for diet consistency in the sample of 9. Findings Include:R3's admission Record document, print date of 1/22/26, documented R3 has diagnoses including Alzheimer's disease, atrial fibrillation, gastro-esophageal reflux disease, hypertension, spinal stenosis, aphasia following cerebral infarction, and glaucoma.R3's MDS (Minimum Data Set), dated 12/4/25, documented R3 is moderately cognitively impaired and requires setup assistance with meals. R3's Physician Order Summary Report, print date of 1/22/26, documented R3's physician order for a pureed texture diet with moderately thick (honey) consistency liquids. On 1/22/26 at 12:39 PM R3 was observed during the lunch meal. R3 was served pureed meat, peas, and carrots in a 3-compartment divided plate. R3 was also served pears with whipped topping in a small plastic bowl. The pears appeared to be diced rather than pureed. On 1/22/26 at 1:00 PM V9 CNA (Certified Nurse Assistant) was observed sitting next to R3 and was cutting R3's pears up with a butter knife. Surveyor asked V9 if the pears were pureed and V9 stated yes. Surveyor then requested V9 to get a scoop of the pears onto a spoon. Chunks of pear pieces were observed on the spoon which V9 continued to leave for R3. On 1/22/26 at 1:05 PM R3 was observed reaching into her mouth and then R3 placed a piece of pear on her plate. On 1/22/26 at 1:47 PM V8 Food Services Supervisor stated a pureed diet is to be the consistency of baby food and there should not have been any chunks in R3's pears. On 1/28/26 at 1:51 PM V1 Administrator stated she expects the residents to be served food according to each resident's physician's orders. The facility's Menus and Meal Service policy, dated 11/22, documented guest tickets should be printed for each resident at every meal to ensure diet accuracy. A system needs to be established to ensure each resident receives their food at every meal.

Based on observation, interview and record review, the facility failed to supervise 2 of 4 (R2 and R3) residents, reviewed for accidents in a sample of 7. This failure resulted in R3 sustaining a left hip fracture. R2 sustaining a right frontal laceration to her head. Both incidents resulted in hospitalization.Findings include: 1.On 10/14/2025 at 9:07 AM, R3 was sitting on the side of her bed, 1 foot on the floor and the other dangling off the bed and the bed was not in the lowest position. No staff were in the room. The bed alarm was underneath the bed pad but was not sounding. R3 was barefoot. R3's call light was on the nightstand out of R3's reach. On 10/14/2025 at 9:07 AM, R3 stated that the night she fell and broke her hip she went to the bathroom, on her own and when she reached to get the soap she fell, landing on her butt. R3 was asked if she used her call light to call for help, she laughed and did not answer. On 10/9/2025 at 10:06 AM, V4, Licensed Practical Nurse (LPN), stated that she was R3's nurse the night she fell, but this was the 1st time working R3's hallway. V4 stated that in report that night she was told that R3 transfers on her own with her walker, did not complain of any pain and that R3's baseline was confusion, but she was also told in report that R3 needed help of 1 staff person for supervision. V4 continued to state that she was on the other side of the hall, and the CNA came and told her that R3 was on the floor. She continued to state that R3 complained of back pain but when they rolled her over, to assess her back, she complained of left hip pain, and they gently rolled her back and called 911. When asked about if a staff member was with R3 when she fell or when she went to the bathroom and V4 stated she did not know. On 10/9/2025 at 11:00 AM, V5, Certified Nurse Assistant (CNA), stated that the night that R3 fell, she was the only CNA for that hallway and that is usually the normal staffing for that hall. She continued to state that she has been with the facility for 14 years and has been R3's CNA, at night, since she was admitted . She stated that R3 was ambulatory with her walker, but she was unsteady because she had a urinary tract infection. V5 stated that night she was in another resident's room, assisting them, and heard someone yell and then a loud noise, she left that room immediately and found R3 sitting on her butt on the floor in the bathroom. She stated that she told her do not move and that she was getting the nurse. She went and got the nurse and that the resident denied pain and the nurse told her she was going to be sent out to the ER. When asked, about if R3 required supervision for ambulation and going to the bathroom, she stated yes but R3 never uses her call light or calls for help. V5 stated that R3 was not supposed to get up by herself but she will not call for help nor will she use her call light, but this was how R3 has always been since her admission to the facility. On 10/14/2025 at 11:42 AM, V10, R3's Primary MD, stated that he does not know if increased staff on the night R3 fell would have prevented her fall, but the facility knew she was not going to use her call light. V10 stated that he would expect the facility to follow R3's care plan interventions they had in place. R3's Face Sheet, dated 10/14/2025, documented a diagnosis of Periprosthetic Fracture around internal Prosthetic Left Hip Joint and Alzheimer's Disease. R3's Progress note, dated 10/4/2025, documented, 0025 CNA notified this nurse that she observed resident on the floor in her bathroom after hearing a loud crash. This nurse went to assess resident and noted resident to be on the floor flat in the bathroom. This nurse asked resident what happened in which resident stated to this nurse that she was in the bathroom using the bathroom when she went to stand up and got dizzy and fell on her bottom. This nurse asked resident if she was in pain and resident stated to this nurse her back was hurting her. Upon assessment no bruising, bleeding, skin tear/ open areas noted. Resident v/s at the time of incident 149/85, 77hr, 18resp, 99oxygen. This nurse attempted to notify (Power of attorney) and noted phone to be going to (voice mail). This nurse attempted to notify Dr. and received message that there was an application error which was inhibiting the phone call to go through. This nurse attempted to notify on call management for the facility and reached (voice mail). 911 called resident transferred to (local) hospital. Report passed to (Emergency Department) nurse. R3's History and Physical for local hospital, dated 10/4/2025, documented, Impression/Plan Ground level fall Left femur periprosthetic fracture . It continues, History of Present Illness: [AGE] year-old woman with above-mentioned medical problems is brought to the ER from assisted living facility for evaluation after she had a fall. Patient reports that she lives in assisted living facility and went to the bathroom. After she got up, she felt dizzy and fell down without loss of consciousness or head trauma. She called for help and then EMS was called by the staff in the assisted living facility. She is found to have left femur periprosthetic fracture. Her main complaint is acute on chronic low back pain. She does not express any pain in the left hip. R3's CT scan, dated 10/4/2025, documented, IMPRESSION: Postsurgical changes of prior left femoral rodding with findings concerning for loosening. Superimposed infectious process is not excluded. Recommend clinical correlation. There is fracture of the proximal left femoral rodding. R3's Morse fall risk scale, dated 8/19/2025, documented that R3 was at a moderate risk of falling. R3's Fall Risk assessment, dated 5/13/2025, documented that she was at a high risk of falling. R3's Care plan, dated 7/25/2025, documented, I am a high fall risk. Do NOT leave me unattended while in the bathroom or while sitting on the side of the bed. It continued to document, Be sure my call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. R3's Minimum Data Set (MDS), dated [DATE], documented, that her cognition was moderately impaired, no impairment of upper or lower extremities and that she used a walker for ambulation. She required supervision or touching assistance for Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair), Toilet transfer: The ability to get on and off a toilet or commode and going from sitting to standing: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. R3's Incident Audit Report, dated 10/4/2025 documented, Nursing Description: This nurse notified by CNA that resident had fallen in bathroom after assessing resident this nurse noted resident to be expressing pain in her left hip during assessment. Resident Description: Resident stated to this nurse she had taken herself to the bathroom because she didn't want to wait to be taken and when she went to stand up from the toilet, she got dizzy and fell. Resident stated to this nurse she had taken herself to the bathroom because she didn't want to wait on to be taken and when she went to stand up from the toilet, she got dizzy and fell. It continues, Factors: Confused and Current UTI. Predisposing Situational: Ambulating without assist and Using Wheeled walker. 2.R2's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, urinary tract infection, cerebral infarction, hemiplegia and hemiparesis on right dominant side, repeated falls, laceration of scalp, dementia, and lack of coordination. R2's Minimum Data Set (MDS) dated [DATE] documented she was moderately cognitively impaired and required substantial/maximal assistance from staff for toileting hygiene and going from a sitting position to a standing position (which meant the helper does more than half the effort, lifts or holds trunk or limbs). R2's MDS continued to document she required partial/moderate assistance with toilet transfers. R2's Care Plan last revised on 4/10/25 documented she was at risk falls related to gait/balance problems, poor communication/comprehension and psychoactive drug use. R2's fall risk care plan continued to document the following interventions, in part, I am a high fall risk and must not be left alone in the bathroom or sitting on the side of the bed (date initiated 7/21/2025), physical therapy/occupational therapy to evaluate (date initiated 7/23/2025), anticipate and meet the resident's needs (date initiated 1/20/2025), ensure R2's recliner alarm is in place, turned on and working properly (date initiated 8/14/2025), increase visual rounding (date initiated 9/11/2025), staff needs to remain with me in the bathroom as I try to do things for myself and fall (date initiated 9/26/2025). R2's Fall Risk Assessments completed post falls were dated 7/19/25, 8/26/25, 9/1/25, and 9/25/25 all rating her high fall risk. R2's Incident Audit Reports documented she fell on the following dates 7/16/25, 7/19/25, 8/26/25, 9/1/25, and 9/24/25. R2's Incident Audit Report dated 7/16/25 documented the root cause of her fall was that she accidentally put her electric lift chair into the standing position which caused her to slide to the floor. R2's Incident Audit Report dated 7/19/25 documented the writer ran into R2's room after hearing R3 yell out, help she fell, and I can't help her up. The report continued to document the root cause of her fall was that she bent over to get briefs off the floor of her closet and fell on her bottom. R2's Incident Audit Report dated 8/26/25 documented the writer and another registered nurse ran to room as R2's roommate (R3) yelled out, She needs help in here. The report continued to document R2's roommate, R3, stated she was walking from the bathroom to the chair and grabbed onto the wall before falling. The report documented R2 was transferring herself without assist, she was looking for something in her closet, R2 forgets limitations and has had a recent age-related decline in mobility and cognition. R2's Progress note dated 8/26/25 documented Remind resident to use call light before ambulating. Make sure chair alarm is in place and out of reach of resident before leaving the room each time. R2's Incident Audit Report dated 9/1/25 documented R2 was found on the bathroom floor by the CNA in front of the toilet in a seated position. The report continued to document R2 was transferring herself to the bathroom without assist, she has to go to the bathroom and forgets limitations and recent age-related decline in mobility and cognition. R2's Progress note dated 9/1/25 documented, Recommend CNA or nurse to stay with patient while she is on the toilet, since she overestimates her abilities and does not always call for assistance. Recommend frequent reminders to patient that she always needs to call for assistance rather than attempting to do things on her own. R2's Progress note dated 9/5/25 documented, Recommend that resident room be moved closer to nurses station for enhanced observations and quicker response. POA (Power of Attorney) refuses for resident's room to be switch because resident has settled into that room and does not want to change things. R2's Progress note dated 9/10/25 documented, Resident experiencing increased urinary frequency. Urine is dark yellow and cloudy and foul smelling. Order for UA (urinary analysis) and CS (culture and sensitivity) received. Collect tomorrow night to be picked up Friday by lab. R2's Progress note dated 9/17/25 documented, Writer reached out to Doctors office regarding numerous unsuccessful attempts at getting urine sample for UA. Resident refusing straight catheterization to obtain sample. Writer discussed resident's recent change in behavior. Order for CBC (complete blood cell) and BMP (Basic Metabolic Panel) received and to be drawn Friday 9/19/2025. R2's Incident Audit Report dated 9/24/25 documented R2 was on the toilet and while given privacy to have a bowel movement R2 attempted to clean herself and fell off the toilet landing on her left side and hit her head. The report continued to document there was blood noted on her head, left arm and on the floor. The report continued documenting R2 was conscious the whole time and 911 was called with pressure applied to the wounds. R2's Hospital Records dated 9/25/25 documented R2 had a fall and was treated for a right frontal laceration that was repaired with 5 absorbable sutures. R2's Hospital Discharge summary dated [DATE] documented R2 was admitted to the hospital for a fall, urinary tract infection, altered mental status, and wound of sacral region. R2 was discharged on bacitracin topical ointment and cefdinir oral antibiotic. R2's Progress note dated 9/26/25 documented, Writer spoke with residents daughter who voiced concern with residents falls. Writer explained to daughter that the CNA was in the bathroom with the resident who tried to wipe herself and fell forward off of the toilet. Resident didn't want the CNA to wipe her as she wanted to do it herself. Moving forward staff will remain present and assist resident with personal hygiene as needed and as resident allows. Explained to daughter that the resident did have rights and we cannot force her to allow staff to wipe her. However, staff will again remain in the bathroom with her at all times while the resident is in there. R2's Progress note dated 9/26/25 documented, Resident sent to hospital r/t (related to) fall right forehead laceration and received 5 absorbable laceration 3 cm (centimeter) X (by) 0.5 cm. Resident also has UTI (urinary tract infection) and is currently taking ABX (antibiotics). On 10/9/25 at 11:05 AM, V5 (CNA) stated R2 is a high fall risk, she used to turn her bed and chair alarms off so they would have to hide the box from her but now after she came back from the hospital from her last fall she stays in bed. V5 stated she takes care of R2 on the night shift and she typically doesn't get up. V5 stated if R2's alarms are in place, she will hear them if she triggers it. V5 stated she walks the halls constantly checking in on the residents and assisting with needs as needed to prevent falls. V5 stated when she notices a resident is unsteady on their feet or having difficulties with tasks, she will constantly check on them. V5 stated R2 always has her call light in reach but rarely uses it. V5 stated after a resident falls, she doesn't move them, goes to get a nurse, they will assess the resident and then will either call 911 or transfer the resident to the bed or chair with a full body mechanical lift. V5 stated we find out updates on interventions in reports each shift. On 10/9/25 at 11:40 AM, V7 (CNA) stated R2 would frequently get up to go to the bathroom without calling for help. V7 stated R2's hall has a lot of confused residents at risk for falls. V7 stated after 2:00 PM they only have 1 CNA for 23 residents now and they really need 2, it's hard to keep up. On 10/9/25 at 11:42 AM, V6 LPN stated her main concern for R2 is falling. V6 stated she does regular checks on her and makes sure her alarms are on. V6 stated there is only 1 nurse working from 10:00 PM to 6:00 AM with 3 CNAs. V6 stated R2 was always getting up to go to the restroom without calling for help but now she has a urinary catheter and doesn't get out of bed. V6 stated after a fall occurs, they document, go over new interventions and the care plan. V6 stated new updates on falls are discussed during daily shift reports. V6 stated falls are always a concern. On 10/14/25 at 11:40 AM, V10 (Medical Director) stated a resident showing urinary tract infection symptoms or a change in mental status would be at an increased risk for falls and he would expect staff to put in place fall precautions. V10 stated he would expect staff to be following the resident's care plan. On 10/14/25 at 1:30 PM, in a joint interview with V1 (Administrator) and V2 (Director of Nursing), V2 stated she would expect to be notified of a significant change. V1 and V2 stated it is the resident's right to have privacy. V1 and V2 both stated they would expect the care plans to be followed. The facility's Falls policy dated 6/2024 documented it is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. The policy continued to document each resident will be assessed using the MDS upon admission, quarterly and with any significant change assessment. The potential for falls will be care planned when appropriate, based on the results of the Fall Risk Assessment. The Interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the resident.

Based on interview and record review, facility failed to have sufficient nursing staff to assure resident safety and care for 4 of 7 (R3, R5, R6 and R7) residents reviewed for staffing. This failure has the potential to affect all 96 residents residing in the facility. Findings include:1.R3's Progress note, dated 10/4/2025, documented, 0025 CNA notified this nurse that she observed resident on the floor in her bathroom after hearing a loud crash. This nurse went to assess resident and noted resident to be on the floor flat in the bathroom. This nurse asked resident what happened in which resident stated to this nurse that she was in the bathroom using the bathroom when she went to stand up and got dizzy and fell on her bottom. This nurse asked resident if she was in pain and resident stated to this nurse her back was hurting her. Upon assessment no bruising, bleeding, skin tear/ open areas noted. Resident v/s at the time of incident 149/85, 77hr, 18resp, 99oxygen. This nurse attempted to notify (Power of attorney) and noted phone to be going to (voice mail). This nurse attempted to notify Dr. and received message that there was an application error which was inhibiting the phone call to go through. This nurse attempted to notify on call management for the facility and reached (voice mail). 911 called resident transferred to (local) hospital. Report passed to (Emergency Department) nurse. R3's Minimum Data Set (MDS), dated [DATE], documented, that her cognition was moderately impaired, no impairment of upper or lower extremities and that she used a walker for ambulation. She required supervision or touching assistance for activities of daily living. R3's Care Plan, dated 7/25/2025, documented, Be sure my call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. It continues, I am a high fall risk. Do NOT leave me unattended while in the bathroom or while sitting on the side of the bed. 2. On 10/14/2025 at 10:50 AM, R6 stated that there was not enough help on the night shift and that usually it is just 1 nurse and 1 CNA and that both shifts could use more help. R6, MDS, dated [DATE], documented that her cognition was intact, that she was dependent upon staff for transfers and mobility. 3. On 10/14/25 at 10:50 AM, R5 stated the facility hardly has any nurses, they need more. R5's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, atrial fibrillation, heart failure and unsteadiness on feet. R5's MDS dated [DATE] documented she was cognitively intact. R5's Care Plan revised on 4/10/25 documented she was at risk for falls. 4. On 10/14/25 at 10:55 AM, R7 stated in the evening and night, there is only 1 CNA and there needs to be more. R7 stated she does not get rounded on every 2 hours. R7 Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, pneumonia, atrial fibrillation and heart failure. R7's MDS dated [DATE] documented she was cognitively intact, uses a wheelchair and required supervision or touching assistance from staff for going from a sitting position to standing. R7's Care Plan revised on 7/7/25 documented she was at risk for falls with the following interventions, in part, do not leave R7 unattended while in the bathroom or while sitting on the side of the bed and anticipate and meet her needs. On 10/9/2025 at 10:06 AM, V4, Licensed Practical Nurse (LPN) stated she was the only nurse working the night of 10/4/ 2025 and she had 3 hallways to take care of. On 10/9/2025 at 11:00 AM, V5, Certified Nursing Assistant (CNA), stated that the night that R3 fell, she was the only CNA for that hallway and that is usually the normal staffing for that hall. On 10/14/2025 at 12:30 PM, V9, Scheduler, stated that there are 3 shifts that she schedules for but nurses and CNA's work 12-hour shifts. V9 stated that V1, Administrator and V2, Director of Nurses, but mainly V2, will tell her how many CNA's and Nurses to schedule for each shift. She continued to state that she schedules 10 CNA's and 5 nurses for day shift and 7 CNA's and 2 Nurses for the night shift and that at night 1 nurse is on one side of the building with 2 halls, and the other is on the other side, and they would have 3 halls. The nurse that has the 2 halls has a total of 4 CNA's and the other 3 halls has a CNA on each hall to take care of residents. On 10/9/25 at 11:40 AM, V7 (CNA) R2's hall has a lot of confused residents at risk for falls. V7 stated after 2:00 PM they only have one CNA for 23 residents now and they really need two, it's hard to keep up. On 10/9/25 at 11:42 AM, V6 (LPN) stated there is only one nurse working from 10:00 PM to 6:00 AM with three CNAs for this side of the building. On 10/14/2025 at 1:45 PM, V1, Administrator, stated that they do not have policy for staffing the facility with nursing staff, but they follow the CMS minimum staffing rules and their facility assessment. Reviewed staff assignment sheets for 7/29/2025, 7/30/2025,9/24/2025, 10/3/2025, and 10/4/2025 all documented that on these dates from 6:00 PM to 6:00 AM, there was 1 nurse and 1 CNA for the hall where R2, R3, R4, R5, R6 and R7 reside. The facility's Grievance Form dated 8/18/25 documented, CNAs need to be checking on the residents every 2 hours to make sure needs are being met. Resident council meeting minutes dated 8/18/2025 documented Call lights are not being answered in a timely manner- all shifts/all hallways. It continues, Skilled unit- CNA's need to check on residents at least every two hours to make sure needs are being met. The Facility Assessment Tool, dated 01/2024 through 12/2024, documented, Staffing plan 4.2. Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Examples of two different ways to look at your staffing plan are provided in the tables below. Choose a methodology that works best for your organization. You may elect to use one or both tables below or choose your own methodology. It may be helpful to review specific staffing references in the regulation regarding the facility assessment ( 483.71). For a discussion on how to determine sufficient staffing, see Appendix 2 Section 7.b. Our facility regularly evaluates staffing, equipment, infrastructure, and services to ensure we effectively meet resident needs while maintaining regulatory compliance and financial stability. We remain committed to continuous quality improvement to enhance resident safety, care quality, and operational efficiency. Staffing calculations we follow: 1. Determine the number of residents needing skilled care. 2. Multiply the number of skilled care residents by 3.8 hours per resident per day. 3. Add the total number of hours needed for each level of care. 4. Multiply the total number of hours by 25% to get the minimum number of licensed nurse hours. 5. Multiply the total number of hours by 10% to get the minimum number of registered nurse hours. It continues, Direct care staff Refer to CMS Minimum staffing rule: 8-9 CNA on day shift, 7 CNA on evening shift, 7 CNA on night shift. The facility's Centers for Medicare and Medicaid Services, dated 10/08/2025, documented that there were 96 residents that reside in the facility.

Based on interviews, observations, and record reviews the facility failed to implement and revise resident care plans after resident falls for 4 out of 7 residents (R2, R3, R4 and R7); reviewed for Resident Care Plans in a sample of 7. Findings include:1. R2's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, urinary tract infection, cerebral infarction, hemiplegia and hemiparesis on right dominant side, repeated falls, laceration of scalp, dementia, and lack of coordination. R2's Minimum Data Set (MDS) dated [DATE] documented she was moderately cognitively impaired and required substantial/maximal assistance from staff for toileting hygiene and going from a sitting position to a standing position (which means the helper does more than half the effort, lifts or holds trunk or limbs). R2's MDS continued to document she required partial/moderate assistance with toilet transfers. R2's Care Plan last revised on 4/10/25 documented she was at risk falls related to gait/balance problems, poor communication/comprehension and psychoactive drug use. R2's fall risk care plan continued to document the following interventions, in part, I am a high fall risk and must not be left alone in the bathroom or sitting on the side of the bed (date initiated 7/21/2025), physical therapy/occupational therapy to evaluate (date initiated 7/23/2025), anticipate and meet the resident's needs (date initiated 1/20/2025), ensure R2's recliner alarm is in place, turned on and working properly (date initiated 8/14/2025), increase visual rounding (date initiated 9/11/2025), staff needs to remain with me in the bathroom as I try to do things for myself and fall (date initiated 9/26/2025). R2's Incident Audit Reports documented she fell on the following dates 7/16/25, 7/19/25, 8/26/25, 9/1/25, and 9/24/25. R2's Fall Risk Care Plan was not updated after her falls dated 7/16/25 and 8/26/25. 2.R4's Face Sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, dementia, aphasia, and lack of coordination.R4's MDS dated [DATE] documented he was severely cognitively impaired and required partial/moderate assistance from staff for all transfers. R4's Care Plan initiated on 7/16/25 documented he was a high risk for falls related to deconditioning, gait/balance problems, dementia, history of seizures, diabetes, osteoarthritis. Interventions included on R4's Fall Risk Care Plan included the following, in part, to ensure bed alarm is in place, turned on and working properly (Date Initiated: 7/16/2025), ensure chair alarm is in place, turned on and working properly (Date Initiated: 7/16/2025), ensure that the resident is wearing appropriate footwear (non-skid socks) when ambulating or mobilizing in w/c (Date Initiated: 7/16/2025), and to follow facility fall protocol (Date Initiated: 7/16/2025). R4's Incident Audit Reports documented he fell on the following dates 7/30/25, 8/11/25, 8/19/25, 8/21/25 and 9/3/25. R4's Care Plan was not updated after his falls occurring on 8/11/25 and 8/19/25. R4's Incident Audit Report dated 8/21/25 documented it was noted that R4 had his own socks on, which were slick and not the socks with treads. The facility's Grievance form dated 9/15/25 documented, Family would like bed alarms on bed, w/c (wheelchair) and recliner at all times. He went to see physician yesterday and did not have w/c alarm. The form continued to document bed and chair alarms are care planned for this resident; recommendations/action taken were to ensure bed and chair alarms are on and in place. 3.R7's Face Sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, pneumonia, atrial fibrillation and heart failure. R7's MDS dated [DATE] documented she was cognitively intact, uses a wheelchair and required supervision or touching assistance from staff for going from a sitting position to standing. R7's Care Plan revised on 7/7/25 documented she was at risk for falls with the following interventions, in part, do not leave R7 unattended while in the bathroom or while sitting on the side of the bed and anticipate and meet her needs. On 10/14/25 at 10:55 AM, R7 stated the staff pays no attention to preventing falls, she doesn't get any assistance to the restroom and does most things on her own. On 10/14/25 at 11:40 AM, V10 (Medical Director) stated a resident showing urinary tract infection symptoms and a change in mental status would be at an increased risk for falls. V10 stated he would expect staff to put in place fall precautions if a resident's mental status declined. V10 stated he would expect staff to be following the resident's care plan. On 10/14/25 at 1:30 PM, in a joint interview with V1 (Administrator) and V2 (Director of Nursing), both stated they would expect the care plans to be followed. 4. R3's Face Sheet, dated 10/14/2025, documented a diagnosis of Periprosthetic Fracture around internal Prosthetic Left Hip Joint and Alzheimer's Disease. R3's Incident Audit Report, dated 7/26/2025 at 9:42 PM, documented, Writer and CNA at desk and heard a loud scream. Resident noted to be on floor on left side on bottom and head against wall when writer walked in room. V2, Dir of Nurses documented the Root cause analysis as Resident turned around to fast while leaving her bathroom and lost her balance. Fall Management Review document back dated for 7/28/2025 at 11:36:00 on 8/3/2025 11:41:48 documented, Background: Resident ambulates using her walker and transfers with assist of 1. Resident forgets to use her call light at times. It continues, Recommendations: Reeducated on using call light for assistance. R3's Care Plan, dated 7/25/2025, documented, I am a high fall risk. Do NOT leave me unattended while in the bathroom or while sitting on the side of the bed. But there was not an intervention put in place after R3's fall on 7/26/2025. The facility's policy, Care Plan Process, dated 11/2017, All plans of care must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessment. The facility's policy, Fall Assessment and Management, dated 6/2024, documented, C. Care planning after a fall: 1. A licensed nurse will consult with the resident's care givers and other interdisciplinary team members in regard to future intervention, and resident specific risk factors. 2. Potential environmental hazards will be reported to the Environmental Services Department.

Based on interview, observation, and record review, the facility failed to provide privacy while performing incontinence care and failed to provide dignity during dining assistance for 5 of 24 residents (R7, R9, R40, R60, R64) reviewed for resident privacy and dignity in the sample of 48. Findings include: 1. R9's admission Record, dated 8/20/25, documents R9 was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (DM), Malnutrition, Congestive Heart Failure (CHF), Atherosclerotic heart Disease (ASHD), Osteoarthritis, Spinal Stenosis, Falls, Hypertension (HTN). R9's Minimum Data Set, dated [DATE], documents R9 is cognitively intact. On 8/20/25 at 11:20 AM, V22, CNA, provided incontinence care to R9. V22 failed to close the door to the room, pull the curtain around the bed, or close the blinds to the window. R9's bed was close to the window with a courtyard outside her window. There was a person walking around watering flowers while incontinent care was going on with R9 being exposed to the window. R9 stated I did not know there was someone outside the window because normally there isn't. I wouldn't like anyone to see me naked through the window, it's embarrassing and it is nothing the public should see. On 8/21/25 at 1:10 PM, V22 stated that Anytime I am doing resident care, the door, the curtain, and the blinds should be closed to maintain the resident's privacy. I did not think about it when I was taking care of (R9) and had thought I at least closed the door. On 8/21/25 at 9:25 AM, V1, Administrator, stated I would expect staff to provide privacy for the resident while performing care, including closing the door, pulling the curtain, and closing the blinds. The Facility's Resident Rights booklet, dated 3/2017, documents You have the right to Privacy: Your medical and personal care are private. 2. On 8/18/25 at 12:57 PM, V10, Registered Nurse, (RN) is standing feeding R64 lunch. On 8/19/25 at 9:10 AM V12, Certified Nurse Aide, (CNA) is standing while feeding R64 lunch. R64’s admission Record, print date of 8/21/25, documents R64 was admitted on [DATE] and has a diagnosis of Alzheimer’s Disease. R64’s MDS, dated [DATE], documents R64 is severely cognitively impaired and is dependent on staff for dining. 3. On 8/18/25 at 12:57 PM, V11, CNA is standing feeding R40 lunch. R40’s admission Record, print date of 8/20/25, documents R40 was admitted on [DATE] and has a diagnosis of Severe Dementia. R40’s MDS, dated [DATE], documents R40 is severely cognitively impaired and dependent on staff for eating. 4. On 8/19/25 at 12:52 PM, V2, Director of Nurses, (DON), is standing while feeding R7. R7’s admission Record, print date of 8/20/25, documents R7 was admitted on [DATE] and has a diagnosis of Dementia. R7’s MDS, dated [DATE], documents R7 is severely cognitively impaired and requires set up clean up assistance. On 8/20/25 at 1:47 PM, V1, Administrator, stated the facility does not have a policy on feeding residents, but staff should sit with the resident instead of standing over them. 5. On 08/18/2025 at 1:08PM V9, CNA standing up and feeding R60 his meal in main dining room. R60's face sheet documents in part a diagnosis of unspecified Dementia, unspecified severity with agitation. R60's care plan dated 6/7/2025 documents R60 at risk for nutritional problems related to potential weight loss, poor intake, hypertension and UTI. R60's care plan documents interventions; R60 prefers to eat in dining room for meals, staff is available to assist if needed.

Based on record review and interview the facility failed to ensure adequate supervision, and precautions in place for falls for 1 of 3 residents (R2) reviewed for accidents in the sample of 8. This failure resulted in R2 falling off bed fracturing her femur and requiring surgical repair. Findings include: R2's Order Summary Report, undated, documented she had the following diagnoses: unilateral primary osteoarthritis, dependence on wheelchair, muscle weakness, unsteadiness on feet, unspecified lack of coordination, abnormal posture. R2's initial report to Illinois Department of Public Health (IDPH) dated 6/24/2025 documents R2 slid off the bed on 6/23/2025 at 8:00AM. The report documented CNA (Certified Nurse's Assistant) was assisting (R2) with her morning cares including dressing, personal hygiene, and transferring her from her bed to her wheelchair. (R2) was sitting up on the side of her bed and slide off the mattress onto the floor on her left side. The report documented Interventions put into place to ensure that resident has ‘gripper socks' on at all times while in bed. R2's X-ray report dated 6/24/2025 at 11:51AM documents R2 presented to the emergency room after a fall this morning. R2's x ray report documents distal femoral shaft fracture.R2's orthopedic report dated 6/25/2025 documents R2 requires surgery of left femur.R2's Fall Risk assessment dated [DATE] documents R2 is a high risk for falls. R2's fall risk assessment documents a score of 60. (High risk 46 or greater). R2's fall risk assessment documents R2 has fallen before and has impaired gait.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact with a Brief Interview Mental Status (BIMS) of 14. R2's MDS documents selfcare- 2 needed some help - resident needed partial assistance from another person to complete any activities. R2's MDS documents R2 has impairment of lower extremities on both sides. R2's MDS documents R2 is dependent on staff for toileting hygiene, showers, transfers from bed to a chair or wheelchair. The MDS documented regarding the ability to move from sitting on side of bed to lying flat on bed and the ability to move from lying on the back to sitting on the side of the bed with no back support R2 required substantial/maximal assistance. R2's Care Plan, revised 6/8/2025 documents R2 has an Activity of Daily living (ADL) selfcare performance deficit related to gait balance problems, CKD (chronic kidney disease), muscle weakness, diabetes, HTN (hypertension), CAD (coronary artery disease). R2's care plan documents the following interventions: 6/9/2025 transfer: R2 requires dependent staff assist times 2 with a mechanical lift with transfers.R2's Care Plan, dated 7/1/2025 documents R2 is a high risk for falls related to (r/t) Gait/balance problems, CKD, muscle weakness, diabetes, HTN, CAD. R2's care plan documents the following interventions: 6/26/2025 will continue to work with therapy as ordered, 4/30/2025 Anticipate and meet the resident's needs, Be sure my call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, educate me/family/caregivers about safety reminders and what to do if a fall occurs, follow facility fall protocol, my family has transferred me from one surface to another. Educate them and I that this is not safe and that all transfers should be done with staff only, Pt evaluate and treat as ordered or PRN. R2's Care Plan failed to document gripper socks as documented in fall investigation to ensure gripper socks in place.V7's, Certified Nurse's Assistant, CNA, witness statement dated 6/24/2025 documents V7 left R2 sitting on side of bed while V7 left the room to get the sit to stand lift. The statement documented I was assisting (R2) in bed to get ready for the day. I sat her on the side of the bed to empty out her (indwelling catheter) (and) to assist w (with) getting up. I was told she uses the sit to stand to get up. I left her sitting on the side of the bed because her feet were touching the ground, and she was holding onto the bed. When I came back in from getting the sit to stand (I was only out of the room for 15 secs (seconds) as it was right outside the room) (R2) was sliding down, kinda like she assisted herself to the ground.On 7/14/2025 at11:03AM, R2 stated she was a sit to stand transfer prior to breaking her femur. R2 stated she was sitting on side of bed and CNA left room to get the lift and was just getting back in room and turned to get sling, R2 stated she told CNA she was falling.On 7/16/2025 at 1:51PM, V1, Administrator, stated fall interventions are to be in place after each fall. V1 stated she would expect care plan to document all fall interventions.On 7/16/2025 at 1:55PM V2, Director Of Nursing (DON) stated R2 is a high fall risk and should not be left sitting on bedside. The Facility's Fall policy, revised 6/2024, documents it is the policy of the facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned.

Based on interview and record review, the facility failed to provide supervision for 1 of 4 (R2) residents, reviewed for falls in a sample of 4. This failure resulted in R2 sustaining a left hip fracture. Findings include: R2's Diagnosis list, dated 1/14/2025, documented diagnoses of high risk for injury related to falls, Dementia, and Lewy Body Dementia. R2's Morse Fall Scale, dated 1/8/2025, documented that she was a high fall risk. R2's Minimum Data Set, dated dated [DATE], documented that her cognition was severely impaired, that she was occasionally incontinent of urine and that she required substantial to maximum assistance with toilet transfers. R2's Care Plan, dated 1/8/2025, documented, Anticipate and meet the resident's needs. It continues, Be sure my call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. R2's Fall investigation, dated 1/12/2025, documented, Writer summoned to room by CNA. Writer observed pt lying on (Right) side in front of toilet. Resident Description: I tried to get up. Was this incident witnessed: (NO) It continues, Root Cause: Resident new to facility and attempted to walk back to her bed from her toilet without calling for assistance. R2's local hospital history and physical, dated 1/14/2025, documented, [AGE] year old lady who has a known history of dementia was recently admitted to the hospital for (non-s-t elevation myocardial infarction) and pneumonia and was discharged to rehab last week has been doing well in rehab. He (sic) is usually able to take a few steps on Sunday she was trying to walk and has a fall. At that time, she hit her head, and she was complaining of lower back pain yesterday she worked with physical therapy she was able to de (sic) few steps she was hunched over but still was able to do some therapy and this morning she was having difficulty with legs so was brought into the ER she was diagnosed with left hip fracture . R2's local hospital Xray result, dated 1/14/2025, documented, Findings Mildly displaced intertrochanteric fractur with resultant varus angulation. No pelvic or distal femoral fracture. Impression: Left intertrochanteric fracture. On 1/21/2025 at 2:20 PM, V6, LPN, stated that she knew R2 had a fall history and was a high fall risk. She continued to state that her shift, day shift, did not leave her on the toilet alone because they all knew she was a high fall risk and that there was a white board in R2's room that had written on it that she was a high fall risk. On 1/22/2025 at 9:43 am V7, Licensed Practical Nurse (LPN), stated that she was the nurse who assessed R2 after her fall. V7, stated, The CNA, (V11), came and got me because (R2) was on the floor in the bathroom. She was lying on her right side on the floor. She had a scrape above her right eyebrow and had no complaints of pain. V7 continued to state that she did active and passive range of motion of her legs and arms and there was no issues. V7 stated that she spoke with R2's granddaughter because her power of attorney did not answer the phone. V7 stated that her granddaughter told her that her grandmother falls all the time. V7 was asked, if she knew R2 was a high fall risk and she stated yes and that there was a call don't fall sign in her room and that all rooms have these signs. V7 also stated she did not think R2 knew how to use the call light or what it was for because of her dementia. V7 stated that she did not know why V11, Certified Nurse Assistant (CNA), put her on the toilet and then left the room, maybe to help another resident. On 1/22/2025 at 9:45 am V9, CNA, stated that on 1/14/2025, she went to get R2 up for the day, she assisted her with sitting on the side of her bed, because she wasn't sitting up very well. She was able to transfer R2 into her wheelchair, into the bathroom and on to the toilet with R2 using the assistance bar in the bathroom because R2 was having trouble standing up that day and usually she transferred pretty good. Once R2 was finished using the toilet, V9 stated that she assisted her back into her wheelchair, got her dressed and took her to the dining room for breakfast. V9 stated that R2's appetite was poor that morning, only taking in about 75% of her meal when she usually eats 100%. V9 stated that R2 told her that she was having pain in both of her hips and in her back. V9 stated that she let the nurse know (V10, LPN), they laid her down and (V10, LPN) checked her out. V9 stated that R2 was in pain and had facial grimacing when she transferred her. V9 stated that R2 was a high fall risk but she never tried to get up on her own. V9 stated that she would not leave R2 unattended on the toilet nor would she never depended on R2 using her call light when she needed to get off of the toilet and that she would stay with her until she was finished. On 1/22/2025 at 10:30 am V10, LPN, stated that R2 never asked for pain medication usually but said her hips and back hurts. V10, stated, The CNA (V9) was putting the footrest on (R2's) wheelchair, and her left leg was rotated outwardly, The CNA (V9) and myself, laid (R2) down in bed and I assessed her further. R2's left leg was rotated outward and shortened. I called her doctor for a stat Xray of those areas, and he wanted her sent to the ER immediately. V10 stated that R2 was a high fall risk by just looking at her diagnosis. V10 stated that she told her CNA's who she works with and the oncoming shift not to leave her alone when on the toilet and she should have never been left alone on the toilet. V10 also stated that with R2's dementia she would not know when or how to use the call light. On 1/22/2025 at 9:30 AM, V8, Licensed Physical Therapy Assistant, (LPTA), stated that she worked with R2 on 1/13/2025, the day after she fell , she did not complain of any pain. V8 also stated that R2 could not safely transfer herself on or off of the toilet. V8 stated that R2 could hold a call light but did not think she would understand how to use it. V8 stated that from a safety standpoint someone should have stayed in the bathroom with her. On 1/22/2025 at 9:45 am, a phone call was placed, and a message was left for V11, CNA, to return call. V11, did not return phone call. On 1/22/2025 at 11:00 am V2, Director of Nurses, when asked since R2 was a high risk for falls, should she have been left unattended on the toilet? V2 stated no. When asked if a resident, who is a high risk of falls, what type of interventions would be put immediately into place when they are admitted with a history of falls, she stated that some time a bed and chair alarm, and a call don't fall sign. V2 was asked how does the staff know, agency staff included, who is a high risk for falls and interventions? V2 stated that agency should check the residents care plan and also when they get report from the previous shift, they should be let known. An electronic mail document from V12, R2's Physician, containing questions from the state agency and his responses regarding R2's fall, cognition and safety, dated 1/27/2025, documented, 1. Could a fall from the toilet, onto the floor, possibly cause a left hip fracture even though she was found on her right side? Possibly. 2. Do you think that this injury could have been prevented if the facility staff would have stayed with her until she was ready to get off the toilet and not leave her unattended due to her severely impaired cognition and dementia? Yes. 3. Do you think (R2) could understand how to use a call light with her cognition being impaired? Unable to determine at this time. The facility's policy, Subject: Fall Assessment and Management Policy, dated 6/2024, documented, It is the policy of this facility to assess each resident's fall risk on admission, quarterly and with each fall. this will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. It continues, D. All staff providing care for the resident will have access to the care plan and/or Kardex.

Based on observation, interview and record review, the facility failed to ensure medications were securely stored, failed to ensure opened medications were labeled with open dates, and the facility was using expired blood glucose control liquids for 16 of 24 residents (R2, R11, R13, R14, R15, R21, R22, R23, R33, R41, R43, R51, R54, R57, R66, R179) reviewed for medication storage in the sample of 55. Findings include: On 8/6/2024 at 11:35 AM, a medication cart was observed with V7, Licensed Practical Nurse (LPN). At this time: 1. There was an open bottle of Timolol eye drops with R13's name on it. At this time V7 stated she couldn't tell the surveyor the date the bottle was opened, because she did not open it, but V7 knows everything is supposed to be dated when it is opened. R13's Physician's Orders dated 10/21/2020 documents, Timolol Maleate Solution 0.25 %- Instill 1 drop in both eyes in the morning for Glaucoma. 2. There was an open bottle of Durezol with R14's name on the label. There was no date to indicate when the bottle was opened. This information was also confirmed by V7. R14's Physician's Orders dated 5/9/2024 documents that R14 is prescribed Durezol Ophthalmic Emulsion 0.05 % (Difluprednate)-Instill 1 drop in right eye six times a day for inflammation. 3. In the bottom of the drawer, there was an open tube of Systane (eye lubricant) that was unlabeled. At this time, V7 stated she knows the tube belongs to V54 because she is the only resident on it. V7 then said, Look her box is here. There was another opened tube of Systane enclosed in the box. R54's Physician's Orders dated 2/6/2024 documents, Systane Nighttime Ophthalmic (eye) Ointment- Instill 1 drop in both eyes every 1 hours as needed for dryness. 4. On 8/8/2024 at 12:53 PM, the Facility's medication storage room was observed with V7. At this time, there was an opened bottle of Pantoprazole Oral Suspension labeled with R57's name on it and an expiration date of 6/8/2024. At this time, V7 stated, That should have been thrown away a long time ago. R57's Physician's Orders dated 5/30/2024 documents, Pantoprazole Sodium Oral Suspension 4 MG/ML (milligram per milliliter) give 1 ML via G-tube (Feeding tube) in the morning. 5. On 8/8/2024 at 12:50 PM, There was a cart located behind the Nurses Station that was noted to be unlocked. This observation was confirmed with V7. At this time V7 stated the medication cart was V8's (Registered Nurse) but V8 had left off the floor (left the area). At this time V7 unlocked the medication storage room and entered with this surveyor. V7 didn't not lock the medication cart (which can be done by pushing a button/lock). On 8/8/2024 at approximately 12:55 PM, after inspecting the medication room (approximately 5 minutes). V7 and this surveyor came out of the medication storage room and V7 stated, Oh there's (V8). At this time V8 was asked if the medication cart was V8's and why was it unlocked. V8 stated I guess because I forgot to lock it. On 8/12/2024 at 11:40 AM, V2, Director of Nursing, stated she expects all medication bottles including eye drops, to be dated when opened and labeled with the resident's name. V2 continued to state expired medications should be disposed of and the medication cart should be locked when unattended. The Facility's Policy Storage of Medication, undated, documents, Al discontinued/expired medications are to be removed from the active storage/medication use area. The policy does not address the labeling and dating of medications nor ensuring medications within the medication carts are secured by locking the cart while unattended. 33112 6. Both the high and low blood glucose machine control liquids had expiration dates of 3/4/24. On 8/6/24 at 12:20 PM, V7 stated that the control liquids are not her responsibility to check and see if they are in date. On 8/6/24 at 12:45 PM, the Zone 3 Hall cart was observed with V8, Registered Nurse. Both the high and low blood glucose machine control liquids had expiration dates of 3/4/24. On 8/6/24 at 12:50 PM, V2, Infection Preventionist, Licensed Practical Nurse, stated, It's night shifts responsibility to check the control liquids. The facility provided listof Diabetics, undated, documents that R2, R11, R14, R15, R21, R22, R23, R33, R41,R43, R51, R66, and R179 are the residents residing on Zone 2 and 3 that are Diabetics. The policy Blood Glucose Testing and Monitoring, dated 2/2016, fails to document how the blood glucose monitor quality control measures.

Based on observation, record review and interview the facility failed to implement infection control practices, failed to wear Personal Protective Equipment (PPE), failed to disinfect multi-use equipment, failed to test residents with COVID-19 symptoms, and failed to ensure residents and staff were tested on COVID-19 days to prevent the spread of COVID-19 infection for 8 of 24 residents (R6, R13, R24, R30, R38, R43, R45, R178) reviewed for infection control in the sample of 55. Findings include: 1. On 8/5/2024 at 11:28AM V23, Licensed Practical Nurse (LPN) donned a gown, placed a surgical mask over a N95 mask, donned gloves, but did not sanitize their hands prior to donning gloves. V23 removed a blood glucose glucometer from a drawer of medication cart and entered R43's room and obtained an accu check. R43 then exited the room with the blood glucose machine and laid it on top of a dispatch wipe on the medication cart. At 11:46AM V23, LPN stated they need to give report to a nurse relieving her. V23 takes the glucometer in dispatch wipe and rubs it few times and places it in drawer of medication cart. R43's physician order (PO) dated 8/5/2024 documents contact/droplet isolation x 10 days. R43's progress notes dated 8/4/2024 documents R43 is positive for COVID 19. The facility infection prevention and control policy and procedure dated revised July 26, 2021, documents the facility uses the CDC guidelines for instruction regarding infection prevention and control practices. The facility Covid -19 testing and response plan dated revised 8/29/2023 documents dedicated medical equipment should be used when caring for a resident with suspected or confirmed SARS-Cov-2 infection. Reusable equipment must be cleaned and disinfected between residents. On 8/12/2024 at 12:25PM, V2, Director of Nursing (DON) stated the facility does not dedicate blood glucose machines to COVID-19 positive residents. V2 stated the facility uses dispatch disinfecting wipes and items are to be cleansed for 3 minutes. 33112 On 8/8/24 at 11:47 AM, V2, Infection Preventionist, stated, On 7/6/24 when we had 2 cases on the rehabilitation unit (VTR). It was R4 and R42. At that time, we tested residents and staff just on that hall. The staff began to wear N95 masks and full PPE when caring for a resident with COVID, no dining room activities, and the rehabilitation unit has dedicated staff, so they weren't going to other halls. We were testing on Tuesdays and Thursdays. I did have a week off during the outbreak and staff nurses were supposed to test all residents and document in the computer system that they were tested and the results. I have realized that this didn't exactly happen. On 7/29/24 (R24's son) took her (R24) to the hospital and she did test positive for COVID. On 8/4/24, I received a phone call telling me we had a couple of employees test positive. We had some that tested before their shift andwere positive, so they did not work. One was an agency nurse and she tested positive at the end of her shift. At that point, we started testing all residents and all staff members facility wide. The zone 2 and 3 residents are eating their meals in their rooms and staying in their rooms. We continued testing on Tuesday and Thursday. All agency and our staff are supposed to test before every shift. They go to a floor nurse and get tested . The staff write their name, and the nurse will fill-in the result. Any resident that has any type of COVID symptom, cold symptom, or allergy symptom should be tested then and not wait until the next test date. Staff should be wearing a N95 mask, gown, gloves, and face shield / goggles. If multi- use equipment is used on a COVID positive resident it should be disinfected before it is used again. We have been in-touch with the Health Department and letting them know of our outbreak status. 2. R24's Admission Record, print date of 8/12/24, documents that R24 was admitted on [DATE] with diagnoses of Congestive Heart failure and Hypertension. R24's Health Status Note, dated 7/16/2024 at 06:48, documents, Res. (resident) tested for COVID and negative. R24's Electronic Medical Record (EMR) fails to document COVID testing being completed between 7/17/24 and 7/29/24. R24's Health Status Note, dated 7/27/2024 at 14:36, documents, Call out to (V19, Physician) to inform him that res. is c/o (complaint of) nasal drainage dripping down the back of her throat which is causing her throat to be irritated and cough. Also, c/o watery eyes and allergy symptoms. Requesting orders for Flonase and Zyrtec daily. (V19) to return call. R24's Health Status Note, dated 7/27/2024 at 14:46, documents, Received call back from (V19) - new orders received for Flonase nasal spray, 1 spray in each nostril daily & Zyrtec 10 mg (milligram) daily for allergies. R24's Health Status Note, dated 7/29/2024 at 11:03, documents, Son, came to desk and stated that he was going to take patient to (local hospital) himself at this time. Face sheet and medicine orders copied and given to son. Patient was sitting in wheelchair alert to surroundings, talking with her daughter who was standing beside her. R24's Health Status Note, 7/29/2024 15:44, documents, Resident admitted to hospital Covid positive. R24's Clinical Admission, dated 8/2/24 5:41 PM, documents, Admission Details: Arrived by: Arrived by - Other: Facility transport. R24's Hospital History and Physical, dated 7/29/24, documents, Impression: Pyelonephritis vs COVID - 19. Patient tested positive in the ED (Emergency Department) Currently saturating 96 % O2 (oxygen on room air, Patient is asymptomatic, negative, CXR (chest x-ray) shows no evidence for acute pneumonia viral panel negative. 3. On 8/6/24 at 1:05 PM, V20, Agency Certified Nurse's Aide, (CNA), was questioned when she was tested for COVID last, V20 stated, Last week. V20 was questioned if she was tested at the facility or at another facility, V20 stated, I tested myself at home. 4. The facility COVID Outbreak Line List of Residents documents that R30 tested positive on 8/6/24, R45 tested positive on 8/13/24, R38 test positive on 8/6/24, R178 tested positive on 8/4/24, and R6 tested positive on 8/6/24. On 8/6/24 all of these residents except R45 (who was negative at the time) had signage on the door indicating staff must wear a N95 mask, gown, gloves, and eye protection and an isolation cart outside of their doorway. On 8/6/24 at 12:46 PM, V20 CNA was observed passing lunch meal trays on the Skilled 3 hall. V20 was wearing a N95 mask. V20 entered R30's room with her meal tray. V20 did not perform hand hygiene before entering the room. V20 only wore a N95 mask. V20 moved items around the bedside table to make room for the meal tray and set up R30's meal tray. V20 exited the room, went to the lunch tray cart, touched multiple trays looking for R45's meal tray. V20 found the tray and entered R45's room and delivered and set up R45's meal tray. V20 exited the room, went to the lunch tray cart, touched multiple trays looking for R38's meal tray. V20 found the tray, put gloves on and entered R38's room, delivered and set up R38's meal tray. V20 exited the room, removed her gloves, went to the lunch tray cart, touched multiple trays looking for R178's meal tray. V20 entered V20's room, set up R178's meal tray for R178, exited the room, and performed hand hygiene. V20 went to the lunch tray cart and found R6's lunch tray. V20 did not perform hand hygiene before entering the room. V20 moved items around the bedside table to make room for the meal tray and set up R6's meal tray. V20 exited the room and performed hand hygiene. During this meal tray pass, V20 did not wear eye protection or a gown. There were multiple observations of V20 not wearing gloves or performing hand hygiene when entering COVID positive rooms. 5. On 8/8/24 at 11:40 AM at V24, LPN, prepared to administer 650 mg of Acetaminophen to R13. R13's door has signage that documents staff must wear a N95 mask, gown, gloves, and eye protection. R13 has an isolation cart outside of her doorway. V24 entered the room with a N95 mask on only. R13 requested stronger pain medication, V24 exited the room, preformed hand hygiene, obtained a Tramadol pill from the medication cart, and entered R13's room again to provide medication with only a N95 mask on. V24 left the room and performed hand hygiene. The facility COVID Outbreak Line List of Residents documents that R13 tested positive on 8/4/24. 6. On 8/6/24 at 12:18 PM, V7, Licensed Practical Nurse entered R43's room. R43's door has contact isolation signage on the door. R43 enters the room in full PPE and sets the blood glucose monitor on top of R43's bed side table. R43 obtains a blood sample and goes to the doorway. V7 leans out of the door and places the blood glucose monitor on top of the isolation cart outside of the doorway. V7 removes her face mask, gloves, gown, sanitizes her hands, and gets a Dispatch disinfecting wipe and lightly wipes down the blood glucose machine and sets it on a paper towel on top of the medication cart. V7 fails to disinfect the isolation cart. The facility COVID Outbreak Line List of Residents documents that R43 tested positive on 8/4/24. The policy COVID- 19 Testing and Response Plan, dated 8/29/23, documents, Healthcare workers must use proper PPE when exposed to a resident with suspected or confirmed COVID- 19 or other sources of SARS-CO-2. If a resident is suspected or confirmed to have COVID-19 or other respiratory illnesses, at a minimum, HCP (health care provider) must wear an N95 respirator, eye protection, gown, and gloves. If a facility is experiencing an outbreak of COVID-19 or other respiratory illness, at a minimum, HCP must wear a well fitted mask while on the unit or floor experiencing an outbreak. COVID-19 testing is required for any of the following: Symptomatic residents or HCP, even those with mild symptoms of COVID-19, should receive a viral test for SARS-CoV-2 infection as soon as possible. It continues, Outbreak Testing. When using the broad based approach, a facility should continue to test every 3 - 7 days until there are no more positive cases identified for 14 days. It continues, Environmental Infection Control. Dedicated medical equipment should be used when caring for a resident with suspected or confirmed SARS-CoV-2 infection. Reusable equipment must be cleaned and disinfected between residents. The policy Blood Glucose Testing and Monitoring, dated 2/2016, documents, Clean blood glucose meter with Dispatch product if meter is shared between residents. The policy Disinfecting Products, dated 1/1/23, documents, Dispatch Wipes - 3 minute contact time.

Based on record review and interviews the facility failed to administer medications to one of three (R4) residents reviewed for medication errors in a sample of 55 residents. R4's face sheet dated 8/13/2024 documents diagnosis of enterocolitis due to clostridium difficile dated 7/11/2024. R4's physicians order sheets documents R4 on Contact/droplet isolation precautions RT C-difficile infection with a start date of 07/11/2024. R4's physicians order sheets documents R4 on vancomycin oral suspension 5ml four times a day until 8/8/2024 with a start date of 7/27/2024. R4's Medication Administration Record (MAR) dated 8/6/2024 documents on dates of 8/4/2025 at 8am,12pm,5pm, 8pm and on 8/5/2024 at 8am and 12pm that vancomycin oral suspension was not administered. On 08/13/24 at 7:45 AM, V27 LPN (Licensed Practical Nurse) stated that she did not administer the vancomycin doses on 8/4/2024 for the 8am and the 12pm dose and 8/5/2024 for the 8am and 12pm dose because the vancomycin did not come in from pharmacy and the convenience box did not have any vancomycin in it. On 8/12/2024 at 3:30 PM, V1, DON (Director of Nursing) stated that she spoke with V27 and that V27 stated that she did not administer the vancomycin on 8/4/2024 for the 8am and the 12pm dose and 8/5/2024 for the 8am and 12pm dose because the vancomycin did not come in from pharmacy. Facility policy titled Medication Administration dated 1/11/2010 documents facility will accurately administer medications per doctor's orders.

Based on interview and record review, the facility failed to provide education or documentation of refusal for the COVID-19 vaccine for 3 of 5 residents (R44, R51, R231) reviewed for immunizations in the sample of 55. Findings include: On 8/5/24 at 2:30 PM, V2, Infection Preventionist Licensed Practical Nurse stated that the facility does not have education material or declination refusals for the COVID-19 immunization. V2 stated that R44, R51, and R231 are the only residents in the building that have not been vaccinated for COVID-19 . The COVID 19 Vaccination Policy for Residents, dated 2/1/22, documents, Procedure: 1. Education is provided for all residents and / or responsible party on the COVID-19 vaccination. This policy fails to document how acceptance or refusal of the vaccine will be documented. 1. R51's Admission Record, print date of 8/12/24, documents that R51 was admitted on [DATE]. R51's Electronic Medical Record (EMR) fails to document that R51 was educated and offered the COVID-19 vaccine. 2. R44's Admission Record, print date of 8/12/24, documents that R44 was admitted on [DATE]. R44's EMR fails to document that R44 was educated and offered the COVID-19 vaccine. 3. R231's Admission Record, print date of 8/12/24, documents that R231 was admitted on [DATE]. R231's EMR fails to document that R231 was educated and offered the COVID-19 vaccine.

Based on interview, observation and record review, the facility failed to discard expired and discontinued medications and label and date medications. This error has the potential to affect all 86 residents living in the facility. Findings include: On [DATE] at 9:45 AM, the zone 2 medication cart was observed with V4, Licensed Practical Nurse (LPN). 1. R16's Lantus (Glargine) insulin pen has an opened-on date of [DATE]. R16's Physician Orders, dated [DATE], documents, Insulin Glargine Solution Pen Injector 100 unit/ ML (millimeter). Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus without complications. 2. R5's Albuterol inhaler had an expiration date of ,d+[DATE]. R5's Physician Orders, dated [DATE], fails to document an order for an Albuterol inhaler. On [DATE] at 10:00 AM, V4, LPN, stated, (R5) never uses that inhaler. (R16) doesn't use the Lantus that much. (R5) doesn't even have on order for that inhaler. I think she got that a while ago when she had pneumonia. On [DATE] at 3:45 PM, V2, Director of Nurses (DON), stated that insulin pens should not be used after 30 days of opening and that a discontinued medication should be discarded. 40650 3. On [DATE] at 08:51 AM, (Facility) Total Rehab 2 Medication cart was checked with V13, LPN. In the top of the cart was an Albuterol Inhaler, opened, not dated and not labeled with a resident's name. V13 stated that she did not know who the inhaler belonged to. 4. On [DATE] at 09:05 AM, V14, Registered Nurse (RN)/ Assistant DON (ADON), was present when the skilled medication room was checked. The refrigerator was unlocked by V14 and there were 4 Bisacodyl 10 milligram suppositories, not in a package, not labeled and not dated in the refrigerator. On [DATE] at 09:50 AM, V2, DON, stated that the Bisacodyl suppositories are a stock medication and can be used on any resident who has an order. V2 continued to state that she would expect suppositories to be in a zip lock bag and dated. On [DATE] at 11:35 AM, V2 stated that they do not have a stock medication policy. Drug Insert for Lantus, dated ,d+[DATE], documented, Do not use Lantus after the expiration date stamped on the label or 28 days after you first use it. The facility's Pharmaceutical Service Policy and Procedure Manual, undated, documented, Drug Packaging and Labeling Specifications, It continues, III. ALL medication for each specific resident shall be labeled with the following information, It continues, C. Resident's name, room and bed number. It continues, G. Expiration date of drug. The Resident Census and Conditions of Residents, CMS-672, dated [DATE], documents that the facility has 86 residents living in the facility.

Based on interview, observation and record review, the facility failed to provide a substantial snack at nighttime. The failure has the potential to affect all 86 residents living in the facility. Findings include: 1. On 05/23/23 at 8:37 AM, the breakfast service began in the main dining room. On 5/23/23 at 9:00 AM, V3, Dietary Manager, stated that the mealtimes are 8:00 AM, 12:00 PM and 5:00 PM. (This leaves a 15-hour time frame between meals overnight without a substantial snack). On 5/23/23 at 3:45 PM, V12, Certified Nurse Aide (CNA), stated that dinner is served at 5:00 PM. V12 stated that the CNAs have a snack box with a variety of snacks in it and they go to each room and ask them what type of snack they want. V12 stated they have a variety of cookies and cakes. On 5/24/23 at 8:30 AM, V13, Licensed Practical Nurse (LPN), stated, There is a snack box that has a snack in it. The snacks vary like cheese crackers, cakes, pies and graham crackers. The staff take the snacks and go and offer the regular residents a snack. The VTR (facility Total Rehab) patients are just asked if they would like a snack. On 5/24/23 at 2:45 PM, V3 stated that he did not realize that staff were not taking snacks out to the residents. V3 stated that the snacks are crackers, cookies and things like that. V3 was questioned if he thought that was a substantial snack and he agreed that it was not. The facility provided Dining Room Mealtimes, undated, documents, Breakfast 7:00 AM - 9:00 AM. Lunch 12:00 PM - 1:00 PM. Supper 5:00 PM - 6:00 PM. The facility failed to follow these mealtimes. 40650 2. On 05/23/2023 at 10:23 AM, R25 stated that at night a big pan of snacks are brought out and put behind the nurses station but it is not brought to their rooms or offered that way. The snacks are usually cookies, cakes or graham crackers. R25's Minimum Data Set (MDS), dated [DATE], documented that her cognition was intact. 3. On 05/23/2023 at 10:23 AM, R36 stated that pan of snacks are brought out at night and put behind the nurses station but it is not brought to their rooms or offered that way. The snacks are usually cookies, cakes or graham crackers. R36's MDS, dated [DATE], documented that his cognition was intact. 4. R34 stated that she is not offered a snack at night and that sometimes her blood sugars the next morning are affected like they are low. R34's MDS, dated [DATE], documented that her cognition was intact. 5. R42 stated that it is around 16 hours between supper and the next day's breakfast. She continued to state that breakfast lunch and supper are all too close together. R42's MDS, dated [DATE], documented that her cognition was intact. The Resident Census and Conditions of Residents, CMS-672, dated 5/22/23, documents that the facility has 86 residents living in the facility.

Based on interview, observation and record review, the facility failed to store and serve food to prevent food borne illness, maintain kitchen storage in a sanitary fashion and assist a resident with dining with gloves on. This failure has the potential to affect all 86 residents living in the facility. Findings include: 1. On 05/22/23 at 8:30 AM, the kitchen was entered. The refrigerator in the kitchen had 1 container of cheese that had a use by date of 5/14/23, 1 container of macaroni salad that had a use by date of 5/18/23 and 1 container of three bean salad that had an use by date of 5/21/23. The walk-in refrigerator had a single premade salad on a shelf that was not covered. A large stainless steel rectangle storage container with multiple pounds of cooked ground beef that was dated cooked 5/22/23 was on a shelf that had items on the rack above. The lid to the container was open so 50% of the ground beef was not covered. The dry storage room had a large cardboard box of Styrofoam storage containers sitting on the floor. 2. On 05/23/23 at 12:10 PM, the noon meal was served from the steam table in the kitchen. One of the substitute meals was a hamburger or a sloppy [NAME]. V8, Cook, would take a bun out of the bun bag with her gloved hand that she has been using during the service touching all the ladles, plates and trays. The main meal was Lasagna and a bread stick. V9, Dietary Aide, placed the bread stick onto the plate with a gloved hand that she has used throughout the service. V8 removed her gloves, went and got 2 new scoops, got a pair of gloves, put a glove on the right hand and with the ungloved left hand rubbed her eyebrow / forehead area then put a glove on that hand. The bottom of the portable rack that holds the plate covers was covered with debris and dry spillage. The bottom of the rack that holds the food trays is covered with food debris and brown debris. 3. On 5/23/23 at 12:40 PM, V7, Certified Nurse Aide (CNA), was assisting R18 with his hamburger. V7 was not wearing gloves. V7 picked up R18's hamburger and tore off a section of the bottom hamburger bun. V7 then flipped the burger over into the palm of her hand and patted the top of the burger to secure hamburger top bun then handed the hamburger back to R18. On 05/23/23 at 3:07 PM, V3, Dietary Manager, stated that nothing should be stored on the floor of the dry storage room, no out of date food should be in the refrigerator, if gloves are changed hands should be washed, single serve items should be placed on the tray with a utensil and staff should not be touching residents' food without gloves on. The Food Labeling and Dating, dated 02/22, documents, 4. Once refrigerated or frozen items are properly labeled, they need to be used or disposed of according to the Refrigerator and Freezer Storage Chart. It continues, Use by date is the last date recommended for the use of the product while at peak quality. The policy Hand Washing and Glove Use, dated 02/22, When should hands be washed? Before putting on new, single use gloves and between glove changes. The Resident Census and Conditions of Residents, CMS-672, dated 5/22/23, documents that the facility has 86 residents living in the facility.

Based on interview, observation and record review, the facility failed to wash hands when needed, change gloves when soiled and wear the proper personal protective equipment to prevent cross contamination for 4 of 18 residents (R3, R72, R47, R69) reviewed for infection control in the sample of 32. Findings include: 1. On 5/23/23 at 10:00 AM, V5, Certified Nurse Aide (CNA), and V7, CNA, entered R3's room to perform incontinent care. R3's incontinent brief was soiled with urine and feces. V7 failed to change her gloves when they became soiled during the care. When care was completed, V7 assisted R3 with rolling over touching R3's bare skin with the same gloves used for incontinent care, applied a new incontinent brief and covered R3 up. On 5/24/23 at 2:21 PM, V6, Infection Preventionist, stated that staff should change gloves when soiled and one pair of gloves should not be used for the process of incontinent care and then putting a new brief or clothing on. 40650 2. On 05/24/2023 at 09:15 AM, V15, CNA, took R45 into the bathroom, donned gloves without benefit of hand hygiene, placed gait belt on R45 and assisted her to the toilet. V15 removed R45's soiled incontinent brief, placed it in the trash. V15 turned on the water, with the same gloves, placed the clean washcloths in the sink. V15 got a clean incontinent brief, added powder to it and placed in R45's pants. Once the washcloths were wetted, she applied shampoo and body wash to the washcloths. V15 changed gloves, without benefit of hand hygiene, and cleansed R45's perineal area. V15 continued to wear the same soiled gloves to towel dry all areas she cleansed. V15 pulled up R45's pants and assisted her back to her wheelchair still wearing the same soiled gloves. V15 then doffed her gloves and performed hand hygiene. The facility's policy, Hand Hygiene Protocol dated 07/26/2021, documented, During routine resident care. Use an Alcohol Based Hand Sanitizer. It continues, Before moving from work on a soiled body site to a clean body site on the same resident. It continues, Immediately after glove removal. 43847 3. On 5/22/23, R69's door has sign posted stating Enhanced Barrier Precautions (EBP). EBP sign on R69's room door states. provider and staff must wear gloves and gown for wound care: any skin opening requiring a dressing change. On 05/24/23 at 10:20 AM, V14, Registered Nurse (RN)/ Assistant Director of Nursing, and V16, Licensed Practical Nurse (LPN), performed dressing change for R69. V14 and V16 entered R69's room with gloves, surgical mask but were not wearing gowns. V16 performed dressing change with V14's assistance with neither wearing a gown. On 5/24/2023 at 10:47AM, V14 stated they should have worn gowns in the room when they did the dressing change for R69. On 5/24/2023 at 10:35AM, V16 stated she just started on Monday, but reading that sign she should have worn a gown in the room while performing the dressing change for R69. On 5/24/2023 at 2:15PM, V6, Infection Preventionist, stated she expects staff to wear gowns when doing dressing changes on R69 due to R69 being on EBP's for an open wound. The Facility's Enhanced Barrier Precautions Protocol dated July 26, 2021, states that Enhanced barrier precautions may be considered for wound, PPE (Personal Protective Equipment) (gloves and gowns) should be used during high contact resident care activities. examples of high contact resident activities requiring gown and gloves use include wound care: any skin opening requiring a dressing change. 32874 4. On 5/24/2023 at 11:15AM, a sign posted on the wall outside R72's room documents contact and droplet isolation; gloves and gowns should be worn, N95 mask is required. At this time, V17, CNA, entered R72's room with surgical mask and gloves. V17 then exited room, donned a gown, then reentered R72's room. V17 then exited R72's room again, donned N95 mask and reentered 72's room. On 5/24/2023 at 2:15PM, V6, Infection Preventionist, stated that she would expect staff to follow contact and droplet isolation policy. The facility's policy contact and droplet precautions protocol dated, revised July 26, 2021, documents personal protective equipment documents a gown should be applied before room entry. N95 respirator is required.

Based on observation, interview and record review, the facility failed to identify, monitor and provide treatments as ordered to prevent the worsening or formation of pressure ulcers for 3 of 4 residents (R41, R6 and R22) reviewed for pressure ulcers in the sample of 37. This failure resulted in R41's Stage III pressure ulcer worsening to an unstageable pressure ulcer. Findings include: 1. R41's Current Face Sheet Documents R41 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's Minimum Data Set (MDS) dated [DATE] documents R41 is cognitively intact and requires extensive assistance of one staff member for transfer, dressing, toileting and personal hygiene. R41's Care Plan dated 8/4/22 documents to provide wound care per treatment order. R41's Braden Pressure Ulcer assessment dated [DATE] documents R41 is a high risk for pressure ulcers. R41's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse wound with normal saline, apply cream to open area, apply dry gauze and cover with [MEDICATION(S)] daily. R41's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/09/22 at 11:16 AM, V14 Licensed Practical Nurse, Wound Nurse, provided wound dressing changes to R41. R41's left heel and left outer ankle (lateral foot) old dressing was dated 8/7. R41's left lateral foot had a black scabbed area with a small amount of clear drainage on R41's old left lateral dressing noted. No measurement was taken. R41's right heel old dressing was dated 8/6. V14 verified the dates on R41's dressing. On 8/10/22 at 9:31 AM, V14, stated she wasn't able to get all the treatments done on Monday so R41 had left R41's wound dressings to be done by the staff nurses and they did not get done. V14 verified that R41 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V14 states she notified day and night shift and they were supposed to do the treatments if she is not here, and they did not get to since date is from 8-6 and 8-7. V14 states resident gets silver and double cream daily but has not gotten as ordered. R41's Skin assessment dated [DATE] documents R41 has a left heel pressure ulcer 3 centimeters (cm) by (x) 2.8 cm, right heel pressure 5.7cm x 4.8 cm and a left outer ankle pressure ulcer 3.4 cm x 2 cm x 0.2 cm, stage 3 pressure ulcer. R41's Skin assessment dated [DATE] documents R41's left heel pressure ulcer is 2.1cm x 1.3 cm, Right heel pressure, 4.7cm x 4.5 cm x 0.1cm and left outer ankle (lateral foot) pressure ulcer 4.3 cmx 3.2 cm x .01 cm stage 3. R41's Treatment Administration Records document R41 received ordered daily treatment to left inner ankle and left lateral foot on 8/6 and 8/7/22, however observation on 8/9/22 of R41's intact wound dressing and interview with V14 verified treatment had not been completed since 8/6 and 8/7/22. On 08/11/22 11:18 AM V2, Director of Nursing (DON) stated she expects staff to measure wounds weekly, expects staff to document accurately when treatments are done and expects wound treatment to be done per physician orders. 08/11/22 11:51 AM, V15, R41's Medical Doctor stated she was not aware R41 had not been getting the ordered topical medications of silver and double cream. R41 stated she expects the facility to follow the order. The Facility's Wound and Ulcer Policy and Procedure dated 1/10/2018 documents: It is the policy of this facility to provide nursing standards and for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. Protocols may include any or all of the following based upon the needs and condition of the resident. Additional measures may be added at the discretion of the facility. Weekly skin checks, changes in condition are promptly reported. When a resident is found to have a wound: document assessment of the wound, initiate treatment protocol, document wound/ulcer treatment on treatment administration record, Assessment of progress toward healing is completed at least weekly, if there is regression, the physician is notified of the condition change. treatment per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. R22's Admission Record, print date of 8/10/22, documents that R22 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/22 at 8:31 AM, R22 was in the dining room with left leg immobilizer covering her pants. R22's MDS, dated [DATE], documents that R22 is cognitively intact, requires extensive assistance of 2 staff members for bed mobility and R22 is totally dependent on 2 staff members for transfers. R22's Ulcer/Wound documentation, dated 7/23/22, document, Date ulcer/wound was initially identified: 7/23/22. L (left) heel outer Pressure 0.3 (cm) length, 0.4 (cm) width, 0.1 (cm) depth. Suspected Deep Tissue Injury. Peri wound Skin: Deep purple tissue over bony prominence. R22's Ulcer/Wound documentation, dated 7/27/22, document, Date ulcer / wound was initially identified: 7/23/22. Left heel. Pressure 1.7 length, 1.3 width, 0.1 depth. Suspected Deep Tissue Injury. Peri wound Skin: area is purple in color, skin intact. There were no documented Ulcer/Wound assessment in R22's medical record from 7/27 through 8/10/22. R22's July and August 2022 Treatment Administration Records (TARs), documents, Left heel: Cleanse area with skin integrity, pat dry, apply xeroform open area, cover with [MEDICATION(S)] gentle. Change daily. Float heels on pillow when in bed. Start date 7/25/22. There was no documentation R22's treatment was done on 7/26/22, 7/28/22 and 8/1/22. R22's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change daily. Float heels on pillow when in bed. Every day shift. R22's Ulcer/Wound documentation, dated 7/23/22, document, Date ulcer/wound was initially identified: 7/23/22. Right buttock 2.5 cm length, 3.3 cm width, 0 depth. Stage 1. Peri wound Skin: intact but fragile. Scant drainage. There was no documented Ulcer/Wound assessment in R22's medial record from 7/23/22 through 8/9/22. R22's July 2022 TAR documents, Right buttocks: Cleanse area with Skin integrity, pat dry and apply Exuderm change Q (every) 3 days every day shift every 3 day(s) for open area -Start Date 07/25/2022 0600 D/C (discontinue) 07/28/2022. R22's August 2022 TAR documents Right buttocks: Cleanse area with Skin integrity, pat dry and apply Exuderm change Q 3 days every night shift every 3 day(s) for open area -Start Date 07/28/2022. R22's Ulcer/Wound documentation, dated 8/9/22, document, Date ulcer / wound was initially identified: 7/23/22. Right buttock 1.5 cm length, 1.6 cm width, 0.1 depth. Stage II. Peri wound Skin: Area has a 100% granulation tissue with macerated edges. Scant drainage. R22's pressure ulcer had increased in depth and was now classified as a Stage II pressure ulcer. R22's Ulcer/Wound documentation, dated 7/23/22, document, Date ulcer/ wound was initially identified: 7/23/22. Left ankle (outer) bruising 0.7 cm (centimeters) length, 0.7 cm width, 0 depth. Unstageable. There was no other Ulcer/Wound documentation in R22's medical record regarding R22's left outer ankle pressure ulcer/pressure injury. There were no treatments orders documented in R22's medical record for R22's left ankle pressure ulcer. R22's Ulcer/Wound documentation, dated 7/23/22, document, Date ulcer / wound was initially identified: 7/23/22. Right inner ankle (outer) pressure 0.5 cm (centimeters) length, 0.8 cm width, 0.1 depth. Suspected Deep Tissue Injury. Peri wound Skin: Deep purple tissue over bony prominence. There was no other wound/pressure documentation for R22's medical record regarding R22's right ankle pressure ulcer/pressure injury. There were no treatments orders documented for R22's right ankle in R22's medical record. R22's Ulcer/Wound documentation, dated 8/9/22, documents, Date ulcer / wound was initially identified: 7/23/22. Right heel: Pressure. 1.0 length, 0.9 width, 0.1 depth. Suspected Deep Tissue Injury. Peri wound: Area is purple in color skin intact. There was no other wound/pressure ulcer documentation in R22's medical record prior to 8/9/22 regarding R22's right heel pressure ulcer/pressure injuries. R22's July and August TARs document, Right heel: Clean heel with skin integrity, pat dry, apply skin prep and allow to air dry. Cover with [MEDICATION(S)] gentle. Change daily. Float heels on pillow when in bed every day shift for soft heel. -Start Date 07/25/2022 0600. R22's TAR does not document R22's treatment to her right heel was completed on 7/26/22 and 7/29/22. R22's Ulcer/Wound documentation, dated 8/9/22, documents, Date ulcer / wound was initially identified: 8/09/22. Coccyx. Pressure. 10 (cm) length. 8.5 (cm) width. 0.1 (cm) depth. Stage II. Peri wound: Area has small stage 2 pressure injuries with DTI (deep tissue injury) surrounding. New treatment in place. Scant drainage. R22's August 2022 TAR documents, Cleanse area on coccyx and apply exuderm to coccyx and change every three days and PRN. start date of 8/9/22. On 08/10/22 at 09:04 AM, V14, stated, that one week was really busy and that is why the measurements weren't done and that she did not realize that she had went over 2 weeks without measurements. On 08/10/22 3:35 PM, V14, Licensed Practical Nurse/Wound Nurse changed R22's dressings to the left heel and right heel. V14 removed R22's left heel old dressing. R22's left outer heel has an area the approximate size of a quarter that is covered in a scab, then there is a line that runs down to the back of the heel with a small open slit in the heel. The area was cleansed, and sure prep was applied then covered with a foam dressing. R22's left outer upper ankle had a deep tissue injury the approximate size of a dime. The area appears to be from the immobilizer brace that R22 is wearing. No dressing/treatment was applied. R22's right outer heel pressure ulcer has pale pink skin over it. R22's coccyx wounds were unable to be observed related to R22's extreme pain. R22's Order Summary Report, print date of 8/10/22, documents, Cleanse area on coccyx and apply exuderm to coccyx and change every 3 days and PRN (as needed). as needed. Cleanse area on coccyx and apply exuderm to coccyx and change every three days and PRN. every night shift every 3 days. Left heel: Cleanse area with skin integrity, pat day, apply skin prep, cover with [MEDICATION(S)] gentle. Change daily. Float heels on pillow when in bed. every day shift. Right heel: Clean heel with skin integrity, pat dry, apply skin prep and allow to air dry. Cover with [MEDICATION(S)] gentle. Change daily. Float heels on pillow when in bed every day shift for soft heel. On 8/11/22 at 11:19 AM, V2, Director of Nursing stated, I would have expected that the nurses would have caught (R22's) coccyx wound before it got as big as it did. 3. R6's Admission Record, dated 8/10/22, documents that R6 was admitted [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R6's MDS, dated [DATE], documents R6 is severely cognitively impaired and requires extensive assistance of 1 staff member for dressing. R6's Health Status Note, dated 7/31/22, documents, Area on res (resident) left outer ankle has re-opened, area measures 1cm (centimeters) X 1cm. TX (treatment) was initiated as follows: Cleanse with wound cleanser, pat dry and sure prep peri wound. Apply Xeroform to wound bed and cover with dry drsg (dressing). R6's Ulcer/Wound documentation, dated 7/3/22, documents, L (left) outer heel blister 3.0 (cm) x 2.5 (cm) x 0.1 (cm). R6's Ulcer/Wound documentation, dated 8/2/22, documents, L lateral heel blister 2.7(cm) x 2.3 (cm) x < 0.1 (cm). Peri wound: Blistered opened up. Area is 75% macerated with some drainage and 25 % granulation tissue. R6 has no other wound documentation available for review regarding R6's pressure ulcers from 7/3/22 through 8/2/22. On 08/08/22 at 1:53 PM, V14 removed R6's shoe to change R6's pressure ulcer dressing on his left outer foot. There was no pressure ulcer dressing on R6's pressure ulcer. The wound bed is red and approximately the size of a dime. On 8/8/22 at 1:55 PM, V14 stated, He should have a had a dressing on it maybe it was his shower day.

Based on interview and record review, the facility failed to identify, monitor and implement interventions to address weight loss for 1 of 3 residents (R34) reviewed for weight loss in the sample of 37. This failure resulted in R34 having a significant weight loss of 47.3 pounds indicating a 28.3% weight loss in 6 months. Findings include: R34's Admission Record, print date of 8/10/22, documents that R34 was admitted on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's Minimum Data Set, dated dated [DATE], documents that R34 is cognitively intact and requires supervision and one staff member physical assist for dining. R34's Weight Record documents the following dates, times and pounds weighed: 8/9/2022 10:01 119.5 Lbs. (pounds) 8/3/2022 14:02 119.0 Lbs. 8/3/2022 10:18 119.0 Lbs. 8/2/2022 12:26 119.0 Lbs. 8/2/2022 10:43 119.0 Lbs. 8/2/2022 08:49 119.0 Lbs. 7/27/2022 11:36 131.0 Lbs. 5/3/2022 17:55 161.6 Lbs. 4/19/2022 10:35 158.5 Lbs. 4/19/2022 09:49 158.5 Lbs. 4/1/2022 11:26 163.6 Lbs. 3/14/2022 15:50 155.0 Lbs. 3/1/2022 09:51 175.2 Lbs. 2/22/2022 16:26 168.0 Lbs. 2/21/2022 09:44 168.4 Lbs. 2/20/2022 10:57 168.0 Lbs. 2/19/2022 10:30 166.8 Lbs. 2/18/2022 12:19 166.8 Lbs. There was no documented weight in June 2022. This weight log documents R34 had a significant weight loss of 47.3 pounds indicating a 28.3% weight loss in 6 months. R34's Health Status Note, dated 6/3/22, documents, Another call out to (V16 Physician) office to request orders regarding res. c/o (complaint of) gastric reflux. Also requested a PRN (as needed) order for [MEDICATION(S)] per res (resident). R34's Health Status Note, dated 6/15/22, documents, RD Note-Weight/Skin Review-HT:62 in (inches). Wt:145#'s. BMI=26.5 wnl (within normal limits). DBWR (desired body weight range) =104-148#'s. Wt. within DBWR. Per weight exception report resident had 10.3% decrease in weight times 1 month and 13.1% decrease in weight times 4 months. Noted resident currently on ABT for [CONDITION(S)]. Diet Rx: Reg, Reg, thin liquids Appetite is ~51% at meals currently. Meds reviewed and noted [MEDICATION(S)] and [MEDICATION(S)] added since last review that may decrease appetite and weight; and [MEDICATION(S)] added that may increase appetite and weight. Per 6/13-pressure wound report resident has pressure wounds on left heel, left big toe, and LLE rear times 2. Resident remains on Vit C, Zinc and MVI w/minerals that supports healing. See recommendation to add Liquid Protein 30ml's one time per day to meet her needs for weight maintenance and wound healing of multiple wounds. Monitor and refer to RD Prn. R34's Health Status Note, dated 7/13/22, documents, per 7/13 wound report resident has pressure wound on left heel and left big toe and DTI (Deep Tissue Injury) on right heel. Diet Rx (prescription): Reg (regular), Reg, thin liquid with Liquid Protein 30 ml one time per day. Appetite is ~26-50% of meals currently. Current wt. (weight): 157#'s. BMI (body mass index) =28.7H DBWR (desired body weight range) =104-148#'s. Wt. above DBWR but within UBWR for resident. Per weight exception report resident had 8.3% increase in weight times 1 month and 10.4% decrease in weight times 4 months. No new nutrition related med (medication) changes since last review. Resident remains on MVI (multivitamin) w (with)/minerals, Vit C (vitamin C) and Zinc that supports healing. No new labs to assess. No changes recommended at this time. Diet and wound supplement along with vitamins and minerals remains appropriate to support healing. Monitor and refer to RD Prn. (Registered Dietician) On 8/11/22 at 11:19 AM, V2, Director of Nurses (DON), stated that she just noticed (R34's) weight loss at the end of July. V2 also stated that the facility does weekly meeting to discuss weight loss and (R34) did not get noticed until the end of July. V2 also stated that R34 should have been weighed every month. V2 stated that R34 was moved from the rehabilitation wing to the room that she is in and maybe that caused some of the weight loss and also, she was put on [MEDICATION(S)]. V2 stated that R34 did have complaints of acid reflux and she has been seen and received medication for it. V2 stated that she did have an esophagram and she needs to see a specialist. On 8/11/22 at 1:19 PM, V16, Physician, stated, I am an outpatient internal medicine doctor. (R34) is usually brought to my office by someone. I last saw her on July 27, 2022 and she was concerned about her wounds and her pain. I was unaware. I can only treat what I am told. I was unaware of her weight loss. She is now malnourished. This will not help her wound healing. She needs to be on a calorie count, fortified foods and supplements. I am not sure if her weight loss is a medical problem or it's just because she does not feel good. She has pain from those wounds. We should try and get her pain under control and maybe that will help. R34's August 2022 Order Summary Report, documents, Weekly weights x 4 in the morning every Tue (Tuesday), Wed (Wednesday) for maintenance for four weeks. Start date 7/27/22. Regular diet, thin texture. Liquid Protein 30 ML (milliliters) in the morning for wound healing. The Facility's Weight Management Policy and Procedure with a revision date of 2/2016 documents, Each resident will be weighed at least once a month on a predetermined schedule. All residents will be monitored for significant weight changes to assure maintenance of acceptable parameters of body weight. Residents will be weighed using the same scale and in a consistent manner unless clinical condition warrants the use of a different scale or an altered manner. A change in scale or method will be noted if this occurs. A resident with a weight fluctuation of greater than five pounds (+ or -) will be re-weighed for accuracy. The new weight will be recorded in the medical record. Monthly weights will be obtained by the 10th of each calendar month and the Dietary Manager or designee will review the monthly weights by the 10th of the month. All scales will be calibrated at least monthly by the Facilities staff or their designee. At least monthly, resident weights will be compared to prior weights to identify any significant, severe or insidious weight changes. The Weight and Vitals Exception Report will be reviewed weekly by dietary staff to determine significant weight changes. Parameters of a significant weight change per OBRA (Omnibus Budget Reconciliation Act) guidelines will be used. Weight loss that occurs quicker than the OBRA guideline parameters will be addressed as they occur. (Example: If a 10% weight loss occurs in four months, the weight loss will be addressed at that time.) OBRA weight change parameters document significant change as 5% in 30 days or 10% change in 180 days. Any resident with a significant or insidious weight change will be referred to the dietitian for assessment of the residents' condition. They dietitian will implement any necessary clinical interventions or make recommendations regarding diet and supplementation to the physician. The physician will be notified of any significant weight change and be made aware of any recommendations made by the dietitian. The POA (power of attorney) for health care will be notified of significant weight changes. The interdisciplinary care plan team will assess the resident's overall condition to see if the weight change impacts more than one area of the resident's health status. A significant change assessment will be completed if there is a consistent pattern of changes, with either two or more areas of improvement/decline.

Based on observation, interview, and record review, the facility failed to ensure food was stored in a manner which prevents potential contamination. This has the potential to affect all 84 residents living in the facility. Findings include: On 8/9/2022 at 8:55 AM in the first standing refrigerator there was a tray of assorted beverages covered with foil. There was a sticker with handwritten dates on the tray, but there was no way to distinguish the contents of each individual beverage. On 8/9/2022 at 9:05 AM in the walk in refrigerator there was a cart covered with plastic that contained ten trays of food. The covering did not reach the bottom of the cart, and the bottom four trays were completely exposed to air. These four trays included approximately 8 individual cups of cottage cheese, 40 individual cups of melon, and 20 slices of chocolate cake on individual dishes. On 8/9/22 at 9:07 AM, V5, Dietary Manager, stated, I would expect all items to be covered, labeled, and dated. Yes, of course. On 8/9/2022 at 9:10 AM in the walk in freezer there was a clear plastic bag of steak fries that had been opened but was not dated or labeled. There was a plastic bag with six (approximately 8 ounce) pieces of an unknown meat that was previously opened but had not been labeled or dated. V5, Dietary Manager, stated, These are pork cutlets. The Facility's Food Labeling and Dating policy dated 2/2022 documents, Labeling and dating food is important to assure foods are used in a timely manner. Proper food labeling includes: name of product, date stored, and in some cases the time of the day. The food must be labeled and dated if it is removed from its original container. The Resident Census and Condition of Residents Form, (CMS 672), dated 8/8/2022 documents the facility has 84 residents residing in the facility.

Based on interview and record review the Facility failed to ensure medications are given to the right resident per physician's orders for one of nine residents (R71) reviewed for significant medication error in the sample of 41. This failure resulted in R71 receiving another resident's medication, resulting in R71 being hospitalized for [REDACTED]. Findings include: On [DATE] at 2:57 PM, R71 stated she went to the hospital a couple of weeks ago because she was given the wrong medication. She stated, I almost died . The nurse admitted she did it and said she was sorry. My daughter figured out what happened. R71's Minimum Data Set ((MDS) dated [DATE] documents, in part, a Brief Interview for Mental Status (BIMS) score of 13, indicating she is cognitively intact. This MDS also documents, under Additional Active Diagnoses, the [DIAGNOSES REDACTED]. On [DATE] at 3:45 PM V2, Director of Nursing (DON) stated that R71 had been given another resident's medication in error on [DATE]. She stated V20, Licensed Practical Nurse (LPN), the nurse who gave the wrong medication was new to the facility and mistakenly gave R71 blood pressure medications and insulin that was ordered for another resident. V2 stated she could not remember if she had gotten a statement from V20 during her investigation of the medication error. V2 stated the physician and R71's family were notified of the error. On [DATE] at 9:00 AM V2 stated she expects the nurses to check the resident's pictures, which are kept updated on their Medication Administration Record [REDACTED]. She stated V20 was a new employee to the facility and did not know the residents yet. On [DATE] at 3:15 PM V2 stated that she did get a statement from V20, the nurse who made the medication error for R71, but she had mistakenly given the written statement back to that nurse, who will now take a picture of the statement and send it to the DON, who will then print it. No documentation of, or interview statement from V2 or V20 was received on [DATE]. On [DATE] at 2:25 PM, during a telephone interview, V21, R71's daughter and Healthcare Power of Attorney (HCPOA), stated a nurse from the Facility called her just before midnight on [DATE] and told her R71 was being sent out by ambulance to the emergency room (ER) because her blood pressure was too low. V21 stated the nurse who called her did not inform her that R71 had been given the wrong medication, and that no one had called her earlier in the evening to let her know. V21 stated she was informed of the medication error by the staff at the hospital emergency room . V21 stated someone from the facility called and informed her the next day and apologized for the error and told her the nurse who made the error was disciplined. V21 stated her mother went to the ER, and then was taken to the Intensive Care Unit. V21 stated, She was in the hospital from Monday night until Saturday. Her (R71's) heart rate got all the way down to 39. It was very scary because she's [AGE] years old. It seems like she hasn't been the same since she got back to the Facility, not as alert, but I'm not sure if it is related to the medication mistake or her age. On [DATE] at 3:15 PM, V30, the Facility's Medical Director, stated he would expect the nurses to follow the current Standards of Practice, including making sure they administer the right medication to the right resident. On [DATE] at 12:00 PM during telephone interview, V20 stated she made a medication error on [DATE] during her 9:00 PM medication pass by giving R61's medication to R71. V20 stated she had left her medication cart with the Electronic Medication Administration Record [REDACTED]. She stated she had R61's medication in a cup in her hand and walked down the hall to give them to her but stopped and talked to another resident along the way. She stated she then went into the wrong room and gave R71 the medications she had for R61 and performed an accucheck on her. V20 stated she forgot whose medication she was carrying. She stated she knew she was giving R71 the medications, and it did not register for her that R71 doesn't get an accucheck and insulin at night. V20 stated she had only worked that hall a few times since she started working at the Facility and didn't know just who got accuchecks and insulin on that hall. She stated she had to wake R71 up to do the accucheck and give her medications and R71 was groggy. When asked why she did not notify R71's daughter of the medication error, V20 stated, I was not aware of the protocol when a medication error is made. I reported it to the charge nurse and followed her instructions. We documented everything on a piece of paper because the charge nurse told me not to document anything in the progress notes because she wasn't sure if we were supposed to document it there. The charge nurse reported the medication error to the Director of Nursing the next morning. V20 stated she got a packet upon hire that had information about medication administration, and she knew she should identify the resident by their name and picture in their EMAR. V20 stated before she made the medication error she did not always take her medication cart and EMAR down the hall with her when she passed her medications. She stated she thinks she may not have made the medication error if she had not stopped to talk to another resident and if she had her medication cart and EMAR with her. R71's Medication Administration Record [REDACTED]. R71's Hospital Physician Discharge Summary dated [DATE] documents her admission [DIAGNOSES REDACTED]. R71's Emergency Department Report dated [DATE] at 3:45 AM documents, in part, Critical Care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Circulatory Failure. According to the ER report of filed vitals, dated [DATE] at 12:24 AM in the ER, R71's heart rate was low at 47 bpm (beats per minute), and lower at 2:42 AM, 40 bpm, and she was admitted to the ICU (Intensive Care Unit) because, the hospitalist felt the patient would be unsafe on the floor as he could not do frequent enough files for monitoring. R71's ER (emergency room ) report, under ED (Emergency Department) Course, dated [DATE] at 3:45 AM, documents that ER staff spoke to charge nurse at the Facility at 1:03 AM, who reported that R71 had been given medication that were not hers this evening ([DATE]) and listed the medications she had been given in error. R71's Hospitalist History and Physical dated [DATE] at 4:13 AM, documents R71's, Chief Complaint; Accidental medication administration that created [MEDICAL CONDITION] and [MEDICAL CONDITION] at nursing home. The Facility's Medication Error Report dated [DATE] documents, in part, that on [DATE] at 9:00 PM, R71 was given another resident's medication. The medications given in error to R71 included [MEDICATION NAME], an anti-hypertensive used to lower blood pressure, [MEDICATION NAME], another medication to lower blood pressure and decrease the heart rate, [MEDICATION NAME], which is used to treat high blood pressure, and [MEDICATION NAME] Insulin, used to manage blood glucose levels. It does not include documentation of notification of R71's daughter of the medication error. The Facility's Final Report to Illinois Department of Public Health dated [DATE], untimed, documents, in part, that R71 did receive the wrong medication on [DATE] at 9:00 PM and that R71's physician and daughter were notified immediately of the error. The report also documents that her physician gave orders to monitor R71 for adverse effects by monitoring her vital signs every 15 minutes, which were stable up until 11:00 PM. According to this report, the physician and R71's daughter were notified and R71 was sent to the ER, and then admitted to monitor her blood pressure. The Facility's Transfer/Discharge Report dated [DATE] documents, in part, under last vital signs, [DATE]- Blood Pressure ,[DATE] and Pulse 64. No vital signs were documented for [DATE], the date the medication error occurred. On the same report, under Chief Complaint (reason for transfer), the area was left blank. A Progress Note dated [DATE] at 7:05 AM documents, in part, patient vitals wnl (within normal limits) this shift prior to 2300 (11:00 PM). Nurse called MD (Medical Doctor) at 2300 r/t (related to) [MEDICAL CONDITION] ,[DATE] hr (heart rate) 48 rr (respiratory rate) 14 O2 (oxygen level) 92. MD ordered ok to send resident to ER to be evaluated and treated via EMS (Emergency Medical Service) at this time. Family emergency contact #1 notified at this time. There were no progress notes documented on [DATE] regarding R71 being given the wrong medication, notification of R71's physician or family when medication error was discovered, or documentation of monitoring R71 s for adverse effects after incorrect medication was given. On [DATE] at 8:10 AM V2 provided a hand written, unsigned report that she stated was V20's statement of R71's medication error on [DATE]. The report was undated and untimed as to when it was written and by whom. The report included documentation of R71 receiving another resident's medication on [DATE] at 9:00 PM, the charge nurse being notified of the medication error, the MD's order that vital signs be checked every 15 minutes for the first hour then every 3 hours, and there was documentation of vital signs taken every 15 minutes for one hour and then every 30 minutes, and all these vital signs documented up to and including 10:30 PM, were within normal limits. At the end of the report, it documents, I left the (facility) at 11 PM after (charge nurse) assured me she would continue checking vitals. Per (charge nurse) at 11:30 PM the resident's blood pressure was ,[DATE], resp (respirations) 14, 92%, pulse 49. (Charge nurse) said she called EMS and the doctor to send the resident to the hospital. The information provided along with this statement included a piece of paper, dated (MONTH) 13th, with hand written note, Report called to (hospital) ED (Emergency Department) with the medications given, [MEDICATION NAME] 0.2 mg(milligrams), [MEDICATION NAME] 1 mg, Tranclalapril-[MEDICATION NAME] ,[DATE], [MEDICATION NAME] ,[DATE] 10 u (units).) There was not documentation of reason for the medication error, or notification of R71's daughter of the medication error. This handwritten documentation did not identify who wrote it, what date or time it was written, and none of the information was found in R71's EMR. The Facility's policy, Medication Administration, dated [DATE], documents, in part, It is the policy of this facility to accurately administer medication following physician's orders. 3. Try to avoid interruptions. The policy continued 16. Report known med errors as soon as possible. Notify physician of known medication error and follow orders received, Monitor resident and document interventions. Complete Medication Error Report and counsel and or in-service staff as needed.

Based on interview and record review, the facility failed to identify, monitor and treat a significant condition change for one of 3 residents (R3) reviewed for significant condition change in a sample of 8. This failure resulted in delay in treatment for [REDACTED]. Finding includes: 1. The Minimum Data Set ((MDS) dated [DATE] documented R3 as an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documented R3 had severe cognitive deficits with a Brief Interview of Mental Status score of 3. The MDS documents R3 required extensive assist of one to two staff members for all activities of daily care. Progress Note dated [DATE] at 6:15 PM entitled Health Status Note entered by V4, Licensed Practical Nurse (LPN), documented Pt (Patient) noted to be lethargic during evening meal time. Able to arouse with voice et (and) touch. Alert to wife. vitals WNL (Within Normal Limits). No intake of evening meal. Able to take in honey thick liquids offered by wife without difficulty. No changes noted with urination or bowel movements. Remains incontinent of both. Wife does not want sent to the hospital for testing. Will alert Dr (V14) if pt declines. Wife remains at bedside. Will cont (continue) to monitor. The next entry into the progress notes was on [DATE] at 9:04 AM written by V5, LPN, as a Health Status Note. The Note documented POA (V8, Power of Attorney) here this a.m. and informed writer that she was here to take res (resident) to ER (emergency room ). Writer inquired why she felt he needed to go to ER, res was up and in Dining room awaiting his breakfast. POA states 'She has a gut feeling that something was off.' Writer informed her the MD would need to be notified and updated on why res needed to go and an order would need to be given. POA states 'regardless if MD (Medical Director) gives an order or not he is going even if she has to call 911.' MD paged at this time to inform of POA wishes. There was no documentation in R3's medical record the nursing staff monitored or assessed R3 for further decline after he was identified as being lethargic on [DATE] at 6:15 PM. On [DATE] at 9:10 AM, V5 documented as a Health Status Note, Res removed from Dining Room at this time and taken to room to assess, d/t (due to) POA concerns. Res a/o (alert/oriented) to self at this time and is able to answer simple questions. Res voices no discomforts at this time but is agitated at writers questions, V/S (Vital signs) stable, 98.8, 88, 16, ,[DATE]. Res remains incontinent of B&B (bowel and bladder). At 9:34 AM, V5 documented, Return call from (V13, MD) on call for (V14, MD) updated on res and POA wishes to send res to ER for eval (evaluation), MD gave order to send res to ER. R3's Progress Noted, dated [DATE] at 10:21 AM, documented R3 was transferred to the emergency room . Emergency Department (ED) Notes dated [DATE] documented The patient presents with lethargy, AMS (Altered Mental Status), so have concerns for UTI (urinary tract infection), BP (blood pressure) low on arrival ,[DATE] and has decreased intake last 2 weeks, decreased urine output none today with catheter, euthermic, LLL (left lower lobe) crackles. The final report documented wife at bedside reports over the past 2 weeks, patient has had progressive increase in general weakness and fatigue. Over the last 2 days, he has had increasing altered mental status and decreased activity. Wife reports he did not know who she was which is new for him. Also not knowing where he is at. Wife reports he has not been talking as much today and has appeared more fatigued. The note also documented appetite has been decreased. Has not been eating or drinking much over the past few days. The Physical Examination of the ED report documented Lethargic, Moderate distress, dry mucus membranes, and was hypotensive and [MEDICAL CONDITION] upon arrival. The Hospital History/Physical dated [DATE] documented Patient is critically ill with vital organ impairment, with high probability of life threatening complications. The Discharge Summary dated [DATE] documented in the emergency room , R3 Was found to be in septic shock with lactic acidosis, acute kidney injury, [MEDICAL CONDITION] and right-sided pneumonia with the family opting for Comfort care only. The Summary documented R3 was discharged to Hospice services. The Death Certificate documents R3 expired on [DATE] with cause of death listed as Septic Shock and Pneumonia. On [DATE] at 9:28 AM, V4 LPN stated she documented R3 was lethargic and did not eat any of his supper meal. V4 stated R3's wife, V8, did not want him sent to the emergency room that night but was concerned that he wasn't himself. V4 stated R3 did have periods of lethargy but his vital signs were stable. V4 stated she passed on her concerns to the night nurse but couldn't remember who that was. V4 stated she documented she would inform R3's physician but did not. On [DATE] at 10:55 AM, V6 LPN stated she worked from 8:00 PM on [DATE] to 6:00 AM on [DATE] but didn't remember receiving a report that R3 was lethargic. V6 stated she did not do any charting on R3 that evening. V6 stated that when she saw him, he was in his room describing him as normal, responsive with no complaints. V6 stated she wouldn't have charted on him as he was not on the hot rack to chart on. V6 also stated the CNA's (Certified Nurse Aides) didn't report anything unusual for him that night. On [DATE] at 10:34:00 AM, V9 CNA stated she took care of R3 during day shift on [DATE]. V9 stated R3 didn't respond normally that day, and had a color about him. V9 stated he was a little more lethargic than what he normally was and ate/drank very little. V9 stated she did not do any vitals on R3 and that she reported her concerns to V5, LPN that day. On [DATE] at 9:20 AM, V5 stated she didn't receiving any concerns regarding R3 on [DATE] and didn't report/record anything. V5 stated she was working the morning of [DATE] when R3's wife/POA (V8) came in and wanted to send him to the emergency room . V5 stated the wife told her she had a feeling something was not right with him and insisted they send him. V5 stated she did not note anything unusual for R3 that day and reiterated that he was up and in the dining room when his wife came in. On [DATE] at 11:00 AM, V10 LPN stated R3 had no episodes the evening on [DATE] and that they usually put residents on the hot rack if they have concerns. V10 stated V5 had no concerns during report but did say R3's wife did not want him sent to the hospital. V10 stated R3 had no issues that night to chart on. On [DATE] at 9:45 AM, V8 R3's wife/POA stated she had come in on [DATE] and found the room window open to the outside and the room was really cold. V8 stated she understood the window had been open since R3's roommate expired the evening before. V8 stated R3 had been declining for a couple weeks with increased lethargy, fatigue, and that she told the nurses of her concerns. V8 stated on [DATE], she came in at suppertime and R3 ate and drank very little. V8 stated she discussed her concerns with the nurse but wanted to wait until the morning to see how he was to make a decision then to send him to the emergency room . V8 stated she same in early on [DATE] and knew he was very ill. V8 stated the doctors stated he was critically ill and they put him in Hospice where he expired a few days later [MEDICAL CONDITION] and pneumonia. On [DATE] at 11:26 AM, V3 Assistant Director of Nurses (ADON) stated R3 was perfectly normal on ,[DATE] and [DATE] stating that sometimes he sat with his eyes shut and wouldn't respond when spoken to. V3 stated the facility uses a Hot Rack for residents who exhibit a condition change or are on an antibiotic which would trigger the nurses to chart on them. 24 hour report sheets provided on [DATE] by V3 document on [DATE] 0k for 3rd shift, episode of lethargy 0 (no) dr (doctor) or hospital for 1st shift and nothing documented for the 2nd shift. For [DATE], R3's accucheck is recorded as 165, with ok written for all three shifts. The 24 report sheet for [DATE] documents ok for 3rd shift, and that R3 was sent to the emergency room per POA request for 1st shift. Meal intake records dated [DATE] and [DATE] document R3 eating ,[DATE]% of breakfast and lunch with ,[DATE]% recorded for supper. Meal Intake records dated [DATE] document R3 ate ,[DATE]% for breakfast and supper with ,[DATE]% documented for supper. For [DATE], R3 was recorded as eating ,[DATE]% breakfast and lunch with no meal recorded for supper. On [DATE], the meal intake record documents R3 ate ,[DATE]% breakfast and lunch with ,[DATE]% recorded for supper. The CNA intake record for [DATE] document poor intake for the majority of the month. Dietary Progress note dated [DATE] documents R3 to have a 5% weight loss of 180 pounds [DATE] from 191.5 on [DATE] and a 10% loss since admission [DATE] of 201 pounds. The facility's policy/procedure entitled Condition Change Documentation dated [DATE] documented the purpose as being to maintain a medical record which is reflective of documentation of the care provided to residents to include, but not limited, nursing assessment and notifications related to the change of a resident's condition. The Procedure documented nursing will assess the resident's complaints and complete a nursing assessment of the resident, document the complaints and nursing assessment into the clinical record, notify the physician of condition change, report to oncoming shift and implement the hot rack OR condition change flowsheet charting for each shifts use to monitor the resident's health status, Continue charting on the resident's condition change until the resident is free of clinical abnormals or symptoms free for three consecutive shifts (24 hours.) Under Note, the policy documented Resident's presenting with condition change may have additional symptoms present thru the course of monitoring, notify the physician of new or worsening symptoms.

Based on observation, interview and record review, the facility failed to ensure residents environment remains free of accident hazards by allowing residents with oxygen in the beauty shop near flammable hair chemicals and hair dryers. This has the potential to affect all of the 87 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 7/9/14 at 4:40PM, the facility remains out of compliance at Severity 2 as the facility continues to educate staff and evaluate and monitor the effectiveness of the facility Policy and Procedure for BEAUTY SHOP OXYGEN USE GUIDANCE. Findings include: 1. Facility Policy and Procedure of 7/2009 for BEAUTY SHOP OXYGEN USE GUIDANCE documents, "Safety of resident(s) and beautician during provision of hair care. Oxygen when in use in a resident's room from any of the three common types of oxygen systems can create an oxygen-enriched atmosphere. In an oxygen-enriched atmosphere, materials that are combustible and flammable in air ignite more easily and burn more vigorously. Examples of these types of materials that may be found on or near residents in health care facilities can include hair oils, oil-based lubricants, skin lotions, facial tissues, clothing, bed linens, acetones, and some plastics. Items in a typical resident area can create a source of ignition if introduced into an oxygen-enriched atmosphere. These items can include hair dryers. For this reason, oxygen will not be administered in the beauty shop of this facility." On 7/9/14 at 10:05AM, R6 was observed in the beauty shop sitting in her wheel chair under the hooded hair dryer with a tank of oxygen on the back of the wheel chair and receiving Oxygen by nasal cannula. R12 was also in the beauty shop and no staff was in the attendance. At 10:07AM, E1, Administrator, was informed of the concern and removed R6 immediately from the beauty shop. E15, Beautician, was observed to bring hair spray out of beauty shop and to use on R6's hair once R6 was taken from the beauty shop. On 7/9/14 at 11:15AM, E17, CNA (Certified Nurse Aide) stated she did not know if staff takes off R6's oxygen when she gets her hair done. At that time, E18, CNA, stated to E17 that E1 needed to talk to E17 to discuss oxygen. On 7/9/14 at 11:20AM, E15, Beautician, stated she had just been inserviced that no residents with oxygen were allowed in the beauty shop. E15 stated she had been unaware of dangers of residents with oxygen being in the beauty shop until E1 talked to her. E15 stated she has hair spray, hair dye, perm solution and other hair products that she keeps in the beauty shop at all times. E15 stated that E1 had just finished putting a sign on the door that no oxygen is allowed in the beauty shop. On 7/10/14 at 11:30AM, E16, LPN (Licensed Practical Nurse) stated she had been unaware of the risks of having oxygen in the beauty shop. 2. The Resident Census and Conditions of Residents, CMS 672, dated 7/8/14 documents that the facility has 87 residents living in the facility. The Immediate Jeopardy began on 7/9/14 when R6 was in the beauty shop with oxygen being administered. E1, E2, DON (Director of Nursing) and E19, Corporate Nurse, were notified of the Immediate Jeopardy on 7/9/14 at 4PM. The facility took the following action to remove the Immediacy: 1. E1, removed R6 from the beauty shop on 7/9/14 at 10:07AM. 2. E15 was inserved on 7/9/14 at 10:30AM by E1 about not having any type of oxygen delivery in the beauty shop. Education of all staff was began at 10:30AM. 3. On 7/9/14 at 10:30AM, E1 posted a sign on the beauty shop door that no oxygen was allowed in the beauty shop. 4. On 7/9/14 at 11:15AM, E1 reviewed the Policy and Procedure on Beauty Shop Oxygen Use Guidance. 5. On 7/9/14, the Interdisciplinary Team reviewed the removal plan and implemented an ongoing monitoring quality assurance for the use of oxygen. The Medical Director was contacted and approved the above plan. This was completed at 4:40PM.

Based on interview, observation and record review, the facility failed to ensure enteral feedings were provided as ordered to maintain and/or prevent weight loss for 1 of 1 residents (R5) reviewed with tube feedings in a sample of 18. This failure resulted in R5 having a 7.8% weight loss in 90 days Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R5 as having cognitive impairment and requiring extensive assist of one staff for eating. The July 2014 physician's orders [REDACTED]. The POS also documents [REDACTED]. The care plan dated 4/26/14 and revised on 5/28/14 identifies that R5 has swallowing problems and will maintain adequate nutritional support and hydration. Interventions include monitoring caloric intake, estimate needs, make recommendations for changes to tube feeding as needed, weekly weights and "Do not give me a tray, provide one food at a time for me. Staff to sit next to me while I am eating" in part. Weights recorded for May 2014 was 145.2 pounds and June 2014 138.5 pounds. There are no weekly weights as indicated in the care plan revised 6/12/14. The Registered Dietician's (RD) E20 note dated 5/5/14 and 6/9/24 identifies the 75cc/hr tube feeding and po (by mouth) as meeting his needs with no recommendations made on 6/9/14 even though his weight went from 145.2 to 138.5 or a 4.7% weight loss. According to the RDs Note dated 7/7/14, R5's weight for July 2014 was 133.2 pounds showing a weight loss of 7.8% in 90 days and 8.3% in 180 days. E20 recommended for R5's tube feeding amount to be increased to 90cc/hr. There is no indication E20, reviewed and/or monitored R5's intake records to ensure he was receiving the correct amount of feeding as ordered. The last E24 Dietary Manager, (DM) documented on 5/28/14 R5's oral intake was 26-75% of his meal intakes. Laboratory Reports (labs) dated 9/9/13 show a low [MEDICATION NAME] 3.0 (Normal 3.5-5.5) and a Total Protein of 6.5 (normal 6-8.3). Most recent labs dated 4/11/14 have Total Protein 6.6, [MEDICATION NAME] 3.1 (L) and BUN 38 (normal 7-25) and Creatinine 1.1 (normal 0.6 - 1.3). Intake records for May, June and July 2014 show incomplete totals for each shifts with no total amounts recorded to ensure that R5 was receiving 900cc/12hr ordered. Amounts of feeding instilled and documented often calculate to less than the 900cc. Examples include 800cc - 7/8/14, 803cc - 7/7, 354cc - 7/6, 859cc - 7/5, 7/4 - 81cc, 7/3 - 875cc, 7/2 - 780cc, and 7/1 - 853cc. In June 2014, numerous amounts of feedings were under 900cc including 6/25/14 - 731cc, 6/22 - 794cc, 6/19 - 645cc, 6/18 - 728cc, 7/17 - 116cc, 6/14 - 124cc, 6/12 - 74cc, and on 6/16/14, no intake was recorded except a statement "off when I arrived" for the 6am time. May 2014 also show numerous incomplete days. This documentation shows a pattern of not monitoring R5's enteral intake to ensure adequate feeding amounts as ordered and according to his care plan and facility policy. The tube feeding amount ordered per shift should be as followed: 6am-2pm shift - 75cc, 2pm-10pm - 225cc, 10pm-6am - 600cc for a total of 900cc. On 7/8/14 at 12:15pm, R5 was served his tray of food. He had potatoes and gravy, ground meat, puree vegetables, and a pureed dessert served in a divided plate. No staff stayed with him after the plate was delivered. He took a few bites, rolled back and forth from the table and tasted the all the food items. He ate no dessert. R5 was observed also at breakfast at 8:20am on 7/9/14 and noted to have no staff attention after his divided plate was delivered and no cueing/encouragement to eat more. He was observed again to pick at his food and ate only bites of his eggs, cream of wheat and sausage with none of his milk or red drink. On 7/11/14 at 9am, meal intake records were reviewed. On 7/8/14, the facility did not document R5's intake at the noon meal at all. R5 ate less than 25% of his porkchop, potatoes and vegetables, none of his milk or lemonade, a bite of dessert and 75% of a small glass of water. On 7/9/14 at the breakfast meal, the facility documented R5's intake as 100%. At 8am on 7/9/14, R5 ate only bites of his yogurt, a bite of egg, a smear of the sausage, 25% of his cream of wheat, none of his red drink or milk and only 75% of his water. He rolled himself away from the table with no staff intervention. On 7/9/14 at the noon meal, the facility documented R5 ate 51-75%. The nurses notes dated 7/8/14 document that the RD's recommendation was ordered by the physician to increase R5's tube feeding to 90cc/hr from 7pm to 7am. A new note written by E24 dated 7/10/14, documents R5 to be on pleasure feedings, "appetite fluctuates from meal to meal" with both 26-75% and <25% circled, indicating a decreased oral intake. On 7/10/14 at 10:30am, E19 Corporate Nurse and E2, Director of Nursing (DON) acknowledged the intake records were incomplete with no totals recorded or monitored for R5's tube feeding. E2 stated the intake record's format is for three shifts but the nurses work 12 hour shifts and that could cause some problem in recording the amount. Both were also aware the amounts recorded were less than the 900cc ordered on the majority of the days reviewed. E19 stated R5 was scheduled to see the physician Both stated that there may be something going on with him that is causing the weight loss and the physician was to see him later that day. On 7/10/14 at 1:52pm, E19 confirmed that no weekly weights had been done. According to the Harris/Benedict Formula, when R5 weighed 145.2 pounds, he required 1980 calories/day to maintain weight. The [MEDICATION NAME] 1.2 at 75cc for 12 hours supplies only 1080 calories leaving 900 calories to be taken by mouth. On 7/10/14 at 2:50pm, E20 stated she reviews the po (Oral) intake records because they are on the computer but she was not aware the nurses documented feeding intake anywhere. E20 stated she looks at his total needs being met with what he eats orally and his tube feeding. However, she did acknowledge that his feedings were pleasure. On 7/11/14, E20 stated she recalculated his needs to be 1650 calories with 66 gm of protein, 1650cc fluids daily. The tube feeding calculated at 90cc/hr for 12 hours equals 1296 calories with 60gm of protein and total fluids provided with the tube feeding is 1592cc. E20 stated she did not watch him eat on 7/7/14 when she was in the facility doing his assessment. When asked about calculating fluids based on 30cc/kg which totals 1812cc not 1650, E20 stated she uses 25-30/cc per kilogram based on labs, skin condition and what the resident eats or drinks. The facility's policy entitled "Enteral/Tube feeding policy" documents that all residents receive basic nutrition while in the facility and the objective is to maintain a consistent plan of care for residents who require tube feedings due to the inability to eat enough to sustain life. Under Documentation requirements, it documents "Administration will be documented on the medication administration record by licensed staff and "the amount of the feeding and water will be accurately recorded for each shift of administration of the feeding by licensed staff."

Based on interview, observation and record review, the facility failed to adequately assess/treat oral pain and coordinate services between Hospice and the facility for 1 of 2 residents (R12) on Hospice in a sample of 18. This failure resulted in ongoing oral pain which affected R12's ability to eat and drink and cause overall discomfort. Findings include: 1. On 8/14/12 at 9:30am, R12 was observed to be laying in bed. His breakfast tray was sitting on his overbed table and remained untouched until 10:30am when it was removed from his bedside. At 2pm, R12 was again noted laying in bed and stated "I'm no good. My mouth hurts and nobody is paying any attention to me." R2 stated he has sores in his mouth that are painful and keeps him from wanting to eat and drink. His lower lip was swollen and he had dried crusty mucous on his lower lip that strung to his upper teeth. R12 stated he had told the nurse but "no body does anything for me." Nurses notes dated 8/14/12 at 10:45am document "res (resident) c/o (complained of) "sores" in mouth @ (at) this X (time) c PRN (as needed) [MEDICATION NAME] et PRN [MEDICATION NAME] given." At 1230, the nurses notes documents that the nurse attempted to assess R12's pain but resident was "tweaking" staff nose et (and) smiling. The nurses notes included no assessment and/or evaluation of any oral [MEDICAL CONDITION] and/or sores in R12 mouth. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. No [MEDICATION NAME] or Tylenol was documented as being given between 8/1/12 and 8/15/12. According to a dental assessment dated [DATE] and updated 8/2/12, R12 was seen by the dentist for complaints of oral pain for a "number of weeks." The exam documents "he wanted to direct my attention to one area of his mouth only and was averse to being touched in the area of his mouth." The exam revealed R12's "left [MEDICATION NAME] mucosa distal to the left corner of the mouth" had an area approximately 2cm in diameter with irregular borders, grayish in color, lobed, and very tender." The examiner documented very likely an area of erosive oral [DIAGNOSES REDACTED]. The exam documents that the hospice nurse "relates that this area has come and gone, appeared and re-appeared in different parts of his mouth over the last year despite various treatments.". Hospice records provided on 8/15/12 dated 7/31/12 included additional notes that documented "Pt (patient) c.o discomfort. NH nurse gave pt oral [MEDICATION NAME]." On 8/8/12, Z1 documented "Pain noted upon touching area. [MEDICATION NAME] applied directly to ulcer. Effective with pain management." Hospice Notes dated 8/14/12 includes documentation "No pain is currently managed wth routine/scheduled and/or prn pain medications." There was no documentation regarding oral [MEDICAL CONDITION]/sores in the Hospice notes provided/ On 8/15/12 at 8:10 am, R12's breakfast tray as again noted on his overbed table beside his bed. It remained there until 10:30 when it was noted to be gone. At 10:54am, R12 stated he doesn't drink much because it "burns." At 11:30am, E10, Licensed Practical Nurse (LPN) stated she worked full time on R12's floor and was familiar with him and was asked about the breakfast tray. She stated he prefers to sleep late and will get up between 10 and 10:30, eat his breakfast and lay back down. E10 confirmed that R12 had mouth sores which she stated he had had off and on for years. E10 stated R12 receives the [MEDICATION NAME] daily from Hospice. E10 was unable to describe the sores/[MEDICAL CONDITION] in R12 mouth but did state that he often refused to have them assess it. E10 entered the room and asked R12 to look at his mouth and he agreed. She offered the [MEDICATION NAME] and he agreed a that being applied and a pain pill rating his pain at the time an "8" on a 1-10 with 10 being the worse. She returned and applied the [MEDICATION NAME] to his lower lip with a q tip. His lower lip was noted to be swollen and his teeth were in need of brushing. He jerked when she placed the qtip in his lower lip and moaned. He jerked again when she placed it again. He had a long grayish lesion extending from his inner right lip to the bottom of his gun line which he stated was very painful along with smaller other [MEDICAL CONDITION] on the left side of the inner lift lip. E10 stated that the Hospice nurse was here everyday and looked at it also but she was unable to provide any documentation from Hospice services including the [MEDICATION NAME] and/or pain assessments. E10 failed to document a description of the [MEDICAL CONDITION] on 8/15/12. On 8/15/12 at 1:30pm, Z1, Hospice Nurse, stated she keeps all her records in her computer and does not leave any with the facility. Z1 agreed that R12 had mouth pain but also was unable to describe what, is any [MEDICAL CONDITION], he had at the time although she stated he receives [MEDICATION NAME] daily. Z1 stated she applies the [MEDICATION NAME] daily but agreed that she did n't document it and added that the facility nurses did. Z1 stated she ordered the [MEDICATION NAME] routinely twice daily on 7/26/12 due to mouth pain but couldn't state whether PRN medications were given prior to ordering it routinely. Z1 offered to print out her notes to review and provided daily notes referenced above. Z1 stated she did attend care plans but acknowledged that there was no Hospice care plan provided to the facility. Z1 stated R12 had no weight loss from not eating. Review of the MAR indicated [REDACTED]. There is no pain assessment for July that reflects the oral pain R12 complained of which resulted in the physician being called and the orders being obtained. The Minimum Data Set ((MDS) dated [DATE] identifies R12 to have no cognitive impairment or memory deficits and requires minimal assist of one staff for all activities of daily living (ADL) except bathing which he requires extensive assist. According to the the MDS, R12 has no mouth discomfort or no abnormal mouth tissue. The MDS also identifies no pain concerns for R12 identified even though he is on multiple routine pain medications and is receiving the [MEDICATION NAME] routinely PRN. The care plan dated 8/15/12 does not reflect any pain management or the oral [MEDICAL CONDITION] R12 complained of although it does document under confusion and dementia that R12 is on Hospice for Failure to thrive, tires easily, can often be resistive to eating and getting out of the chair and is being followed by Hospice for comfort cares. One of the interventions include monitoring for pain and comfort. There is no plan evident to keep his mouth clean and pain free and none that is evident of a coordinated effort between Hospice and the facility to meet his needs. This was confirmed in interview with E13, Care Plan Coordinator on 8/16/12 at 1:30pm. His current weight for August is 116 pounds acccording to the monthly weight record. The Registered Dietician dated 12/11/11 and subsequent notes by the dietary manager dated 3/13/12 and 5/24/12 fail to reflect oral pain. On 8/16/12 at 1:30pm, Z1 stated she will be providing documentation from here on and then stated she doesn't apply the [MEDICATION NAME] but the facility nurse does. On 8/17/12 at 2:30pm, E14 the MDS/Care Plan Coordinator confirmed that the most recent MDS dated [DATE] failed to identify R12's mouth [MEDICAL CONDITION] and pain appropriately. The Contract for Hospice services dated 3/12/10 documents that each record shall completely, promptly, and accurately document all services provided to, and events concerning each Hospice Patient (including evaluations, treatments, and progress notes). Each record shall reflect such services in accordance with this agreement and shall be readily accessible. The contract documents that the Hospice shall furnish a copy of the plan of care of a Hospice patient who requires Hospice respite services and will conduct conferences necessary to coordinate provision of Hospice Respite Services.

Based on interview and record review, the Facility failed to ensure that an alarm device was in place for 1 (R1)of 3 residents on the sample who experienced falls. This failure resulted in R1 falling from her recliner and sustaining an undisplaced fracture of the sixth rib, with a possible occult fracture of her seventh rib. Findings include: According to the current face sheet, R1 was originally admitted to the facility on [DATE], with diagnoses, in part, of Dementia, Confusion and Depression. During an interview with E4, Licensed Practical Nurse (LPN), on 12/1/10, at 1:45 PM, it was stated that she had been R1's nurse the past 6 months. E4 said that R1 had experienced a decline in her condition and that up until about 6 months ago, R1 ambulated independently. After that time, R1 mainly used the wheelchair. E4 said that "the girls" would also walk R1 utilizing a gait belt, "depending on how cooperative she was that day". R1's Facility Incident/Accident Investigation Reports show that R1 experienced falls in the Facility on 3/26/10, 4/30/10, 5/15/10, 8/5/10, 10/19/10 and 10/20/10. R1's Facility investigation, dated 8/5/10, 10:10 AM, states "found resident lying on the floor. Did range of motion on all extremities. No complaints of pain". The "Follow Up Procedures" for this fall includes "It is the conclusion that the resident was either getting out of the recliner unassisted of bent over in the recliner and fell . Resident was transferred to the emergency room due to a condition change, where she was noted to have a urinary tract infection (UTI)". The "Recommendations" for this fall is "application of an alarm to her recliner to remind resident she needs assist to transfer". The investigation states that a "bruise was noted later in the day to her right temple. Faint blue in color. Appears to be from her glasses". Facility investigation, dated 10/19/10, 00:05 AM, states "writer called to room where resident was noted to be sitting on the floor in front of her recliner. When asked what she had been doing, resident stated she fell out of the drapes. No complaint of pain". The "Follow Up Procedures" for this incident states "Resident currently being treated for [REDACTED]. Slipper socks to be used when ambulating to the bathroom at night". There are no other corrective actions given for this fall. This investigation does not state when R1 was last visually observed or toileted. The investigation does not state if R1 had an alarm in her recliner, or if an alarm was sounding at the time of the fall. Facility investigation, dated 10/20/10, 2:10 PM, states "Resident found by staff during rounds lying on her right side next to her recliner. Resident had been in her recliner prior to the fall. She has Dementia with increased behaviors, with a UTI and treatment in place". The "Follow Up Procedures" for this incident states "Resident currently being treated for [REDACTED]. After participating in a activity, resident complained of pain in the right rib area. Family and physician aware and order received to send to the emergency room for evaluation. Resident returned from the emergency room with negative x-ray findings on 10/20/10. On 10/22/10, at 1:30 PM, physician notified the facility that the x-ray results were read by a radiologist and resident has a subtle fracture of ribs 6 and 7". The "Recommendations" for this fall is "Seat alarm placed in recliner. Hi/Low bed placed". R1's Facility plan of care, dated 3/5/09 - 11/10/10, shows a "Problem" of "Fall Risk - At risk for falls, related to a history of falls, impaired mobility, urinary incontinence, use of assistive device, use of psychotropic medication, history of hip fracture, mental functions varies over the course of the day". Included in the "Interventions/Approaches"for this "Problem", is "8/5/10, fall noted - alarm to recliner to remind resident she needs assist to transfer". During an interview with E2, Director of Nursing, on 12/1/10, at 1:15 PM, she stated that she was unaware if R1 had an alarm in her recliner prior to E2 assessing R1 for an alarm after R1's fall on 10/20/10. On 12/1/10, at 1:45, E4 said that she cannot recall R1 having an alarm in her recliner.